Module 3 Integumentary Flashcards
What are the 6 vital signs
Temperature, height, weight, respirations, pulse, BP
What guideline does a patient have to have to be able to delegate a vital sig to somebody else?
The patient has to be stable
What is temperature regulated by?
The hypothalamus in the brain
What is the average temp?
98.6
What is the normal range of a temperature?
96.4- 100.4
If a patient has drank water recently or smoked how long should you wait to take it
15min or more
What is the most invasive technique of taking a temperature
Rectal
What is the least invasive way of taking a core temp?
Tympanic
Exercise, gender, circadian rhythm, age, and environment are examples of
Normal variations of temp alterations
Fever, hypothermia (low), hyperthermia (high), heatstroke, heat exhaustion are examples of
Abnormal temp alterations
What is pyrexia?
Fever
Your patient has a temp of 101.4 should you treat with antipyretics?
No, you only treat a patient with antipyretics if their temp is 102.2 or higher unless ordered by physician
What to antipyretics do?
Reduce fever by lowering the body’s set point temp in hypothalamus ex. Tylenol, ibprophen, aspirin
What are some fx’s of the skin?
Protection, temp regulation, identification, communication, wound repair, absorption, excretion, produce vitamin d
What question could you ask a patient to give subjective data bailout their skin?
Have you noticed any changes with your skin?
What health history topics should you ask about pertaining to a patients skin?
If they have a chronic disease, changes in color, rashes, excessive moisture or dryness, swelling (lymphedema), sun protection , medication, smoking
What is skin integrity?
How intact or strong the skin is
During assessment of the skin what should you analyze the color of the skin based off of?
General pigmentation, localized bruising, any widespread color change
What are the 4 types of widespread color changes?
Pallor- when skin has lack of color, can look pale, grey, or more yellow-vasoconstriction
Cyanosis- cause by lack of oxygen in the blood- blue or purple
Jaundice- yellowing of skin caused by increase in bilirubin from liver disease
Erythema- redness of skin caused by increase in temp or allergic rx- vasodilation
What is the difference between cyanosis and pallor
Cyanosis is caused by lack of oxygenated blood throughout the body
Pallor is caused by lack of oxygenated blood coming to to them surface of the skin
What side of hands should your palpate with
Dorsa (back of hand)
Hypothermia vs hyperthermia
Cold vs hot
Your patient has a high temp and while assessing their skin you very most all throughout this is an example of
Diaphoresis
When testing the skin turgor, where should you tent the skin?
Collarbone or sternum, NOT back of hand
When you test skin turgor how long should it take for the skin to fully release?
3’s, 4s for elderly
what does turgor test?
Elasticity and hydration of skin
Edema
Swelling of skin
Macule
Flat, circumscribed, color change- freckles
Papule
Solid,elevated, circumscribed- raised mole
Nodule
Solid, elevated, extends into dermis- cyst
Tumor
Firm soft deep into dermis- > 2-3 cm
Wheal
Superficial raised, irregular erythematous, Irregular- allergic rxn, hives
Vesicle
Elevated filled with clear serum- herpes, chicken pox
Pustule
Pus filled cavity, circumscribed, elevated- pimple
Ulcer
Deep loss of skin surface that extends to dermis, frequently bleeds
Atrophy
Thinning of skin with loss, skin appears shiny or translucent
What method can you use to determine abnormal malignant skin lesion
A- asymetrical
B-boarders
C-color
D-diameter-6mm
E- elevated
You are doing a physical assessment of your patients nails and notice their nail bed profile is distorted with an angle of more than 108 degrees. What is the called what causes it?
Clubbed fingers, cause by hypoxia
When testing capillary refill, how long should it take for patients to nail bed to turn red again?
3s, 4 for elderly
What factors contribute to a patients hygiene practices?
Culture and age
Hygiene is routine true or false
False- hygiene routines are specific rot the patient depending on their culture age, beliefs, and physical/ mental status
You notice when your patient tried to sit up in bed it is a struggle and cannot complete task without assistance , it is hard for them to breathe and they get very light headed. This is an example of
Activity intolerance
A nurse is caring for a patient who has been diagnosed with activity intolerance due to heart failure. Which of the following is the most important intervention to promote activity tolerance in this patient?
A) encourage the patient to rest in bed all day
B) assess the patients vital signs before during and after any activity
C) provide a high calorie diet to promote energy levels
D) encourage patient to perform deep breathing exercises everyday
B- monitoring patients vitals signs helps determine the patients tolerance to activity and ensures that any potential adverse reaction are addressed promptly
A nurse is caring for a patient with a bathing self care deficit due to recent hip surgery. Which interventions would be most appropriate to assist this patient?
A) encourage the patient to take a full shower independently
B) offer the patient a bed bath while maintain privacy and comfort
C) Instruct the patient to avoid bathing until they are completly healed
D) perform the entire bathing task for the patient to prevent discomfort
B- allows for hygiene while considering their limitations and promoting independence
