Skin Assessment, Skin Care, and Supporting Patient Hygiene

Question 1

epidermis

Answer 1

outer layer of skin

Question 2

visiable part of the nail

Answer 2

nail body

Question 3

cresent shaped white area of the nial is known as the

Answer 3

lunula

Question 4

Functions of the skin

Answer 4

• protection
• sensation
• tempurature regulation
• absorption
• secretion

Question 5

constant exposure to miasture can cause

Answer 5

maceration

Question 6

the buccal muscosa is also known as the

Answer 6

oral mucosa

Question 7

chewing is also known as

Answer 7

mastication

Question 8

how many permeant teeth are there for chewing

Answer 8

32

Question 9

regular oral hygiene is nessasary to maintain the integrity of tooth surfaces and prevent

Answer 9

• gingivitis
• peridontal disease

Question 10

where are hair follicles located

Answer 10

dermis

Question 11

A patients personal preferances for hyginene can be influenced by

Answer 11

• social practices
• personal preferences
• body image
• socioeconomic status
• health benefits and motivation
• cultural variables
• physical conditions

Question 12

risk factors for skin impariment

Answer 12

• immobilization
• reduced sensation
• nutrition and hydration alterations
• secretions and excretion on the skin
• vascular insufficenceny
• external devices

Question 13

individuals with diabetes mellitus should be assed for

Answer 13

neuropathy

Question 14

what is neuropathy

Answer 14

• degration of the peripheral nerves characterised by a loss of sensation, which can lead to injury

Question 15

halitosis

Answer 15

bad breath

Question 16

stomatitis

Answer 16

inflammation of the oral mucosal tissues

Question 17

alopecia

Answer 17

loss of hair

Question 18

Oral risks for hygiene

Answer 18

• inability to move the upper extremities
• dehydration
• presensce of nasogastric or oxygen tubes
• medications ( antihistamines)
• over the counter lozenges, cough drops, antacids, and chewable vitamins
• radiation therapy to head or nech
• oral surgury, trauma
• immunosepression
• diabetes

Question 19

skin risks for hygiene

Answer 19

• immobilization
• reduced sensation (stroke)
• nutrition (limited protein or reduced hydration)
• excessive secretions (urine, feces, wound drainage)
• presence of external devices (restraints, casts, bandages, ect.)

Question 20

foot risks for hygine

Answer 20

• inability to bend over
• inability to see feet

Question 21

eye care risks for hygiene

Answer 21

• reduced dexterity and hand coordination

Question 22

complete bed bath is used for patients

Answer 22

who are totally dependent and require total hygiene care

Question 23

a partial bed bath includes bathing

Answer 23

parts of the body that would cause disconfort or odour if not cleaned

Question 24

benefits of back rubs

Answer 24

• promotes relaxation, releives muscular tension, stimulates circulation, and improves sleep

Question 25

enucleation

Answer 25

removal of eye

Question 26

tissue ischemia

Answer 26

reduction in blood flow

Question 27

pressure injury

Answer 27

- localized to the skin and underlying tissue - usually over a boney prominance - result of pressure, shear, friction or a combination of theses factors

Question 28

hyperemia

Answer 28

redness

Question 29

blanching occurs when

Answer 29

normal red tones of light skinned patients are absent

Question 30

characterisitics of dark skin at risk for skin breakdown

Answer 30

- color - tempurature - appearance - palpation

Question 31

risks for pressure injury development

Answer 31

- impaired sensory perception - impaired mobility - alteration in level of conciouness - shear, fiction - moisture - nutrition - tissue perfusion - infection - pain - age - psychological impact of wounds

Question 32

what is the Bradens Scale used for

Answer 32

to asses the risk of skin breakdown

Question 33

what are the 6 characteristics of the bradens scale

Answer 33

1. sensory preception 2. mositure 3. activity 4. mobility 5. nutrition 6. shear and friction

Question 34

what are the stages of pressure injuries

Answer 34

- stage 1 - stage 2 - stage 3 - stage 4 - unstageable

Question 35

characteristics of a stage 1 pressure injury

Answer 35

- intact skin with localized nonblanchable erythema - presensce of blanchable erythema or changes in sensation, tempurature, of firmness - color changes do not include purple or maroon discoloartion

Question 36

stage 2 pressure injuries characteristics

Answer 36

- partial thickness loss with exposed dermis - wound bed is visible red or pink - may also present as an intact or ruptured sebum filled blister - adipose tissue is not yet exposed

Question 37

stage 3 pressure injuries characteristics

Answer 37

- full thickness loss of the skin - adipose tissue is visable - epibole (rolled wound edges) are present - undermining and tunneling can occur

Question 38

stage 4 pressure injury characterisitics

Answer 38

- full thickness and tissue loss with exposed or directly palpatable fascia, muscle, tendon, ligament, cartilage or bone - epibole (round wound edges) present - undermining or tunneling often occurs

Question 38

unstageable pressure injury characteristics

Answer 38

- full thickness skin and tissue loss in which the extent of damage within the ulcer cannot be confirmed because it is obstructed by slough or eschar

Question 39

exudate

Answer 39

describes the amount, color, constiancy, and odour of wound drainage - apart of the wound assesment

Question 40

how to prevent pressure injuries

Answer 40

- positioning - support surfaces - education - management of pressure injuries

Question 41

elevating the head of the bed _____ degress or less will decrease the chances of pressure injuries developing

Answer 41

30

Question 42

patients with some independent mobility should be encouraged to reposition every __ minutes

Answer 42

15