skin & neuro (333 E2) Flashcards by Stef Sis

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

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example of non pitting edema

swelling / swollen ankle

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pallor

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

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jaundice

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

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erythema

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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risk factors for impaired skin integrity

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

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how often should you check an incontinent pt

every hour

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three major factors involved in pressure injury development

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

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intertriginous dermatitis

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

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what nutrients are critical for wound healing

protein, vit A, vit C, zinc, copper

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

lower

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what are the 3 key components of wound mgt

1) assessment
2) cleansing
3) protection

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hydrogel

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

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alginates

non adherent dressing that conform to wounds shape and absorb exudate

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collagen

powders, pastes, granules, gels

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wound vacs

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

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what should we first be concerned about in a neuro assessment

oxygen

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the 4 H’s of neuro

-hypoxia
-hypoglycemia
-hypotension
-hypoventilation

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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

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alert

-awake
-easily arousable
-receptive
-responsive

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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

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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

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stupor or semi comatose

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

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comatose completely unconscious

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

proprioception

body's ability to sense movement, action and location

a braden below what is high risk

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