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Med-Surg Nursing > Objective 2 (1) > Flashcards

Objective 2 (1) Flashcards

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1
Q

Largest organ system of the body
Consists of skin, hair, nails, and glands
Forms a barrier between the internal organs and external env
Participates in vital body functions

A

integumentary system

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2
Q

what are the functions of the integumentary system?

A

Protection: against bacteria, foreign matter, water loss
Sensation: pain, temp, touch
Fluid balance: absorbs water, prevents excessive loss
Temp regulation: heat dissipation, evaporation
Vitamin production: vitamin D
Immune response functio: dermatitis, asthma. Cells in skin are diff inppl with allergies than those who are healthy

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3
Q

bruising

A

ecchymosis

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4
Q

red, pinpoint spots from blood leakage

A

petechiae

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5
Q

itchy skin

A

pruitis

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6
Q

redness

A

erythema

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7
Q

bluish skin

A

cyanosis

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8
Q

pale skin

A

pallor

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9
Q

yellowing of the skin

A

jaundice

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10
Q

ease of rising of skin

A

tugor

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11
Q

ability of the skin to return to place

A

mobility

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12
Q

moles

A

nevus

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13
Q

what are the factors that affect the skin integrity?

A

physical, emotional and lifestyle
medical management
environment, socio-economic, care setting, potential for self-management
systems; health care support and communication

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14
Q

Detailed history of general health
Diabetes, age, peripheral artery disease, collagen vascular disease cancer, chemo, among others

A

physical, emotional and lifestyle

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15
Q

Overall health, OTC meds/creams, allergies, hydration, and nutrition, psychological factors
Pain assessment: painscales, one of the worst aspects of chronic wounds, lead to anx
Quality of life: mental and physical well being

A

medical management (listen)

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16
Q

Overall impressionL body language, effect, interaction, clothing, assistive devices
Skin assessment: skin and mucous membranes, mobility/tugor, maceration, bruising, red shiny lower legs, edema, nail thickness, hair distribution

A

medical management (look)

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17
Q

Skin temp, pitting edema, nutritional status, hemoglobin

A

medical management (touch)

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18
Q

Income
Working conditions, food, housing/env\
Early childhood development
edu/literacy
Social supports
Health behaviours/access to healthcare
Lower income negatively impacts health, lack of resources and social supports can lead to smoking, alcohol/substance abuse

A

environment, socio-economic, care setting, potential for self-management

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19
Q

Access to funding, access to services and wound-related products
Diagnostic services, service delivery personnel

A

systems; health care support and communication

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20
Q

what are the changes related to aging?

A

Skin dryness, wrinkling, thinning, decreased tugor, increased skin fragility
Loss of subcut tissue
Decreased blood supply
Thinning hair
Photoaging

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21
Q

what are the goals of care?

A

Should aim goals to SMART principle:
Specific – what needs to be accomplished (how, when, where
Measurable – how much, how many, how often
Attainable – realistically achievable
Rewarding –all should feel good when goal is achieved
Timely – realistic timeframe (short, intermediate and long

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22
Q

what are the factors associated with increased wound infection?

A

Characteristics of the Individual
Poorly controlled diabetes
Prior surgery
Radiation or chemo
Hypoxia, anemia, arterial/vascular disease, rheumatoid arthritis,shock)
Immune system disorders (AIDS, malignancy)
Malnutrition, alcohol, smoking, drug abuse

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23
Q

Contaminated wounds, trauma from delayed treatment
Pre-existing infection / sepsis
Penetrating wounds over 4 hours

A

acute wound

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24
Q

Duration of wound, large wound area, deep wound
Located near a site of potential contamination (perineum, sacrum)

A

chronic wound

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25
Q

what are the S&S associated with bacterial burden?

A

contamination
colonization
local infection

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26
Q

wound acquires microorganisms, if not successful in invading host they will not multiply or persist

A

contamination

27
Q

microbial species grow and divide but does not cause damage or infection

A

colonization

28
Q

bleeding, wound breakdown and enlargement, delayed healing, pain, odour

A

covert (subtle)

29
Q

erythema, local swelling, purulent discharge, delayed healing, pain, odour

A

overt (classic)

30
Q

what are the S&S of spreading infection?

A

Extending induration, erythema
Lymphagitis
Wound breakdown with dehiscence (wound rupture along surgical incision)
Malaise, nonspecific deterioration
Loss of appetite
Swelling of lymph glands

31
Q

what are the S&S associated with systemic infection?

A

Severe sepsis
Septic shock
Organ failure
Death

32
Q

identify and implement an evidence-informed plan to correct the causes that affect skin integrity…

A

Physical activity – beneficial effects physically and mentally
Nutrition – vital role in prevention and management of wounds
Moisture control – keep skin dry, avoid irritants, treat secondary infection (manage incontinence)
Pain management
Smoking cessation, weight management, stress management, mental health programs

33
Q

normal saline, sterile water, tap water and antiseptics

A

wound cleansing

34
Q

antimicrobial or antiseptics (povidone-iodine)

A

infected wounds

35
Q

maggots liquify necrotic tissue and secrete substances that destroy bacteria

A

biological debridement

36
Q

applying moistened gauze and periodically removing it (wet to dry dressing); non-traumatic irrigation systems (syringe and needle) 19 gauge needle gives 15 pounds of pressure; ultrasound (sound waves through saline)

A

mechanical debridement

37
Q

specialized, powered surgical tool

A

hydrosurgical debridement

38
Q

sodium hypochlorite

A

chemical debridement

39
Q

self-digestion of enzymes naturally present in the wound

A

autolytic debridement

40
Q

application of proteolytic substances to breakdown tissue

A

enzymatic debridement

41
Q

fastest way to remove devitalized (slough), contaminated or infected tissue

A

surgical debridement

42
Q

removal of only devitalized tissue with scalpel or scissors

A

conservative sharp wound debridement

43
Q

how do we manage bacterial balance>

A

Optimize host response and wound environment
Reduce the number of microorganisms
Antibiotics – agents that kill selectively and require metabolic activity for action

44
Q

non-selective agents that does not require metabolic action

A

antiseptics

45
Q

umbrella term used to group antibiotics and antiseptics

A

antimicrobial

46
Q

Greyish-blue tone, especially in nail beds, earlobes, lips, mucous membranes, and palms and soles of feet Ashen or greyish colour most easily seen in the conjunctiva of the eye, mucous membranes, and nail beds

A

cyanosis

47
Q

Dark red, purple, yellow, or green colour, depending on age of bruise. Purple to brownish-black; difficult to see unless occurring in an area of light pigmentation

A

ecchymosis

48
Q

Reddish tone, possibly accompanied by increased skin temperature secondary to localized inflammation Deeper brown or purple skin tone with evidence of increased skin temperature secondary to inflammation

A

erythema

49
Q

Yellowish colour of skin, sclera, fingernails, palms of hands, and oral mucosa Yellowish-green colour most obviously seen in sclera of eye, palms, and soles

A

jaundice

50
Q

Pale skin colour that may appear white or ashen; also evident on lips, nail beds, and mucous membranes May appear yellowish, ashen, or grey

A

pallor

51
Q

Lesions appear as small, reddish purple pinpoints, best observed on abdomen and buttocks Difficult to see; may be evident in the buccal mucosa of the mouth or the conjunctiva of the eye

A

petechiae

52
Q

May be visualized as well as felt with light palpation. Not easily visualized, but may be felt with light palpation

A

rash

53
Q

Narrow scar line, usually white or pink. Higher incidence of keloid development, resulting in a thickened, raised scar

A

scar

54
Q

collect subjective data about overall health, family history, medications, skin disorders, allergies

A

health history

55
Q

assessment of all skin areas, mucous membranes, scalp, hair and nails

A

physical exam

56
Q

color, vascularity, temperature, mobility, turgor, texture and edema

A

inspection and palpation

57
Q

how do we assess lesions?

A

Type of lesion – primary or secondary (e.g. macule, papule, pustule, vesicle)
Color of lesion
Associated pain, redness, heat or swelling
Size and location
Configuration (pattern) of eruption

58
Q

what does documentation include for skin lesions?

A

Wound bed – necrotic or granulation tissue, exudate, color and odor
Wound edges and margins – observe for extension of the wound under the skin surface
Wound size – measure in mm or cm to determine diameter and depth
Surrounding skin – color, suppleness and moisture and irritation

59
Q

what is the ABCDE method for screening moles

A

A : Asymmetry – one half is not like the other half
B : Borders – irregular edges, ragged, notched and not well defined
C : Color – variation or change
D : Diameter – growth in size larger than a pencil
E : Evolution – change in size, shape, symptoms, surface elevation, bleeding, color

60
Q

tissue obtained from nodules, plaques, blisters and other lesions for microscopic examination. Used to rule out malignancies or other disease

A

skin biopsy

61
Q

identifies site of immunologic reaction using dye

A

immunofluorescence

62
Q

applying suspected allergens to healthy skin

A

patch testing

63
Q

tissue samples and scraped from suspected fungal lesions and examined under microscope (scabies)

A

skin scrapings

Med-Surg Nursing (13 decks)

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