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ABSN > skin & neuro (333 E2) > Flashcards

skin & neuro (333 E2) Flashcards

1
Q

edema

A

1+: barley detectable, immediate rebound 2mm
2+: deep pit, a few seconds to rebound 4mm
3+: deep pit, 10-12 sec rebound 6mm
4+: very deep pit, >20 sec rebound 8mm

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2
Q

example of non pitting edema

A

swelling / swollen ankle

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3
Q

pallor

A

-loss of color, black skin can change to grey
-look in mucous membranes
-indications: anemia, shock, lack of blood flow

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4
Q

jaundice

A

-yellow discoloration -> look at sclera, skin, mucous membranes and palms of black individuals
-indications: liver dysfunction

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5
Q

erythema

A

redness, difficult to see in darker skin so palpate and look for warmth & texture changes
-indications: vasodilation, inflammation, sun exposure, elevated temp

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6
Q

risk factors for impaired skin integrity

A

-impaired sensory perception
-impaired mobility
-altered level of consciousness

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7
Q

how often should you check an incontinent pt

A

every hour

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8
Q

three major factors involved in pressure injury development

A

1) pressure intensity
2) pressure duration
3) tissue tolerance (low bp, poor nut, aging, hydration status)

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9
Q

intertriginous dermatitis

A

inflammatory dermatitis r/t moist skin rubbing together -> can lead to a yeast infection in skin folds, breast & penis

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10
Q

what nutrients are critical for wound healing

A

protein, vit A, vit C, zinc, copper

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11
Q

for braden, is lower or higher at increased risk for skin injury

A

lower

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12
Q

what are the 3 key components of wound mgt

A

1) assessment
2) cleansing
3) protection

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13
Q

hydrogel

A

for infected, deep wounds or necrotic tissue
not for wounds that drain a lot

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14
Q

alginates

A

non adherent dressing that conform to wounds shape and absorb exudate

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15
Q

collagen

A

powders, pastes, granules, gels

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16
Q

wound vacs

A

help w/ tissue generation, decrease swelling and enhance healing in moist, protective environment

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17
Q

what should we first be concerned about in a neuro assessment

A

oxygen

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18
Q

the 4 H’s of neuro

A

-hypoxia
-hypoglycemia
-hypotension
-hypoventilation

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19
Q

14 parts of a neuro statements

A

-subjective data
-mental status/LOC
-gait
-reflexes
-sensation
-coordination
-proprioception
-GCS/EMV
-pupils
-visual fields
-muscle strength
-speech
-swallowing
-gag

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20
Q

alert

A

-awake
-easily arousable
-receptive
-responsive

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21
Q

somnolent (lethargic)

A

-not fully alert
-drifts off to sleep when not stimulated
-appears drowsy
-awakens to name
-responds appropriately
-slow to respond
you wake someone up in the middle of the night

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22
Q

obtunded

A

-sleeps more of the time
-difficult to arouse (needs loud noise/vigorous shake)
-acts confused when aroused
-speech mumbled or incoherent
-requires constant stimulation to stay awake
can stay awake

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23
Q

stupor or semi comatose

A

-spontaneously unconscious
-responds only to vigorous shake or pain
-groans, mumbles
cannot stay awake

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24
Q

comatose completely unconscious

A

-no meaningful response to stimuli
-light coma, no purposeful movement, some reflex activity
-deep coma, no motor response
no motor response

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25
Q

below what GCS score do we have to worry about the airways

A

8

26
Q

proprioception

A

body’s ability to sense movement, action and location

27
Q

a braden below what is high risk

A

12

28
Q

coordination

A

rapid alternating movements
test by touching thumb to each finger

29
Q

what is our goal for neuro pts

A

protect and maintain safety & assist pt in gaining independence

30
Q

passive range of motion

A

pt needs help in movement

31
Q

active range of motion

A

pt can do movement by themselves

32
Q

x ray

A

-only shows bones
-first step in evaluating back/neck pain
remove metal & make sure armband is on

33
Q

CT scan

A

think stroke & trauma
-3D images of organs, bones, tissues
-w/ or w/o contrast
-quickly detects hemorrhage, bone, vascular abnormalities, tumors, cysts

34
Q

CT nursing considerations

A

-informed consent (for contrast)
-allergies to iodine (contrast)
-NPO for some, not needed for neuro
-might need to give meds for claustrophobic pts

35
Q

what organ is contrast hard on

A

kidney -> check creatinine levels

36
Q

ct angiogram

A

IV contrast

37
Q

MRI

A

-3d image from a 2D slice
-more detailed than CT
-very $$
-screen for metal & remove all
-remove medicated patches bc burns
remove all leads & non mri safe oxygen

38
Q

EEG

A

-monitors brains electrical activity
-helps dx seizures
-confirms brain death
-can be completed sleeping, awake, or stimulate

39
Q

factors influencing sensory function

A

-age
-meaningful stimuli
-amount of stimuli
-social interaction
-environmental factors
-cultural factors

40
Q

expressive aphasia

A

inability to name common objects or express ideas in words or writing
understand what you say but cannot speak back

41
Q

receptive aphasia

A

inability to understand written or spoken language

42
Q

things to think about reduced olfaction

A

-smoke detector
-check food dates/appearance bc cant smell bad stuff
-dangers of cleaning with chemicals
-gas appliances

43
Q

hyperesthesia

A

(in pts w/ tactile deficits)
-overly sensitive
-minimize irritating stimuli
-avoid loose fitting linens

44
Q

adaptations for tactile sensations

A

-water temp
-ice/heat therapy do not use
-good fitting shoes

45
Q

what does sensory deprivation effect

A

-cognitive
-affective
-perceptual

46
Q

what causes sensory deprivation

A

-isolation
-loss/impairment of senses
-confinement
-emotional disorders
-brain injury

47
Q

excessive stimuli prevents

A

meaningful brain response

48
Q

causes of sensory overload

A

-pain
-lack of sleep
-ICU/care
-visitors/staff

49
Q

symptoms of sensory overload

A

-fatigue, sleepiness, irritable
-disorientation
-scattered/restless/anxiety

50
Q

how to tell if sensory ability has improved

A

the pt says it has

51
Q

migraine

A

-recurring headache characterized by unilateral throbbing pain
-more common in females

52
Q

what types of headaches are more common in males

A

cluster

53
Q

care of a migraine pt

A

-rule out an intracranial or extra cranial disease
-meds: NSAIDs, Tylenol, aspirin, combo drugs likes excedrin

54
Q

what drug is for migraines

A

triptan (take at the begin/aura, not daily)

55
Q

what headache can you use oxygen for

A

cluster(high flow 02 throuhg a non rebreath)

56
Q

hemorrhage

A

-greatest risk 24-48 hr after injury or surgery
-can be caused by clot dislodgment, slipped suture, or blood vessel damage
-internal bleeding (sanguineous drainage) w/ swelling & distention
-increase HR, decrease BP.

57
Q

what type of hemorrhage can be an emergency

A

wound hemorrhage -> apply dressing, monitor VS & notify provider

58
Q

dehiscence

A

partial or total rupture of surgical wound, usually with a separation of underlying skin layers

59
Q

evisceration

A

a dehiscence that involves the protrusion of visceral organs through wound opening

60
Q

evisceration manifestations

A

-significant increase in flow of serosanguinous fluid on the wound dressing
-immediate history of sudden straining
-pt reports a sudden popping or giving way in wound area
-visualization of the viscera

ABSN (118 decks)

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