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NCLEX-RN® > NCLEX-RN (5) Adult Health > Skin/Burns > Flashcards

Skin/Burns Flashcards

Review the most important skin conditions and burns.

1
Q

What are petechiae and purpura?

A

Purple or red colored spots on the skin that occur when a small blood vessel bursts.

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2
Q

What is ecchymosis?

A

Bruising of the skin.

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3
Q

What is a spider angioma?

A

Small broken blood vessels on the surface of the skin.

They occur in the elderly and are not a concern. It also occurs with clients who have liver disease.

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4
Q

What are Steven’s Johnson syndrome and Toxic epidermal necrolysis?

(Immediate complication)

A

Really bad adverse reactions of many meds that cause a severe rash all over the body.

Always let the HCP know if you notice a rash, especially after the client starts a new med.

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5
Q

What is the general teaching to prevent a skin disorder from getting worse?

A
  • not scratch the rash or damaged skin
  • keep nails short
  • not pick sores or lesions
  • wear loose clothing
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6
Q

What is the client at risk for when there is an open wound or rash?

A

Infection, due to a break in the skin.

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7
Q

How often are clients turned to prevent pressure ulcers?

A

At least every 2 hours.

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8
Q

What is pruritus?

A

Itchy skin.

It is common for clients to receive diphenhydramine to decrease itching.

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9
Q

What is serous wound drainage?

A

Clear or straw-colored.

It is a normal finding.

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10
Q

What is purulent wound drainage?

A

Thick, yellow, green, brown or tan.

It indicates an infection.

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11
Q

What is serosanguinous wound drainage?

A

Pale red and watery.

It is a normal finding.

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12
Q

What is sanguineous wound drainage?

A

Bright red.

It indicates active bleeding.

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13
Q

What are the 3 main layers of the skin?

A
  1. epidermis: top layer
  2. dermis: includes blood vessels, nerves, sweat glands
  3. hypodermis: subcutaneous fat
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14
Q

What are the steps to getting a skin or wound culture?

A
  1. clean area first with normal saline going from close to the wound to away from the wound
  2. debride if needed
  3. use a sterile applicator or nasal swab to get a sample
  4. put in container
  5. send to lab
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15
Q

When are antibiotics started: before or after collecting the culture?

A

AFTER the culture is collected.

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16
Q

Describe:

Candida albicans

A

An infectious fungal disease of the skin.

It is also called a yeast infection, thrush, or oral candidiasis.

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17
Q

Risk factors:

Candida albicans

A

Frequently due to a decreased immune system from:

  • chemotherapy
  • steroids
  • immunosuppressed
  • long term antibiotics
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18
Q

On what areas of the body is candida albicans frequently found?

A

In warm, moist places where fungus likes to grow such as:

  • skin folds
  • mouth
  • vagina
  • under breasts
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19
Q

Interventions:

Candida albicans

A
  • keep skin folds dry
  • antifungal such as fluconazole or nystatin powder or suspension
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20
Q

Describe:

Cellulitis

A

An infection of the skin caused by Streptococcus or Staphylococcus. It frequently causes one leg to be red and edematous.

The client is treated with antibiotics, and warm compresses.

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21
Q

Describe:

Acne vulgaris

A

A chronic skin disorder that occurs more often in teenagers due to hormone changes.

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22
Q

What are acne lesions called?

A
  • “zits”
  • blackheads (closed comedones)
  • whiteheads (open comedones)
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23
Q

Prevention and treatment:

Acne vulgaris

A
  • don’t pick at face
  • gently wash the face using prescribed topical agents
  • benzoyl peroxide or antibiotics may be prescribed
  • wear sunscreen
  • keep hands off face
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24
Q

Describe:

Psoriasis

A

A chronic non-infectious inflammatory skin disorder.

The cause is not known.

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25
Q

What do psoriasis lesions look like?

A

Silvery-white scales on a raised, reddened, round plaque.

It normally affects the scalp, knees, elbows.

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26
Q

Medications:

Psoriasis

A

Focus on decreasing the inflammation. The most common meds are:

  • steroids
  • salicylic acid to soften the plaque
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27
Q

Describe:

Eczema (atopic dermatitis)

A

An allergic skin reaction that is itchy. There are small blisters and redness.

The cause is unknown but there is a higher risk if other allergies are present.

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28
Q

Teaching:

Eczema

A
  • use warm water to bathe, not hot water
  • don’t bathe every day
  • use mild soap
  • apply non-scented lotions
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29
Q

Medications:

Eczema

A

Topical steroids are applied to the rash.

30
Q

Who is most at risk for skin cancer?

A
  • older clients
  • light-skinned clients
31
Q

How often should clients do a thorough skin cancer check?

A

Once a month.

32
Q

What is a skin cancer assessment?

A
  • A: asymmetry
  • B: border irregularity
  • C: color that is not uniform
  • D: diameter > 1/4 inch (6mm)
  • E: evolving (changing) size, shape or color

Notify HCP of these changes.

33
Q

At what times during the day should a client stay out of the sun?

A

Between 10 a.m. and 4 p.m.

34
Q

What SPF factor of sunscreen should be used?

A

At least 15 SPF or higher.

Apply 30 minutes before going outside.

35
Q

Describe:

Melanoma

A

A highly metastatic skin cancer.

It is typically a red, dark blue, black or even a white color.

36
Q

Describe:

Basal cell carcinoma

A

A type of skin cancer that rarely metastasizes.

It is described as having a “waxy nodule with pearly borders”.

37
Q

Describe:

Squamous cell carcinoma

A

A type of skin cancer that looks like an oozing, bleeding and crusting lesion.

Larger tumors are associated with higher risk of metastasis.

38
Q

How are skin cancers diagnosed and treated?

A

A biopsy is performed and then surgery to remove the tumor.

39
Q

What is a stage 1 pressure ulcer?

A

Skin is intact, red, non-blanching, warm and painful.

Non-blanching means that when you press your finger on it, it stays red.

40
Q

What is a stage 2 pressure ulcer?

A

The first or second layer of skin has come off and it looks like a shallow, pink wound or blister.

41
Q

What is a stage 3 pressure ulcer?

A

There is full-thickness skin loss into the dermis and subcutaneous tissue.

42
Q

What is a stage 4 pressure ulcer?

A

There is exposed bone, tendon or muscle.

43
Q

What is an unstageable pressure ulcer?

A

When the ulcer is covered with slough or eschar.

  • Slough is dead white blood cells and skin debris.
  • Eschar is dead tissue and is black in color.
44
Q

On what areas are pressure ulcers more common?

A

On bony and thin skin areas such as:

  • back of head and ears
  • shoulder
  • elbows
  • hips
  • coccyx
  • heels
45
Q

Risk factors:

Pressure ulcers

A
  • moist skin
  • immobility
  • poor nutrition
  • skin being pulled on when moving up or down in bed - called “friction and shear”
46
Q

How are pressure ulcers prevented?

A
  • keep skin dry
  • don’t massage bony areas - can cause capillary damage and necrosis
  • ​turn every 2 hours
  • apply skin lotion or cream
  • Keep HOB at 30 degrees or less
47
Q

Why do burns have a high risk of airway problems?

(Immediate complication)

A

Smoke inhalation.

Always assess airway first and give oxygen.

48
Q

What is the best indicator of fluid intake and output in a burn client?

A

Urine output.

It needs to be at least >30 mL/hour for an adult.

49
Q

What is the Parkland formula?

A

Used to calculate how much fluids a burn client needs in 24 hours.

Give Lactated Ringer’s = 4 mL X kg X % of body burned

Example: 4 mL X 75 kg X 40% = 6000 mL

50
Q

How are the fluids divided up when calculating the 24-hour amount of fluids needed (using the Parkland formula)?

A

Divide fluids up:

  • give 1/2 of the amount in the first 8 hours
  • give the remaining amount in the next 16 hours

Example: If 6000 mL is to be given total

  • give 3000 mL (375 mL/hr) for the first 8 hours
  • give 3000 mL more (or 187.5 mL/hr) for the next 16 hours
51
Q

Why is there ↑ potassium in a burn client?

A

The burn destroys the cells and the potassium is released into the vascular space increasing the amount in the blood.

52
Q

Why is the hematocrit ↑​ in a burn client?

A

There is fluid loss, causing the hematocrit to become concentrated.

53
Q

What type of room does a burn client need to be placed in?

A

In a private room and placed on protective isolation (neutropenic precautions) to prevent them from getting an infection:

  • wear gown and gloves
  • sterile procedures
54
Q

What type of injections should a burn client NOT get?

A

Do not give IM or subcutaneous injections in a burned client since the client will be unable to absorb the medicine.

55
Q

How will the burn client receive pain meds?

A

Through IV.

56
Q

What is the room temperature kept at for a burn client?

A

Keep the room warm since the client has heat loss due to skin loss.

57
Q

What is the “Rule of 9’s”?

A

Assesses the percentage of the burned area on a client.

58
Q

What is a stage 1 burn?

It is also called a superficial burn.

A

When the epidermis (first layer) is damaged.

It is red without blisters.

59
Q

What is a stage 2 burn?

It is also called a superficial partial-thickness burn.

A

When the epidermis and dermis are damaged.

There is edema with blisters that are yellow.

60
Q

What is a stage 3 burn?

It is also called a deep partial-thickness burn.

A

When all the layers of the skin are damaged.

The area is stiff, red or white and dry.

61
Q

What is a stage 4 burn?

It is also called a full-thickness burn.

A

When the burn has gone through all the layers of the skin and reached the muscle, tendon or bone.

It is a black color.

62
Q

What surgery will be needed if the burn is not healing on its own?

A

Skin grafts.

63
Q

How should the burned area be positioned in order for skin grafts to heal?

A

Immobilize the area to promote the adhering of the graft to the skin.

64
Q

Describe:

Tinea corporis

A

A fungal infection on the skin. It is also known as ringworm.

65
Q

Medications:

Tinea corporis

A

Antifungals

Antifungals end in -azole.

66
Q

Describe:

Herpes zoster (shingles)

A

A viral infection that causes a rash on the skin. In children it is known as chicken pox or varicella zoster.

67
Q

What are the characteristic signs and symptos of herpes zoster/shingles?

A

Painful and itchy rash along the nerves on back or face. The vesicles can be filled with fluid.

68
Q

Diagnostic test:

Herpes zoster/shingles

A
  • culture skin and send to lab or
  • direct florescent antibody test
68
Q

Interventions:

Herpes zoster/shingles

A
  • airborne and contact precautions
  • antiviral medications
  • prevent by getting vaccine starting at age 50
68
Q

What are the 4 types of burns?

A
  1. chemical
  2. thermal
  3. electrical
  4. radiation

NCLEX-RN (5) Adult Health (13 decks)

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