Exam 3- Tissue Integrity Flashcards
1
Q
Integumentary:
Initial reaction to a problem that alters one of the structural components of the skin
A
Primary
2
Q
Integumentary:
Changes in the appearance of the primary lesion with progression of an underlying disease or in response to a topical or systemic therapeutic intervention
A
Secondary
3
Q
Integumentary:
Related to blood vessel integrity
A
Vascular
4
Q
Protects tissues from physical, chemical & biologic damage. Prevents water loss, serves as a water-repellent layer. Stores melanin, converts cholesterol to vitamin D when exposed to sunlight. Contains phagocytes, which prevent bacteria from penetrating skin.
A
Epidermis
5
Q
Regulates body temp. by dilating & constricting capillaries.Transmits messages via nerve endings to CNS.
A
Dermis
6
Q
Secretes sebum, which lubricates skin & hair & plays role in killing bacteria.
A
Sebaceous (oil) glands
7
Q
Regulate body heat by excretion of perspiration.
A
Eccrine sweat glands.
8
Q
Remnants of sexual scent gland
A
Apocrine sweat glands.
9
Q
A reddening of the skin. May occur during fever, hypertension, inflammation. May also result from sunburns, drug reactions, acne rosacea etc.
A
Erythema
10
Q
A bluish discoloration of the skin and mucous membranes.
A
Cyanosis
11
Q
Why does cyanosis occur?
A
Results from poor oxygenation of hemoglobin.
12
Q
Paleness of skin, may occur with shock, anger, fear, anemia & hypoxia.
A
Pallor
13
Q
An abnormal loss of melanin in patches. Typically occurs over the face, hands or groin.
A
Vitiligo
14
Q
Appears as patches of pale, itchy wheals in an erythematous area.
A
Urticaria (hives)
15
Q
Raised bluish or yellowish vascular lesions.
A
Bruises (Ecchymosis)
16
Q
An accumulation of fluid in the body’s tissues.
A
Edema
17
Q
How is edema graded?
A
Depress patient’s skin.
1+ Slight pitting - no obvious distortion
2+ Deeper pit, no obvious distortion
3+ Pit is obvious; extremities are swollen
4+ Pit remains with obvious distortion
18
Q
When/why is edema commonly found? (think health reasons, not time of day) (5)
A
- Cardiovascular
- Renal failure
- Trauma
- Cirrhosis of liver
- Side effect of drugs
19
Q
Hair loss - may be related to hormones, chemical or drug treatments (radiation).
A
Alopecia
20
Q
Flat, nonpalpable change in skin color. Usually a circumscribed border. Smaller than 1 cm.
Ex. freckles, measles, petechiae.
A
Macule
21
Q
Flat, nonpalpable change in skin color. May have irregular border. Larger than 1 cm.
Ex. Mongolian spots, port-wine stain, vitiligo.
A
Patch
22
Q
Elevated, fluid-filled, round or oval shaped, palpable mass with thin translucent walls & circumscribed borders. SMALLER than 0.5cm.
Ex. herpes, early chickenpox, poison ivy.
A
Vesicles
23
Q
Elevated, fluid-filled, round or oval shaped, palpable mass with thin translucent walls & circumscribed borders. LARGER than 0.5cm.
Ex. Contact dermatitis, friction blisters, large burn blisters.
A
Bulla
24
Q
Elevated solid, palpable mass with circumscribed border. SMALLER than 0.5 cm.
Ex. Elevated moles, warts.
A
Papule
25
Elevated solid, palpable mass with circumscribed border. LARGER than 0.5 cm.
Ex. Psoriasis, actinic keratosis.
Plaque
26
Elevated, often reddish area with irregular border caused by diffuse fluid in tissues rather than free fluid in a cavity. Size varies.
Ex. insect bites, hives.
Wheals.
27
Elevated, solid, hard or soft palpable mass extending deeper into the dermis than a papule. Measure 0.5 to 2 cm.
Ex. small lipoma, intradermal nevi, fibroma.
Nodule
28
Elevated, solid, hard or soft palpable mass extending deeper into the dermis than a papule. Measures LARGER than 2 cm.
Ex. Large lipoma, hemangioma, carcinoma.
Tumor
29
Elevated, pus-filled vesicle or bulla with circumscribed border. Size varies.
Ex. Acne, impetigo, carbuncles.
Pustule
30
Elevated, encapsulated, fluid-filled or semisolid mass originating from the sub-q tissue or dermis, usually larger than 1 cm.
Ex. sebaceous cyst, epidermoid cyst.
Cyst.
31
Translucent, dry, paper-like, sometimes wrinkled skin surface resulting from thinning or wasting of the skin due to loss of collagen & elastin.
Ex. Striae, aged skin
Atrophy
32
Deep, irregularly shaped area of skin loss extending into the dermis or sub-q tissue. May bleed.
Ulcer
33
Wearing away of the superficial epidermis causing a moist, shallow depression.
Ex. scratch marks, ruptured vesicles.
Erosion
34
Linear crack with sharp edges, extending into the dermis.
| Ex. cracks at corner of mouth, on hands.
Fissure
35
Rough, thickened, hardened area of epidermis resulting from chronic irritation such as scratching or rubbing.
Lichenification
36
Flat, irregular area of connective tissue left after a lesion or wound has healed.
Scar
37
Shedding flakes of greasy, keratinized skjn tissue.
| Ex. dandruff, dry skin, psoriasis, eczema.
Scales
38
Elevated, irregular, darkened area of excess scar tissue caused by collagen formation during healing. Extends beyond the site of the original injury.
Keloid
39
Dry blood, serum, or pus left on the skin surface when vesicles or pustules burst.
Crust
40
Benign vascular tumors, come in different forms. Ex. Port wine stain.
Angioma
41
Raised, reddened round circumscribed plaques covered by silvery white scales.
Psoriasis
42
Epidermal skin lesion directly related to chronic sun exposure & photodamage.
Actinic keratosis - AKA senile or solar keratosis.
43
Physical Assessment of Integumentary Includes:
Skin, Hair, Nails
44
Assessing the skin:
Inspect: Moisture, Vascular changes/markings, Skin Integrity, Hygiene
Palpate: Lesions, Moisture, Temperature, Texture, Turgor
Document lesions: Color, Size, Location, Shape, Texture, Distribution, Drainage, Related findings.
45
premalignant skin changes related to sun exposure and chronic skin changes
Actinic Keratosis
46
Most common type of skin cancer but least aggressive, appears on sun-exposed areas of body and incidence increases with age
Basal Cell Carcinomas
47
- Malignant proliferation of the epidermis, may occur on sun-damaged skin or normal skin
- Can metastasize by blood or lymphatic system, so need to evaluate lymph nodes
- Typically appears as rough, thickened, scaly tumor, common sites are head and face, and upper extremities, may also be nodular
- Treatment – excision, cryosurgery, radiotherapy
Squamous Cell carcinoma
48
cancerous neoplasm arising from melanocytes, 10 times more likely in fair-skinned individuals, can originate anywhere there is pigment, but 1/3 originate in existing nevi
Malignant Melanoma
49
Usually > than 6 mm in diameter, are asymmetric, develop within the epidermis over a long period of time ( in-situ)
When they penetrate the dermis can metastasize
Malignant Melanoma
50
ABCD (and E)rule for assessing suspicious nevi
A – asymmetry (one half of the nevi does not match the other half of the nevi)
B – border irregularity (edges are ragged, blurred, or notched)
C – color variation or dark black color
D – diameter greater than pencil eraser (6 mm)
E – evolving (change in size, shape, color, etc)
51
The immediate experience of being strengthened by having needs for relief, ease, and transcendence met in four contexts (physical, psychospiritual, social and environmental); much more than the absence of pain
Comfort
52
Subjective Comfort
Must understand normal for that client. Client's expression of contentment & ease.
53
Objective Comfort
Neurological, medical functions, processes typically associated with comfort. Nurse may note vital signs in normal range, calmness in facial expressions.
54
- The fifth vital sign.
- Unpleasant sensory, emotional experience
- Associated with actual or potential tissue damage
- Described in terms of damage
- Plays protective role
- Relief of pain is a client right
Pain
55
The most common reason for seeking health care?
Pain
56
"Whatever the person experiencing it says it is, and existing whenever the person says it does."
Pain
57
4 ways to describe pain:
1-location
2-intensity
3-etiology
4-duration
58
Duration of pain
Establishes difference between acute and chronic pain.
59
What is used to measure intensity of pain?
A 0-10 pain scale.
60
Pain scale range:
1-3=
4-6=
7-10=
```
1-3= mild pain
4-6= moderate pain
7-10= severe pain
```
61
Prolonged pain that is constant or recurring for longer than 6 months. May be mild to severe, involves parasympathetic nervous system response.
Chronic pain
62
Pain that lasts only through the expected recovery period. May be mild to severe, has sympathetic nervous system response.
Acute pain
63
Pain that may result from direct effects of treatment of this disease...
Cancer pain.
64
Lack of energy and motivation that may/may not be accompanied by drowsiness
Fatigue
65
Common causes of fatigue
- anemia
- sleep disorders
- depression or grief
- pregnancy
- respiratory disorders
- hypothyroidism
- use of alcohol or drugs
66
Chronic disorder characterized by widespread musculoskeletal pain, fatigue & multiple tender points.
Fibromyalgia
67
Insomnia
inability to fall asleep or remain asleep.
68
Hypersomnia
cannot stay awake during the day.
69
Narcolepsy
sleep attacks or excessive daytime sleepiness.
70
Sleep apnea
frequent short breathing pauses during sleep.
71
A term referring to interventions used to promote sleep.
Sleep hygiene
72
Properly functioning nervous system sends signals that tissues are damaged, requiring attention and proper care.
Physiological pain
73
Damaged or malfunctioning nerves due to injury, illness or undetermined reasons cause "this" pain.
Neuropathic pain
74
Sharp and localized or dull & diffuse - pain originating from nerve receptors in the skin or close to body surface.
Somatic pain
75
Pain that arises from body organs - often radiates or is referred. May be described as cramping, intermittent or colicky pain. Dull achy pain.
Visceral pain
76
Pain perceived in an area distant from the site of stimuli.
Referred pain
77
Gate Pain Theory
- Pain impulses can be modified at spinal cord level before reaching the brain
- Gates at dorsal horn synapses in spinal cord
78
Pain Experience:
- Perceives pain
- physiological indicators may vary so behavioral observation is recommended for pain assessment.
- responds to pain w/ increased sensitivity.
Infant pain
79
Pain Experience:
- ability to describe pain & its intensity & location
- may consider pain a punishment
- tends to hold someone accountable for pain
- perceives pain a threat to security
Toddler & preschooler pain
80
Pain Experience:
- tries to be brave when facing pain
- responsive to explanations
- identify location & describe the pain
- may regress to earlier stage of development with persistent pain
School-age child
81
Pain Experience:
- may be slow to acknowledge pain
- giving in to pain may be considered a weakness
- wants to appear brave in front of peers and not report pain
Adolescent
82
Pain Experience:
- exhibiting pain behaviors may be gender based
- may ignore pain b/c perceived as sign of weakness or failure
- fear of what pain means may prevent some from taking action
Adults
83
Pain Experience:
- decreased sensation or perceptions of pain.
- lethargy, anorexia, fatigue may be indicators of pain.
- multiple conditions with vague symptoms
- may withhold complaint in fear of treatment or lifestyle changes
Older adult
84
The nurse is aware that the A-delta fibers conduct which of the following types of pain?
Sharp, shooting pain impulses
85
Pain that exceeds baseline.
Breakthrough pain
86
Pain that is experienced in high frequency bursts
Central pain
87
Pain that has an Absence of any diagnosed cause or event
Psychogenic pain
88
-Mild pain step 1
Nonopioid analgesics (with/without coanalgesic)
-Persists, moderate pain step 2
Weak opioid, combination of opioid and nonopioid, (with/without coanalgesic)
-Persists, severe pain step 3
Strong opiates administered around the clock
Titrated until pain relieved, respiratory effects
WHO Three step approach
89
Does not affect platelet function
Rarely causes GI distress, renal, skin, CV
Hepatotoxicity with high dose, long-term use
Acetaminophen
90
Vary in anti-inflammatory properties
Metabolism, excretion, side effects
Narrow therapeutic index
Acetaminophen, ibuprofen, aspirin
91
Pure opioid drugs bind tightly to mu receptors
Found throughout the body
Morphine, oxycodone, hydromorphone
Full agonists
92
Name 3 Full agonist opioid drugs
Morphine
Oxycodone
Hydromorphone
93
Have ceiling effect
Block mu receptor or neutral
Buprenorphine
Alternative to methadone
Partial agonists
94
Name one partial agonist
Buprenorphine
95
Act like opioids and relieve pain (agonist effect)
Works only if client has not taken any pure opioids (antagonist effect)
Blocks, inactivates other opioid analgesics
Includes dezocine, pentazocine, butorphanol tartrate, nalbuphine hydrochloride
Mixed agonist-antagonists
96
Weak opioid analgesics
| mixed opioid analgesics
```
Weak opiods (codeine, tramadol)
Mixed agonist-antagonist drugs (Stadol, Nubain)
```
97
```
Strong opioid analgesics
Most potent class of pain relievers
```
Opium derivitives morphine, methadone, hydromorphone, oxycodone, fentanyl,
98
Chemical interruption of nerve pathway
| Injection of local anesthetic into nerve
Nerve block
99
COLDERR
| Pain Assessment
```
C = character
O = onset
L = location
D = duration
E = exacerbation
R = relief
R = radiation
```
100
```
What are these examples of:
Acute Pain
Chronic Pain
Hopelessness
Anxiety
Ineffective Coping
Ineffective Health Maintenance
```
Examples of Pain Nursing Diagnosis
101
What is this an example of:
Client will
Report reduction in pain to allow for comfort
Be able to contribute to self-care activities
Obtain adequate pain relief to allow for mobility
Obtain adequate pain relief to allow for sleep
Nursing Plan
102
```
What is this an example of:
Assess client’s pain
Time for pain relief highly dependent on
Route of administration
Nonpharmacological intervention
Client’s pain level prior to initiation of therapy
Evaluate vital signs
Objective data may validate/conflict with subjective data
```
Nursing evaluation
103
```
What is this an example of:
Teaching of client and family includes
Specific drugs to be taken
How to take or administer drugs
Importance of taking pain medications before the pain becomes severe
Explain risk of addiction very small
Importance of scheduling rest and sleep
Suggest resources
```
Community based care
104
Occurs when the structures of the pharynx or oral cavity block the flow of air. Begins with snorting, then breathing ceases.
Obstructive apnea
105
Is thought to involve a defect in the respiratory center of the brain.
central apnea
106
A combination of obstructive apnea and central apnea
Mixed apnea
107
Behavior that may interfere with sleep and may even occur during sleep. Example: sleepwalking
Parasomnia
108
Two risk factors of insomnia:
- older age
| - female
109
Risk factors for sleep apnea
- male
- increasing age
- obesity
- large neck circumference
110
Mental health problems associated with poor sleep:
- anxiety
- depression
- substance abuse disorders
111
Alternative sleep therapies
- Melatonin
- herbal chamomile tea
- lemon balm
- valerian
- Cognitive-behavioral therapy
- guided imagery
112
What is this an example of:
- sleep history
- talk to the client and their sleep partner
- sleep assessment scales
- obtain objective data - pallor, dark circles under eye, level of consciousness, reflexes, vital signs...
Nursing assessment
113
What is this an example of:
- disturbed sleep pattern
- impaired gas exchange
- anxiety related to diagnosis of a sleep disorder
- fatigue
- risk for injury related to somnambulism
Nursing diagnosis
114
```
What is this an example of:
The client will
-sleep through the night
-use good sleep hygiene
-remove distractions from the bedroom
```
Nursing Plan
115
A client is going to have a sleep study done and wants to know what type of tests to anticipate. The nurse’s best answer is:
Electroencephalography - electrodes placed on the scalp to record brain waves
116
What is this an example of:
Healthy individuals obtain less sleep than needed
19 hours awake produces same impairments as blood alcohol level of 0.05
Nurses with reduced hours of sleep more likely to make errors
Insufficient sleep
117
Diagnostic studies for sleep disorders
```
Polysomnography (PSG)
Electroencephalogram (EEG)
Electromyogram (EMG)
Electro-oculogram (EOG)
O2 saturation
Electrocardiogram (ECG)
```
118
What is this an example of:
Data collection
Observations of duration of client’s sleep
Questions about how client feels upon awakening
Observations of client’s level of alertness during day
Nursing evaluation
119
Refers to physical change, increase in size
Growth
120
Refers to increase in complexity of function
Skill progression
Capacity, skill to adapt to environment
Development
121
Erikson's 8 stages of development:
| Infancy
- Birth to 18 months
| - Trust vs. Mistrust
122
Which Erikson stage:
| Learning to trust others vs. mistrust, withdrawal, estrangement...
Infancy
| Trust vs. Mistrust
123
Erikson's 8 stages of development:
| Early Childhood
- 18 months to 3 years
| - Autonomy vs. shame and doubt
124
Which Erikson stage:
| Self-control w/o loss of self-esteem vs. compulsive self-restraint or compliance
Early childhood
| -Autonomy vs. shame and doubt
125
Erikson's 8 stages of development:
| Late Childhood
3 - 5 years
| Initiative vs. guilt
126
Which Erikson stage:
Learning the degree to which assertiveness & purpose influence the environment vs. lack of self-confidence; pessimism, fear of wrongdoing.
Late childhood
| Initiative vs. guilt
127
Erikson's 8 stages of development:
| School Age
6-12 years
| Industry vs. inferiority
128
Which Erikson stage:
| Beginning to create, develop, & manipulate vs. loss of hope, sense of being mediocre.
School Age
| Industry vs. inferiority
129
Erikson's 8 stages of development:
| Adolescence
12-20 years
| Identity vs. role confusion
130
Which Erikson stage:
| Coherent sense of self vs. feelings of confusion, indecisiveness and possible antisocial behavior.
Adolescence
| Identity vs. role confusion
131
Erikson's 8 stages of development:
| Young adulthood
18-25 years
| Intimacy vs. isolation
132
Which Erikson stage:
Intimate relationship with another person, commitment to work vs. impersonal relationships, avoidance of relationship, career or lifestyle commitments.
Young adulthood
| Intimacy vs. isolation
133
Erikson's 8 stages of development:
| Adulthood
25 - 65 years
| Generativity vs. stagnation
134
Which Erikson stage:
| Creativity, productivity, concern for others vs. self-indulgence, self-concern, lack of interests and commitments.
Adulthood
| Generativity vs stagnation
135
Erikson's 8 stages of development:
| Maturity
65 to death
| Integrity vs. despair
136
Which Erikson stage:
| Acceptance of worth & uniqueness of one's own life; acceptance of death VS. Sense of loss, contempt of others.
Maturity
| Integrity vs. despair
137
A Factors that influence Development
| Genetics:
Remains unchained throughout life – physical characteristics, gender, temperament.
138
A Factors that influence Development
| Chromosomes and genes:
- Carry messages that encode for characteristics, diseases.
| - Sex chromosomes and autosomal chromosomes
139
A Factors that influence Development
| Prenatal influences –
mothers nutrition, maternal smoking, maternal alcohol consumption
140
A Factors that influence Development
| Family & parenting
- Profile of family characteristics
| - Families influence children profoundly
141
A Factors that influence Development
| Cultural influences –
- Traditional practices
- Genetic variations
- Rules regarding patterns of social interaction
- Genetic traits
142
A Factors that influence Development
| Nutrition –
-Essential to growth and development
-Poorly nourished= More likely to get infections
& Not attain full height potential
-Prenatal nutrition
143
A Factors that influence Development
| Environment – living conditions
- Living conditions
- Socioeconomic status
- Climate
- Community
144
A Factors that influence Development
| Health – injury, illness
- Injury, illness
| - Prolonged, chronic illness
145
Nine Parameter of Personality:
| Activity Level
- Degree of motion during eating, playing, sleeping, bathing.
- Score: high, medium, low
146
Nine Parameter of Personality:
| Rhythmicity
- Regularity of schedule maintained for sleep, hunger, elimination
- Score: regular, variable, irregular
147
Nine Parameter of Personality:
| Approach or withdrawal
- Response to new stimulus such as a food, person or activity
- Score: approachable, variable, withdrawn
148
Nine Parameter of Personality:
| Adaptability
- Degree of adaptation to new situations
| - Score: adaptive, variable, nonadaptive
149
Nine Parameter of Personality:
| Threshold or responsiveness
- intensity of stimulation needed to elicit a response to sensory input, objects in the environment or people.
- Score: High, medium, low
150
Nine Parameter of Personality:
| Intensity or reaction
- Degree of response to situations
| - Score: Positive, variable, negative
151
Nine Parameter of Personality:
| Quality of mood
-Predominant mood during daily activity & response to stimuli
Score: positive, variable, negative
152
Nine Parameter of Personality:
| Distractibility
- ability of environmental stimuli to interfere with the child's activity.
- Score: distractible, variable, nondistractible
153
Nine Parameter of Personality:
| Attention span & persistence
- amount of time devoted to activities & the degree of ability to stick with an activity in spite of obstacles
- Score: persistent, variable, nonpersistent
154
developmentally inappropriate behaviors involving inattention
ADD
155
hyperactivity, impulsivity accompany inattention
ADHD
156
Risk factors for ADD &/or ADHD
- Interaction of genetic, biologic, environmental
- Prenatal exposures
- No single gene located at this time
157
Clinical manifestations for ADD / ADHD
- Decreased attention span
- Impulsiveness
- And/or increased motor activity
158
Diagnoses ADD / ADHD
| -History
- Family history
- Birth history
- Growth and developmental milestones
159
Diagnoses ADD / ADHD
| Behaviors
- Sleep, eating patterns
| - Progression, behaviors in school
160
Diagnoses ADD / ADHD
| Social, environmental conditions
Reports from parents, teachers
161
Frequently diagnosed after beginning school
Often brought in when behaviors interfere with daily functioning of teachers, parents
Diagnostic criteria
Inattention
Hyperactivity
impulsivity
ADD / ADHD
162
Medications for moderate to severe ADD/ADHD
Ritalin
Adderall
Strattera
163
Environmental Support for ADD / ADHD kids
- Decreasing stimulation
- Orderly environment
- Behavioral support
- Reward child for desired behaviors
- Applying consequences for undesirable behaviors
164
What is this an example of:
Family and birth history
Developmental testing
Observation of child
Nursing Assessment
165
```
What is this an example of:
Impaired Verbal Communication
Impaired Social Interaction
Chronic Low Self-Esteem
Risk for Injury
Risk for Caregiver Role Strain
```
Nursing Diagnosis
166
```
What is this an example of:
-Discourage regular television, encourage physical activity for young children
-Hospitalized child
Administering medications
Manage environment
Implementing behavioral management plan
Emotional support
Promoting self-esteem
Ensuring ongoing care
```
Nursing Plan
167
```
What is this an example of:
Administer medications
Minimize environmental distractions
Implement behavioral management plans
Provide emotional support
Promote self-esteem
```
Nursing Implementation
168
What is this an example of:
Parents, child demonstrate understanding
Family accurately, safely manages medication administration
Child demonstrates increased attentiveness, decreasing hyperactivity
Child displays formation of positive self-image
Nursing Evaluation
169
Autistic Spectrum Disorders (ASDs)
| Autism, Asperger syndrome & PDD (pervasive developmental disorder).
-impairments in language, cognition & social skills that make them seem different than others.
170
Risk factors for ASDs
- Fetal Alcohol Syndrome (FAS)
- Fragile X syndrome
- Phenylketonuria (PKU)
- Down syndrome
- Environmental factors
171
Pervasive developmental disorders (PDDs)
-Impaired social interactions & communication - -restricted interests, activities & behaviors
172
Clinical Manifestations
- Impairments in social interactions
- Communication
- Difficulties and delays
- Abnormal communication patterns
173
What nursing stage is this an example of:
- No babbling or communication gestures by 12 months
- No single word by 16 months
- No spontaneous two words by 24 months
- Loss of language or social skills previously achieved
- History
Nursing Assessment
174
```
What nursing stage is this an example of:
Child will
Remain free of injury
Acquire communication strategies
Perform self-care
Demonstrate developmental progress
Participate in small group activities
```
Nursing Plan
175
```
What nursing stage is this an example of:
Stabilize environmental stimuli
Provide supportive care
Enhance communication
Maintain a safe environment
Provide anticipatory guidance
```
Nursing Implementation
176
Stereotypy
rigid, obsessive behavior. Repetitive behaviors include: head banging, biting themselves, twirling in circles.
This is often self-stimulating or self-distructive.
177
Echolalia
compulsive parroting of a word or phrase just spoken by another.
178
A syndrome in which an infant falls below the fifth percentile for wight and height on a standard growth chart or is falling in percentiles on a growth chart.
Failure to Thrive
179
Risk factors for failure to thrive:
- Infants deprived of mothering
- Parental depression
- Substance abuse
- Mental retardation
180
Clinical Manifestations of failure to thrive:
- Persistent failure to eat adequately
| - No weight gain/weight loss in child < 6 years
181
Collaboration for failure to thrive
- Thorough history
| - Physical examination
182
Nursing assessment for failure to thrive
- Physical assessment: Measurements, Percentiles
- History: Stressors in parents lives, Ask about pregnancy and birth
- Observe behaviors when parents feed child
183
Flat, macule, vascular lesion, non-blanchable, hemorraged tissue, emboli (trauma to long bone, fatty stuff released into system and causes fatty pulmonary emboli) - may see if someone has low platelet count, meningial, Rocky Mountain spotted fever.
Petichiae
184
tumor, soft & yellow, lipoprotiens and cholestrol in them.
Xanthoma
185
- Benign - Fatty tumor.
Lipoma
186
Lesions
- Primary
- Secondary
- Vascular
- Primary - original skin issue.
- Secondary - happens after the primary stage.
- Vascular - related to blood vessel integrity.
187
medication caused scar, at IV site. Under the skin.
Extravasation
188
Related to severe illness, then grows out and leaves a ridge, is on multiple fingers.
Beau's Line
189
Club nail -
finger has club like appearance r/t COPD - hypoxia caused.
190
Phases of healing:
1. Hemostasis - vasoconstrict, platelet release, clot formation
2. Inflammation
3. Proliferation
4. Maturation
