FoN Exam 2 Flashcards
What are the main components of the integumentary system?
Skin, hair, nails, sweat and sebaceous glands
The integumentary system is the body’s largest organ system.
What is the primary function of the epidermis?
Protection, sensation, and temperature regulation
The epidermis is the outermost layer of skin and does not contain blood vessels.
What is the role of melanocytes in the skin?
Secrete melanin, the main determinant of skin color
Melanocytes are located in the bottom layer of the epidermis.
List the functions of the skin.
- Protection
- Sensation
- Temperature regulation
- Excretion (sweat) and secretion (sebum)
The skin serves multiple essential functions for the body.
True or False: Mucous membranes are considered part of the integumentary system.
False
Mucous membranes are part of the respiratory tract and line cavities that open to the outside.
What factors influence personal hygiene practices?
- Socioeconomic background
- Economic status
- Knowledge level
- Ability to perform self-care
- Personal preferences
- Cultural differences
These factors can significantly affect hygiene behaviors.
Which areas of the skin are most susceptible to pressure injuries?
Joints, high-pressure areas or areas often bearing weight
Particularly relevant for bed-bound or wheelchair-bound patients.
List risk factors for altered skin integrity.
- Immobility
- Incontinence
- Maceration
- Diaphoresis
- Inadequate nutrition
- Lowered mental awareness
- Excessive diaphoresis
- Extreme age
- Edema
These factors can lead to skin breakdown and pressure injuries.
Describe Stage 1 of pressure injuries.
Area of reddened skin that does not blanch when touched
May show discoloration in individuals with dark skin.
What is the significance of the Braden Scale?
Predicts pressure sore risk
The Braden Scale is used to assess patients upon admission.
What is the primary method for preventing pressure injuries?
Excellent nursing care
Awareness of risk factors and regular skin assessments are crucial.
What is a therapeutic bath?
A bath having healing or medicinal qualities
This type of bath may include whirlpool or sitz baths.
Fill in the blank: A _______ bath uses pre-moistened disposable cloths.
Bag
This bath type is convenient but has a cost disadvantage.
What special considerations should be taken for older patients during bathing?
- Use warm water, not hot
- Minimize soap use (alternate days)
- Prewarm the bath area
- Provide adequate draping
- Prevent slips and falls
Because of decreased sweat and sebaceous gland activity, a full bath is not needed every day.
What is the purpose of a back rub?
Communicates caring, fosters trust, and stimulates circulation
Back rubs should be performed during morning care and at bedtime.
What is the recommended frequency for mouth care in an unconscious patient?
At least once every 8 hours
If the patient is mouth-breathing, care should be done every 4 hours.
What should be done before contacting a primary care provider by telephone?
- Have patient data on hand
- Keep chart handy
- Know patient allergies
- Prepare a concise problem statement
These steps ensure effective communication.
What are the components of the communication process?
Sending a message, receiving it, processing it, and indicating interpretation
Communication can be verbal or nonverbal.
List three blocks to communication.
- Changing the subject
- Offering false reassurance
- Making defensive comments
These blocks can hinder effective communication.
What distinguishes a therapeutic nurse-patient relationship from a social relationship?
Defined boundaries based on the patient’s problems and the nurse’s role
The therapeutic relationship ends when the patient is discharged.
How can a nurse effectively delegate tasks?
- Give clear, concise messages
- Include desired results and timelines
- Ask for feedback and understanding
- Ensure tasks are completed
Effective delegation improves patient care and team efficiency.
What is the purpose of using computers in healthcare communication?
- Transmitting requests for services
- Medication orders
- Updating patient care plans
Computers are essential for efficient communication in healthcare settings.
What is essential for today’s nurse in terms of communication?
The ability to use a computer for communication.
List five ways the computer is used for communication within the healthcare agency.
- Transmit requests for laboratory services
- Medication orders
- Supplies for patient care
- Update patient care plans
- Computerized form of charting
What are the purposes of patient education?
- Preventing illness or promoting wellness
- Teaching patients about their disease or disorder, diet, medications, treatment, and self-care
- Preparing patients for self-care at home before discharge
- Starting patient teaching at the time of admission
- Assessing learning needs and forming a teaching plan
What is one overarching goal of Healthy People 2030?
Attain healthy, thriving lives and well-being free of preventable disease, disability, injury, and premature death.
Describe three ways in which people learn.
- Visual learning: Through what they see
- Auditory learning: Through what they hear
- Kinesthetic learning: By actually performing a task or handling items
List factors that can affect learning.
- Physical limitations
- Situational factors (including pain)
- Readiness to learn
- Personal values and expectations
- Age
- Attitude
- Ability to comprehend
What environmental factors can affect learning?
- Room temperature
- Noise level
- Lighting
- Interruptions by others
What are some barriers to teaching and learning?
- Poor vision or hearing
- Impaired motor function
- Impaired cognition
- Personal stress
- Illness
- Low literacy
- Lack of support
What adjustments should be made for teaching older adults?
- Provide good lighting
- Use written materials with large type
- Ensure glasses are clean
- Check hearing aids are functioning
- Use short sentences and speak slowly
- Minimize medical terms and explain those used
- Frequently check for comprehension
- State important points first and repeat them
What types of resources are available to assist in patient education?
- Books and articles
- Audiovisual materials
- Pamphlets
- Hands-on equipment
- Closed circuit TV patient education modules
- Community educational tools
- Local government program listings
- Nursing specialists
- Hospital social workers and patient representatives
Name three things that must be included in the documentation of patient education.
- Specific content taught
- Method of teaching used
- Evidence of evaluation with specific results
How can patient education continue after hospital discharge?
Patients need to receive written or printed information about what has been taught.
The two main layers of the skin are:
the epidermis (thin outer layer) and dermis (thicker inner layer)
The epidermis (outer, thinner layer) consists of ____ tissue and does not contain blood vessels.
stratified squamous epithelial
It receives its nutrition by diffusion from vessels in the underlying tissues.
The uppermost layer of the epidermis is called the
stratum corneum
The dermis (inner, thicker layer) is made of dense connective tissue that gives the skin strength and elasticity. It is also called the ____.
corium
The dermis contains ____; the nails are derived from the epidermis. Fibroblasts produce new cells to heal skin after injury.
- blood vessels
- nerves
- fibroblasts
- the base of hair follicles
- glands
Hair and nails are made of ____ and do not have nerve endings or a blood supply.
keratin
Excretion (sweat) includes:
- Sweat glands help maintain the homeostasis of fluids and electrolytes
- Sweat glands: organs of excretion, secrete nitrogenous waste
- Sweat glands in axillae and external genitalia secrete fatty acids and proteins
Secretion (sebum) includes:
*Sebum lubricates the skin and hair
* Sebum keeps structures pliable and elastic
* Sebum decreases heat loss
* Sebum decreases bacterial growth
Loss of full thickness of tissue. The base of the injury is covered by eschar (tan, brown, or black) in the wound bed, or the base of the injury contains slough (yellow, tan, gray, green, or brown).
Unstageable Pressure Injury
Localized discolored intact skin that is maroon or purple or a blood-filled blister resulting from damage to underlying soft tissue from pressure or shearing. The area may be painful, firm, mushy, boggy, warmer, or cooler when compared to adjacent tissue.
Deep Tissue Pressure Injury
An area that feels hard
Induration
Necrotic tissue
When eschar is present, the pressure injury is described as unstageable.
Eschar
Eschar must be removed to stage the pressure injury properly.
Partial-thickness skin loss. May look like an abrasion, blister, or shallow crater; surrounding skin may feel warmer
Stage 2
Full-thickness skin loss. Looks like a deep crater; may extend into the fascia; subcutaneous tissue damaged or necrotic.
Stage 3
Full-thickness skin loss with extensive tissue necrosis or damage to muscle or supporting structures. May appear dry and black.
Stage 4
Applies moist heat and cleansing to perineal area; medication may be added to water. Used for wounds (post-operative, OB, rectal pain, etc.).
Sitz bath
type of therapeutic bath
A special whirlpool tub used to cleanse and stimulate peripheral circulation
Whirlpool bath
type of therapuetic bath
May be used to bring down fevers
Sponge bath
type of therapuetic bath
Nail care:
- Trimming, cleaning under the nails, and cuticle care usually done with the bath
- Soak the nails in warm soapy water
- Use an orangewood stick to clean under nails
- Push cuticles back gently
- Use nail clippers to cut toenails straight across
- Make sure to use acetone-free nail polish remover– when needed
Rub hands together for ____ seconds OR until ____ when using hand sanitizer.
20, dry
