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Nursing test three Flashcards

0
Q

What does what’s up stand for

A 
Where is it.
How does it feel. 
Aggravating and alleviating factors.
Timing. 
Severity. 
Useful other data. 
Patient's perception.
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1
Q

What are some signs of aging in the integumentary system

A

Hair becomes gray and thin. Skin becomes thinner and more fragile. Healing is slower. Wrinkles develop. Temperature becomes harder to regulate. Skin becomes dry.

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2
Q

Subjective assessment information

A

History of skin disorders. Risk factors. Hair and nails. Medications. Exposures. WHAT’S UP

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3
Q

Physical assessment information of integumentary system

A

Inspection and palpitation. Color. Lesions. Moisture. Edema. Vascular markings. Integrity. Cleanliness

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4
Q

Define turgor

A

Tension

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5
Q

Things to consider when doing a hair assessment

A

Color, quantity, thickness, texture, alopecia

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6
Q

Things to consider when doing a nail assessment

A

Color, shape, texture, thickness, abnormalities

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7
Q

Define lesion

A

Any change or injury to tissue

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8
Q

Define petechiae

A

Reddish purple reddish spots that are smaller than .5 mm in diameter

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9
Q

Define ecchymosis

A

A bruise that changes from blue, black to greenish brown, or yellow overtime

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10
Q

Define macule. Primary lesion

A

Flat, nonpalpable change in skin color, with different sizes, shapes, color. Rubella, scarlet fever, freckles

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11
Q

Define papule. Primary lesion

A

Palpable solid raised lesion that is less than 1 cm in diameter due to superficial thickening in the epidermis. Ringworm, wart, mole

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12
Q

Define nodule. Primary lesion

A

Solid elevated lesion that is larger and deeper then papule. Fibroma, intradermal Nevi

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13
Q

Define vesicle. Primary lesion

A

A small, blister like raised area of the skin that contains serious fluid, up to 1 cm in diameter. Poison ivy, shingles, chickenpox

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14
Q

Define bulla Primary lesion

A

A fluid filled vesicle for blister larger than 1 cm. Burns, contact dermatitis

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15
Q

Define pustule. Primary lesion

A

Small elevation of skin or vesicle or bulla that contains lymph or pus. Impetigo, scabies, acne

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16
Q

Define wheal. Primary lesion

A

Round, transient elevation of the skin caused by dermal edema and surrounding capillary dilation. White in Center and red around. Hives, insect bite

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17
Q

Define plaque. Primary lesion

A

patch or solid, raised lesion on the skin or mucous membranes that is greater than 1 cm in diameter. Psoriasis

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18
Q

Define cyst. Primary lesion

A

closed sac or pouch which consist of semisolid, solid, or liquid material. Sebaceous cyst

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19
Q

Define scale. Secondary lesion

A

Dry exfoliation of dead epidermis that may develop as a result of inflammatory changes. Very dry skin, cradle cap, psoriasis

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20
Q

Define crust. Secondary lesion

A

Hey scab formed by dry soon, plus, or blood. Infected dermatitis, impetigo

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21
Q

Define excoriation. Secondary lesions

A

Traumatized abrasions of the epidermis or linear scratch marks. . Scabies, dermatitis, Burns

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22
Q

Define fissure. Secondary lesion

A

A split or crack like sore that extends into dermis, usually due to continuous inflammation and drying. Athletes foot, anal fissure

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23
Q

Define ulcer. Secondary lesion

A

An open sore or lesion that extends to the dermis. Pressure sores

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24
Q

Define lichenification. Secondary lesion

A

Thickening and hardening of skin from continuing irritation such as From intense scratching

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25
Q

Define scar. Secondary lesion

A

Mark left in the skin due to fibrotic changes following healing of a wound or surgical incision

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26
Q

Explain woods light examination

A

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

27
Q

Which protein in epidermal cells makes the skin relatively waterproof

A

Keratin.

28
Q

What are the functions of subcutaneous tissue

A

cushions bony prominences. It provides insulation. stores energy.

29
Q

What are risk factors for pressure ulcers

A

Immobility, impaired circulation, impaired sensory perception, elderly, very thin or obese

30
Q

Ways to prevent pressure ulcers

A

Asses daily, cleanse and dry daily, lubricate daily, using moisture barrier, do not massage red areas, shift weight every 15 minutes

31
Q

What is the Braden scale

A

An instrument used to find all risk factors associated with the development of pressure ulcers. Assesses sensory perception, activity, mobility, nutrition, friction and shear

32
Q

When it comes to pressure ulcers, how can they be described according to the three colors system

A

Black wounds indicate necrosis.
Yellow may be infected.
Red wounds are pink or red and are in the healing stage

33
Q

What are the different types of debridement

A

Mechanical, enzymatic, autolytic, surgical

34
Q

Describe a stage one ulcer

A

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

35
Q

Describe stage to ulcer

A

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.

36
Q

Describe a stage III ulcer

A

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

37
Q

Describe stage lV Ulcer

A

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

38
Q

define pallor cyanosis, jaundice, erythema and what they indicate

A

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

39
Q

describe serous drainage

A

portion of the blood (serum) that is watery and clear or slightly yellow in appearance

40
Q

describe sanguineous drainage

A

contains serum and red blood cells. it is think and appears reddish

41
Q

describe serosaguineous draingage

A

contains both serum and blood. it is watery and appears blood-streaked or blood tinged

42
Q

describe purulent drainage

A

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

43
Q

what interventions do you take for a suspected deep tissue injury and stage 1 ulcer

A 
relieve pressure
encourage frequent turning/repositioning
use pressure-relieving devices
implement pressure-reduction surfaces
keep clients dry, clean, well-nourished, and hydrated
44
Q

what interventions are taken for a stage II ulcer

A

maintain a moist healing environment
promote natural healing while preventing the formation of scar tissue
provide nutritional supplements as prescribed
administer analgesics as prescribed

45
Q

what interventions are taken for stage III ulcers

A 
clean and/or debride
prescribed dressing
surgical intervention
proteolytic enzymes
provide nutritional supplements as prescribed
administer analgesics as needed
administer antimicrobials as prescribed
46
Q

what interventions are taken for a stage IV ulcer

A

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

47
Q

what are interventions taken for an unstageable ulcer

A

eschar should cover wound s protective barrier
provide nutritional supplements as prescribed
administer analgesics as prescribed
administer antimicrobials as prescribed

48
Q

after discharge-client education about wound care

A

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

49
Q

in wounds, what are signs of infection (sepsis) that need to be monitored

A 
level of consciousness
persistent recurrent fever
tachycardia
tachypnea
hypotension
oliguria
increased WBC
50
Q

what is the difference between dehiscence and eviscertaion

A

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

51
Q

define psoriasis

A

a skin disorder that is characterized by scaly, dermal, patches and is caused by an overproduction of keratin. thought to be autoimmune disorder

52
Q

define seborrheic dermatitis

A

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.

53
Q

risk factors for psoriasis

A

genetics
stress
seasons
hormones

54
Q

medications used for psoriasis

A 
topical corticosteroids (kenalog)
tar preparations
topical epidermopoiesis suppressive medications(dovonex)
cytotoxic medications (mexate)
55
Q

therapeutic procedures for treating psoriasis

A

ultraviolet light A

oil or coal tar baths

56
Q

risk factors for seborrheic dermatitis

A

genetics
stress
hormones
older adults can develop seborrheic keratoses, which are more plaque-like in appearance

57
Q

physical findings in seborrheic dermatitis

A

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

58
Q

medications used for caring for seborrheic dermatitis

A

topical corticosteroids-reduces secondary inflammatory response of lesions
antiseborrheic shampoos-contain selenium, sulfur, or salicylic acid

59
Q

what is the leading cause of skin cancer

A

sunlight exposure

60
Q

what are precancerous skin lesions called

A

actinic keratoses

61
Q

what are the three types of skin cancer

A

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

62
Q

health promotion and disease prevention of skin cancer. advise clients to do what

A

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

63
Q

risk factors of developing skin cancer

A

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

64
Q

what are the ABCD’s of suspicious skin cancer lessions

A

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

65
Q

What are the three phases of wound healing

A

Inflammatory phase. Proliferation or reconstruction phase. And then maturation Or remodeling phase

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