skin & neuro (333 E2) Flashcards
edema
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
example of non pitting edema
swelling / swollen ankle
pallor
-loss of color, black skin can change to grey
-look in mucous membranes
-indications: anemia, shock, lack of blood flow
jaundice
-yellow discoloration -> look at sclera, skin, mucous membranes and palms of black individuals
-indications: liver dysfunction
erythema
redness, difficult to see in darker skin so palpate and look for warmth & texture changes
-indications: vasodilation, inflammation, sun exposure, elevated temp
risk factors for impaired skin integrity
-impaired sensory perception
-impaired mobility
-altered level of consciousness
how often should you check an incontinent pt
every hour
three major factors involved in pressure injury development
1) pressure intensity
2) pressure duration
3) tissue tolerance (low bp, poor nut, aging, hydration status)
intertriginous dermatitis
inflammatory dermatitis r/t moist skin rubbing together -> can lead to a yeast infection in skin folds, breast & penis
what nutrients are critical for wound healing
protein, vit A, vit C, zinc, copper
for braden, is lower or higher at increased risk for skin injury
lower
what are the 3 key components of wound mgt
1) assessment
2) cleansing
3) protection
hydrogel
for infected, deep wounds or necrotic tissue
not for wounds that drain a lot
alginates
non adherent dressing that conform to wounds shape and absorb exudate
collagen
powders, pastes, granules, gels
wound vacs
help w/ tissue generation, decrease swelling and enhance healing in moist, protective environment
what should we first be concerned about in a neuro assessment
oxygen
the 4 H’s of neuro
-hypoxia
-hypoglycemia
-hypotension
-hypoventilation
14 parts of a neuro statements
-subjective data
-mental status/LOC
-gait
-reflexes
-sensation
-coordination
-proprioception
-GCS/EMV
-pupils
-visual fields
-muscle strength
-speech
-swallowing
-gag
alert
-awake
-easily arousable
-receptive
-responsive
somnolent (lethargic)
-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
obtunded
-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
stupor or semi comatose
-spontaneously unconscious
-responds only to vigorous shake or pain
-groans, mumbles
cannot stay awake
comatose completely unconscious
-no meaningful response to stimuli
-light coma, no purposeful movement, some reflex activity
-deep coma, no motor response
no motor response
below what GCS score do we have to worry about the airways
8
proprioception
body’s ability to sense movement, action and location
a braden below what is high risk
12
coordination
rapid alternating movements
test by touching thumb to each finger
what is our goal for neuro pts
protect and maintain safety & assist pt in gaining independence
passive range of motion
pt needs help in movement
active range of motion
pt can do movement by themselves
x ray
-only shows bones
-first step in evaluating back/neck pain
remove metal & make sure armband is on
CT scan
think stroke & trauma
-3D images of organs, bones, tissues
-w/ or w/o contrast
-quickly detects hemorrhage, bone, vascular abnormalities, tumors, cysts
CT nursing considerations
-informed consent (for contrast)
-allergies to iodine (contrast)
-NPO for some, not needed for neuro
-might need to give meds for claustrophobic pts
what organ is contrast hard on
kidney -> check creatinine levels
ct angiogram
IV contrast
MRI
-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
EEG
-monitors brains electrical activity
-helps dx seizures
-confirms brain death
-can be completed sleeping, awake, or stimulate
factors influencing sensory function
-age
-meaningful stimuli
-amount of stimuli
-social interaction
-environmental factors
-cultural factors
expressive aphasia
inability to name common objects or express ideas in words or writing
understand what you say but cannot speak back
receptive aphasia
inability to understand written or spoken language
things to think about reduced olfaction
-smoke detector
-check food dates/appearance bc cant smell bad stuff
-dangers of cleaning with chemicals
-gas appliances
hyperesthesia
(in pts w/ tactile deficits)
-overly sensitive
-minimize irritating stimuli
-avoid loose fitting linens
adaptations for tactile sensations
-water temp
-ice/heat therapy do not use
-good fitting shoes
what does sensory deprivation effect
-cognitive
-affective
-perceptual
what causes sensory deprivation
-isolation
-loss/impairment of senses
-confinement
-emotional disorders
-brain injury
excessive stimuli prevents
meaningful brain response
causes of sensory overload
-pain
-lack of sleep
-ICU/care
-visitors/staff
symptoms of sensory overload
-fatigue, sleepiness, irritable
-disorientation
-scattered/restless/anxiety
how to tell if sensory ability has improved
the pt says it has
migraine
-recurring headache characterized by unilateral throbbing pain
-more common in females
what types of headaches are more common in males
cluster
care of a migraine pt
-rule out an intracranial or extra cranial disease
-meds: NSAIDs, Tylenol, aspirin, combo drugs likes excedrin
what drug is for migraines
triptan (take at the begin/aura, not daily)
what headache can you use oxygen for
cluster(high flow 02 throuhg a non rebreath)
hemorrhage
-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.
what type of hemorrhage can be an emergency
wound hemorrhage -> apply dressing, monitor VS & notify provider
dehiscence
partial or total rupture of surgical wound, usually with a separation of underlying skin layers
evisceration
a dehiscence that involves the protrusion of visceral organs through wound opening
evisceration manifestations
-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
