Nursing test three Flashcards
What does what’s up stand for
Where is it. How does it feel. Aggravating and alleviating factors. Timing. Severity. Useful other data. Patient's perception.
What are some signs of aging in the integumentary system
Hair becomes gray and thin. Skin becomes thinner and more fragile. Healing is slower. Wrinkles develop. Temperature becomes harder to regulate. Skin becomes dry.
Subjective assessment information
History of skin disorders. Risk factors. Hair and nails. Medications. Exposures. WHAT’S UP
Physical assessment information of integumentary system
Inspection and palpitation. Color. Lesions. Moisture. Edema. Vascular markings. Integrity. Cleanliness
Define turgor
Tension
Things to consider when doing a hair assessment
Color, quantity, thickness, texture, alopecia
Things to consider when doing a nail assessment
Color, shape, texture, thickness, abnormalities
Define lesion
Any change or injury to tissue
Define petechiae
Reddish purple reddish spots that are smaller than .5 mm in diameter
Define ecchymosis
A bruise that changes from blue, black to greenish brown, or yellow overtime
Define macule. Primary lesion
Flat, nonpalpable change in skin color, with different sizes, shapes, color. Rubella, scarlet fever, freckles
Define papule. Primary lesion
Palpable solid raised lesion that is less than 1 cm in diameter due to superficial thickening in the epidermis. Ringworm, wart, mole
Define nodule. Primary lesion
Solid elevated lesion that is larger and deeper then papule. Fibroma, intradermal Nevi
Define vesicle. Primary lesion
A small, blister like raised area of the skin that contains serious fluid, up to 1 cm in diameter. Poison ivy, shingles, chickenpox
Define bulla Primary lesion
A fluid filled vesicle for blister larger than 1 cm. Burns, contact dermatitis
Define pustule. Primary lesion
Small elevation of skin or vesicle or bulla that contains lymph or pus. Impetigo, scabies, acne
Define wheal. Primary lesion
Round, transient elevation of the skin caused by dermal edema and surrounding capillary dilation. White in Center and red around. Hives, insect bite
Define plaque. Primary lesion
patch or solid, raised lesion on the skin or mucous membranes that is greater than 1 cm in diameter. Psoriasis
Define cyst. Primary lesion
closed sac or pouch which consist of semisolid, solid, or liquid material. Sebaceous cyst
Define scale. Secondary lesion
Dry exfoliation of dead epidermis that may develop as a result of inflammatory changes. Very dry skin, cradle cap, psoriasis
Define crust. Secondary lesion
Hey scab formed by dry soon, plus, or blood. Infected dermatitis, impetigo
Define excoriation. Secondary lesions
Traumatized abrasions of the epidermis or linear scratch marks. . Scabies, dermatitis, Burns
Define fissure. Secondary lesion
A split or crack like sore that extends into dermis, usually due to continuous inflammation and drying. Athletes foot, anal fissure
Define ulcer. Secondary lesion
An open sore or lesion that extends to the dermis. Pressure sores
Define lichenification. Secondary lesion
Thickening and hardening of skin from continuing irritation such as From intense scratching
Define scar. Secondary lesion
Mark left in the skin due to fibrotic changes following healing of a wound or surgical incision
Explain woods light examination
Involves the use of ultraviolet rays to detect fluorescent materials in the skin and hair present in certain diseases such as Ringworm. Performed with a handheld black light in a dark room
Which protein in epidermal cells makes the skin relatively waterproof
Keratin.
What are the functions of subcutaneous tissue
cushions bony prominences. It provides insulation. stores energy.
What are risk factors for pressure ulcers
Immobility, impaired circulation, impaired sensory perception, elderly, very thin or obese
Ways to prevent pressure ulcers
Asses daily, cleanse and dry daily, lubricate daily, using moisture barrier, do not massage red areas, shift weight every 15 minutes
What is the Braden scale
An instrument used to find all risk factors associated with the development of pressure ulcers. Assesses sensory perception, activity, mobility, nutrition, friction and shear
When it comes to pressure ulcers, how can they be described according to the three colors system
Black wounds indicate necrosis.
Yellow may be infected.
Red wounds are pink or red and are in the healing stage
What are the different types of debridement
Mechanical, enzymatic, autolytic, surgical
Describe a stage one ulcer
An area of red, deep pink, or molted skin that does not Blanche with fingertip pressure. In people with darker skin discoloration of the skin, warm, edema, or induration maybe signs
Describe stage to ulcer
Partial thickness skin loss involving epidermis and or dermis. It may look like an abrasion, a blister, or a shallow crater. The area surrounding the damage skin may feel warmer.
Describe a stage III ulcer
Full thickness skin loss that looks like a deep crater and may extend to the fascia. Subcutaneous tissue is damaged or neurotic. Bacterial infection of the ulcer is common and causes drainage from the ulcer. There maybe damage to the surrounding tissue
Describe stage lV Ulcer
Full thickness skin loss with extensive tissue necrosis or damage to muscle, bone, or supporting structures. The ulcer may appear dry and black, with a buildup of tough neurotic tissue or it can appear wet and oozing
define pallor cyanosis, jaundice, erythema and what they indicate
pallor=loss of color=anemia or lack of blood flow
cyanosis=bluish=hypoxia or impaired venous return
jaundice=yellow=liver dysfunction, red blood cell destruction
erythema=redness=inflammation
describe serous drainage
portion of the blood (serum) that is watery and clear or slightly yellow in appearance
describe sanguineous drainage
contains serum and red blood cells. it is think and appears reddish
describe serosaguineous draingage
contains both serum and blood. it is watery and appears blood-streaked or blood tinged
describe purulent drainage
result of an infection. it is think and contains white blood cells, tissue debris, and bacteria. maybe have a foul odor and its color reflects the type of organism present
what interventions do you take for a suspected deep tissue injury and stage 1 ulcer
relieve pressure encourage frequent turning/repositioning use pressure-relieving devices implement pressure-reduction surfaces keep clients dry, clean, well-nourished, and hydrated
what interventions are taken for a stage II ulcer
maintain a moist healing environment
promote natural healing while preventing the formation of scar tissue
provide nutritional supplements as prescribed
administer analgesics as prescribed
what interventions are taken for stage III ulcers
clean and/or debride prescribed dressing surgical intervention proteolytic enzymes provide nutritional supplements as prescribed administer analgesics as needed administer antimicrobials as prescribed
what interventions are taken for a stage IV ulcer
clean and/or debride
perform nonadherent dressing changes every 12 hours
treatment may include skin grafts
provide nutritional supplements as prescribed
administer analgesics as prescribed
administer antimicrobials as prescribed
what are interventions taken for an unstageable ulcer
eschar should cover wound s protective barrier
provide nutritional supplements as prescribed
administer analgesics as prescribed
administer antimicrobials as prescribed
after discharge-client education about wound care
instruct clients how to perform wound care
encourage to eat a diet high in protein and vegetables to promote wound healing
encourage to take vitamins and supplements to promote wound healing
remind clients to keep skin clean and dry
remind clients to report any signs of infection or further skin breakdown
in wounds, what are signs of infection (sepsis) that need to be monitored
level of consciousness persistent recurrent fever tachycardia tachypnea hypotension oliguria increased WBC
what is the difference between dehiscence and eviscertaion
dehiscence is a partial or total rupture of a sutured wound, usually with separation of underlying skin layers.
evisceration is a dehiscence that involves the protrusion of visceral organs through a wound opening
define psoriasis
a skin disorder that is characterized by scaly, dermal, patches and is caused by an overproduction of keratin. thought to be autoimmune disorder
define seborrheic dermatitis
a skin disorder caused by inflammation of areas of the skin that contain a high number of sebaceous glands. characterized by papulopustules (oily form) or flaky plaques (dry form) that form on the surfaces of the skin. dandruff is a type.
risk factors for psoriasis
genetics
stress
seasons
hormones
medications used for psoriasis
topical corticosteroids (kenalog) tar preparations topical epidermopoiesis suppressive medications(dovonex) cytotoxic medications (mexate)
therapeutic procedures for treating psoriasis
ultraviolet light A
oil or coal tar baths
risk factors for seborrheic dermatitis
genetics
stress
hormones
older adults can develop seborrheic keratoses, which are more plaque-like in appearance
physical findings in seborrheic dermatitis
waxy or flaky-appearing plaques and/or scales
skin lesions primarily on the oily areas of the body (scalp, forehead, nose, axilla, groin)
lesions may be pigmented tan, brown, or black
medications used for caring for seborrheic dermatitis
topical corticosteroids-reduces secondary inflammatory response of lesions
antiseborrheic shampoos-contain selenium, sulfur, or salicylic acid
what is the leading cause of skin cancer
sunlight exposure
what are precancerous skin lesions called
actinic keratoses
what are the three types of skin cancer
squamous cell carcinoma=cancer of the top layer of the epidermis that can be localized, but it may metastasize to other tissues and organs
basal cell carcinoma=cancer of the basal cell layer. can damage surrounding tissue and can advance to include underlying structures. usually not metastatic
malignant melanoma=aggressive, metastatic cancer that originates in the melanin-producing cells of the epidermis
health promotion and disease prevention of skin cancer. advise clients to do what
limit exposure to sunlight
use sunblock with APF of at least 15 with both UVA and UVB
wear protective clothing
avoid tanning beds/equipment
examine body monthly for suspicious lesions
risk factors of developing skin cancer
exposure to ultraviolet light
chronic skin irritation and burn scars
fair complexion with tendency to burn easily
presence of several large or many small moles
family or personal history of melanoma
living in locations in upper elevations or close to equator
what are the ABCD’s of suspicious skin cancer lessions
Asymmetry-one side does not match the other
Borders-ragged, notched, irregular or blurred edges
Color-lack of uniformity in pigmentation (shades of tan, brown, or black)
Diameter-width greater than 6mm or about the size of a pencil eraser
What are the three phases of wound healing
Inflammatory phase. Proliferation or reconstruction phase. And then maturation Or remodeling phase
