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Management Of Nursing Care > Integumentary System > Flashcards

Integumentary System Flashcards

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1
Q

What is the largest organ?

A

The skin

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2
Q

What are the 4 techniques used by nurses in physical assessment?

A

Inspection, Percussion, Palpation, and Auscultation.

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3
Q

What kind of information can the skin provide us with?

A

Changes in oxygenation, circulation, tissue damage, hydration, mental issues. Ect

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4
Q

What kind of information can the skin provide us with?

A

Systemic problems, and self-care abilities.

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5
Q

What are some examples of systemic skin problems?

A

Impaired circulation, respiratory disorders, endocrine imbalance, and allergies.

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6
Q

What are some examples of self care abilities related to skin?

A

Hygiene, excercise, and maintenance could be related to mental health.

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7
Q

What is the biggest endocrine system in the human body?

A

The pancreas

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8
Q

What can nails help us with?

A

Assessing a persons mental and physical health.

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9
Q

When do we assess the skin?

A

During comprehensive assessments, when a concern is present, an injury, during hygiene cares, beginning of shift, and when assessing health status.

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10
Q

What is cyanosis?

A

A bluish discoloration of the skin due to poor circulation or inadequate oxygenation of the blood.

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11
Q

Which nursing techniques are most important when assessing skin, hair, and nails?

A

Inspection and pal-station.

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12
Q

When do we wear sterile gloves?

A

Only during important procedures such as surgery or inserting catheters ect

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13
Q

What are some examples of subjective data when assessing skin? (6)

A

Problems/conditions, current symptoms (past family history), lifestyle, practices.

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14
Q

What does COLDSPA stand for?

A

COLDSPA. Definition. Character, Onset, Location, Duration, Severity, Pattern, Associated Factors / How it Affects the client.

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15
Q

What is Parkinson’s disease?

A

Nerve cell damage in the brain causes dopamine levels to drop, leading to the symptoms of Parkinson’s.
Parkinson’s often starts with a tremor in one hand. Other symptoms are slow movement, stiffness and loss of balance.

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16
Q

What is subjective data?

A

Subjective data are information from the client’s point of view (“symptoms”)

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17
Q

Define short term memory loss?

A

Short-term memory loss is when you forget things you heard, saw, or did recently.

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18
Q

True or False? Family are apart of the patient

A

True

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19
Q

What’s important when preforming a physical examination?

A

Preparing the patient - aka getting informed consent, positioning, privacy, protection, and equipment.

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20
Q

What’s involved in positioning of a patient?

A

Ensuring they are in a position that helps for an examination but that is comfortable and warm for the patient.

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21
Q

What equipment should you have when preforming a skin assessment?

A

Gloves, and alcohol based hand rub (or you are frequently washing your hands), an examination light / penlight, a centimetre ruler, and an examination gown and drape.

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22
Q

What are the key assessment points of skin assessment?

A

Skin colour, temp, moisture, and texture. Skin integrity. Skin lesions. Hair condition. And nail condition (capillary refill)

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23
Q

What’s involved in a basic skin inspection?

A

Distinctive odour, colour variations, skin breakdown, primary, secondary or vascular lesions, and level of moisture.

24
Q

What is skin integrity?

A

Overall skin health

25
Q

What is involved in a colour variation skin inspection?

A

General colour and pigmentation, general appearance, smooth - moles - acne - hair growth, consistent with genetic backround, lips and conjunctivia- sclera (jaundice), increased areas of pigmentation.

26
Q

What is normal pigmentation?

A

Light pink to brown or olive

27
Q

What is involved in a lesions skin inspection?

A

ABCDE. Asymmetry (pattern), Border irregularity, Colour variation, Diameter, Elevation.

28
Q

Why do we use a ruler?

A

To assess the size of abnormalities on the skin.

29
Q

What do we look at when inspecting for skin integrity?

A

Nutrition, tissue perfusion, infection, and age.

30
Q

What do we look at when inspecting for skin integrity?

A

Nutrition, tissue perfusion, infection, and age, signs of pressure injury.

31
Q

What risk assessment scales may we use when inspecting skin integrity?

A

Braden or water low scale.

32
Q

What are pressure ulcer risk factors?

A

Perception, Mobility, moisture, nutrition, friction or shear, and decreased tissue tolerance.

33
Q

What are the common pressure injury sites of someone in the posterior position? (10)

A

Occipital prominence (neck), Spinous process (upper spine), scapula, elbow, iliac crest (lower left back), sacrum (just above anus), lschium (butt) Achilles’ tendon, heel, and sole.

34
Q

What is the posterior position?

A

Standing

35
Q

What is the lateral position?

A

Laying on side

36
Q

What is the prone position?

A

Laying tummy down

37
Q

What are nursing interventions for pressure injury’s?

A

Ensure dry clear moisturised skin, 2 hourly position changes, 2 hourly skin checkups (at pp), relief aids, avoid friction during transferring, and insure healthy diet/fluid intake.

38
Q

What do we look at in terms of texture and thickness of the skin?

A

Whether the ski is rough/smooth, thin/thick/fragile, or scaliness.

39
Q

How do you determine skin texture?

A

Stroke the skin lightly with fingertips.

40
Q

What should normal skin texture feel like?

A

Smooth, soft, and flexible.

41
Q

True or false, texture is different in parts of the body.

A

True it can be for example comparing thickness of feet to hands.

42
Q

How should you assess temperature differences?

A

Using the back of your hand assessing changes of upper / lower limbs and opposing limbs.

43
Q

What may localised heat indicate?

A

Inflamination or infection

44
Q

What may coldness indicate?

A

Decreased blood flow

45
Q

How do you palpate for turgor/elasticity?

A

You gently pinch the skin under the clavicle or sternum and then release. (In elderly use skin on back near clavicle)

46
Q

What is a normal result when palpating for turgor/elasticity?

A

You will see the skin easily move back to its place

47
Q

If the skin is dehydrating what will happen during a turgor/elasticity palpate?

A

It will not return so easily and it will usually tent

48
Q

How do you palpate for oedema?

A

Press firmly for 5 seconds with the thumb and release?

49
Q

What is pitting oedema?

A

Pitting edema is when a swollen part of your body has a dimple (or pit) after you press it for a few seconds. It can be a sign of a serious health issue.

50
Q

What is non pitting oedema?

A

accumulation of excess fluid in soft tissues, causing swelling

51
Q

How do you palpate for tenderness?

A

Palpate lightly and watch for facial expressions.

52
Q

The accumulation of fluid in intercellular space is what?

A

Not normal.

53
Q

What is oedema?

A

a condition characterized by an excess of watery fluid collecting in the cavities or tissues of the body.

54
Q

What does the palpating of capillary refill test for?

A

The circulation of the periphery

55
Q

When palpating capillary refill what are you looking for?

A

Colour returning in the nail bed

56
Q

How quick should your nail return to pink in a good capillary refill?

A

1-2 seconds

Management Of Nursing Care (10 decks)

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