Test 3 Flashcards
Functions of the skin
Protection
Body temp regulation
Psychosocial
Sensation
Vitamin D production
Immunologic
Absorption
Elimination
Factors affecting the skin
Unbroken and healthy skin and mucous membrane defend against harmful agents
Resistance to injury is affected by age, amount of underlying tissue and illness
Adequately nourished and hydrated body cells are resistant to injury
Adequate circulation is necessary to maintain cell life
Skin younger than 2
Thinner and weaker
Infants skin
The skin and mucous membranes are easily injured and subject to infection
A child’s skin becomes increasingly resistant to injury and infection
Skin and aging
The structure of the skin changes, the maturation of epidermal cells is prolonged, leading to thin, easily damaged skin
Circulation and collagen formation are impaired leading to decreased elasticity and increased risk for tissue damage from pressure
Causes of skin alteration
Very thin and obese people are more susceptible to skin injury
- fluid loss during illness causes dehydration
- skin appears loose and flabby
Excessive perspiration during illness predisposes skin to breakdown
Diseases of the skin such as eczema and psoriasis may cause lesions that require special care
Unintentional wound
Caused by an accidental fall or accident
Intentional wounds
Made by a healthcare professional like for surgery
Open wound
Like a cut, something that breaks the skin
Closed wound
Does not break the skin, like a bruise
Acute wound
Lasts for < 30 days
Goes through normal steps of healing
Chronic wound
Lasts for months or years
Partial thickness wound
Damages the epidermis and sometimes the dermis but does not go past the dermis
Full thickness wound
Damage goes past the epidermis and dermis and into the subcutaneous tissue
Could go to bone
Complex wound
Could be all of the above, partial and full
Difficulty healing
Principles of wound healing
Intact skin is the first line of defense against microorganisms
Careful hand hygiene **
Body responds systematically to trauma of any parts
Adequate blood supply is essential for normal body response
Normal healing is promoted when the wound is free of foreign material
Principles of wound healing
Intact skin is the first line of defense against microorganisms
Careful hand hygiene **
Body responds systematically to trauma of any parts
Adequate blood supply is essential for normal body response
Normal healing is promoted when the wound is free of foreign material
Extent of damage and state of health affects healing
Response to wound is more effective is proper nutrition
Need to know how person got wound**
Phases of wound healing
Hemostasis
Inflammatory
Proliferation
Maturation
Hemostasis
Immediately after initial injury
Involved blood vessels constrict and blood clotting begins
Exudate is formed, causing swelling and pain
Increased perfusion results in heat and redness
Platelets stimulate other cells to migrate to the injury to participate in other phases of healing
Inflammatory phase
Follows Hemostasis and lasts about 2-3 days
WBCs, mostly leukocytes and macrophages, move to wound
Macrophages enter the wound area and remain for an extended period
They ingest debris and release growth factors that attract fibroblasts to fill in the wound
Patient has a generalized body response
Proliferation phase
Lasts for several weeks
New tissue is built to fill the wound space through the action of fibroblasts
Capillaries grow across the wound
Think layer of epithelial cells forms across the wound
Granulation tissue forms a foundation for scar tissue development
Granulation tissue
Beefy red marbled tissue
Pink would mean you want more blood supply
Maturation phase
Final stage of healing, begins about 3 weeks after the injury, possibly continuing for months or years
Collagen is remodeled
New collagen tissue is deposited
Scar becomes a flat, thin, white line
Healed but never looks 100%
Local factors affecting wound healing
Pressure
Desiccation
Maceration
Trauma
Edema
Infection
Excessive bleeding
Necrosis
Presence of biofilm
Desiccation
Dehydration
Maceration
Ovehydration
Systemic factor affecting wound healing
Age
Circulation and oxygenation
Nutritional status
Wound etiology
Health status
Immunosuppression
Medication use
Adherence to treatment plan
Wound complications
Infection
Hemorrhage
Dehiscence or evisceration
Fistula formation
Dehiscence
Wound reopens
Evisceration
Wound reopens and everything comes out like organs
Factors affecting pressure injury development
Aging skin
Chronic illnesses
Immobility
Malnutrition
Fecal and urinary incontience
Altered level of consciousness
Spinal cord and brain injuries
Neuromuscular disorders
Mechanisms in pressure injury dev
External pressure compressing blood vessels
Friction and shearing forces tearing or injuring blood vessels
Friction vs shearing
Friction caused by when you move them up in bed
Shearing caused by them sliding back down in bed
Stage one pressure injury
Nonblanchable (doesn’t return to normal color), erythema (redness) of INTACT skin
Stage two pressure injury
Partial thickness skin loss with exposed dermis
Ex: blister
Stage three pressure injury
Full thickness skin loss, not involving underlying fascia (tendons, bones or ligaments)
Stage four pressure injury
Full thickness skin and tissue loss
Possibly see bones, ligaments or tendons
High probability of coming back b/c doesn’t ever fully heal
Unstageable pressure injury
Obscured full-thickness skin and tissue loss
Black, white or yellow wound bed
Cannot tell how deep it goes so can’t stage
Deep tissue pressure injury
Persistent nonblanchable (doesn’t go away even when offloading the pressure) deep red, maroon or purple discoloration
Slough tissue
Yellowish debris
Escher tissue
Neocratic tissue
If dry a lot will leave it
If wet will cut out and might have to amputate
Necrotizing faciatis
Necrotic tissue spreads and eats away at skin
Measurement of pressure injury
Size of wound - length, width and height
Depth of wound
Presence of undermining, tunneling or sinus tract
Cleaning a pressure injury/wound
Clean with each dressing change
Use new gauze for each wipe and clean from top to bottom and/or center to outside
0.9% saline solution
Once clean dry area using gauze sponge in same manner
Report any drainage or necrotic tissue
Serous drainage
White, clearish, watery
Serous drainage
White, clearish, watery
Sanguineous drainage
Bloody
Serosanguineous drainage
Pink, some serous some sanguineous
Purulent drainage
Yellow/brown, smells
Wound assessment
Inspection for sight and smell
Palpation for appearance, drainage and pain
Sutures, drains or tubes, and manifestations of complications
Purpose of wound dressings
Provide physical, psychological and aesthetic comfort
Prevent, eliminate or control infection
Absorb drainage
Maintain moisture balance of the wound
Protect from further injury
Protect skin surrounding
Debride (remove damaged/necrotic tissue)
Stimulate/optimize healing response
Consider ease of use and cost-effectiveness
Signs of wound infection
Swollen
Deep red in color
Feels hot on palpation
Drainage is increased and possibly purulent
Sound odor may be notes
Edges may be separated, with dehiscence present
Types of bandages
Roller bandage
Circular turn
Spiral turn
Figure of eight turn
Types of binders
Slings
Abdominal binders
Chest binders
T binders
Penrose drain
Open system
In pocket of infection to get all of it
Jackson-Pratt drain
Closed system
Suction drain
Hemovac drain
Closed system
Used in orthopedics
Color classification of open wounds
R = red - protect
Y = yellow - cleanse
B = black - debride
Mixed wound = components of all
Pressure injury assessment
Risk assessment
Mobility
Nutritional status
Moisture and incontinence
Appearance of existing pressure injury
Pain assessment
Topics for home health care teaching
Supplies
Infection prevention
Wound healing
Appearance of the skin/recent changes
Activity/mobility
Nutrition
Pain** so important to ask about before redressing
Elimination
Factors affecting response to hot and cold treatment
Method and duration of application
Degree of heat or cold applied
Patients age and physical condition
Amount of body surface covered
Effects of applying heat
Dilates peripheral blood vessels
Increases tissue metabolism
Reduces blood viscosity and increases capillary perm
Reduces muscle tension
Helps relieve pain
Effects of applying cold
Constricts peripheral blood vessels
Reduces muscle spasms
Promotes comfort
Swelling = elevate
Skin cancers
Most common kinds
Three types: melanoma, basal cell carcinoma, squamous cell carcinoma
Asians are less susceptible
Skin exam for skin cancer
A - asymmetry
B - border
C - color
D - diameter
E - evolution (changes over time)
Male external genitalia
Scrotum
Scrotal sac
Male internal genitalia
Tests
Spermatic cord
Epididymis
Vas deferens
Inguinal area
Located between the anterior superior iliac spine laterally and symphysis pubis medically
Frequent site of hernia development
risk factors for HIV/AIDS
Being the fetus of an HIV+ mother
Mother-infant transmission during pregnancy or delivery
Exchange of blood or body fluids through blood transfusion, needle sticks, breast feeding or body piercings
Age and prostate cancer
Rare in men under 40, rises rapidly after age 50
Race/ethnicity and prostate cancer
Highest for African American or Caribbean males of African origin
Occurs less often in Asian, Hispanic/Latio men than in whites
Geography and prostate cancer
Most common in North America, northwestern Europe, Australia and on Carribbean islands
Less common in Asia, Africa, Central America and South America
Fam history and prostate cancer
Having a brother or father with it increases chances
Risk factors for prostate cancer
Certain gene changes
Exposure to agent orange (Vietnam war)
Working on a farm, tire plant, with paint, with cadmium
Firefighters exposed to toxic chemicals
Slightly high risk for those who eat high amounts of red meat or high fat and fewer veggies
Low melatonin levels
Symptoms of Prostate Cancer
Trouble urinating
Decreased force in the steam of urine
Blood in the semen
Swelling in the legs
Bone pain
Erectile dysfunction
Education topics for prostate cancer
Don’t overeat
Diet low in fat and rich in fruits and veggies, high in fiber and high in omega 3 fatty acids
Soy products and other legumes positive effect
Drink green tea daily
No more than 2 alc drinks a day
Moderate exercise daily
Sleep in dark room
Testicular cancer
High mortality rate, especially if not caught early
ACS recommends exams as part of routine cancer check ups
Male clients should be aware they should be doing monthly self exams
Penis assessment
Inspection and palpation
Base of penis and pubic hair
Shaft, foreskin and glans
Urethral discharge
Scrotum assessment
Inspection:
Size shape and postion
Scrotal skin
Palpation: of scrotal contents
Auscultation
Transillumination
Inguinal area assessment
Inspect for Inguinal and femoral hernia
Older client findings male genitalia
Lumps
Swelling
Masses
Sexual dysfunction or decrease in
Risk factors for cervical cancer
Human papilloma virus (HPV)
Smoking
Immunosuppression
Chlamydia infection
Diet low in fruits and veggies
Overweight
Intrauterine device use
Having multiple full term pregnancies
Being <17 during first full term pregnancy
Poverty
Mother took DES (synthetic estrogen) while pregnant
Fam history
Incidence of cervical cancer
Lowest is in Eastern Mediterranean countries
Unusually high rate was found in the African region where income levels tend to be low
History of current health problem (female genitalia)
Menstrual cycle
Age of first period
Menopause
Vaginal discharge
Pain or itching
Lumps, swelling or masses
Urinating difficulty, color change or odor
Female external genitalia assessment
Inspection:
Mons pubis
Labia Majorca and perineum
Labia minors, clitoris, urethral meatus and vaginal opening
Palpation:
Bartholin glands
Urethra
Female internal genitalia assessment
Inspection:
Vaginal opening
Vaginal musculature
Cervix
Vagina
Bimanual examination:
Palpation:
Cervix
Uterus
Ovaries
Vaginitis
Inflammation in the cannal
Older female client findings genitalia
Vaginal infection b/c of atrophy of the vaginal mucosa
Gray, thinning pubic har
Cervic appears pale after menopause
Urinary incontinence from weakness or loss of urethral elasticity
Urinary system
Kidneys - main function unit
Ureters - carry it down
Bladder - worked by ANS, sfinkder guards open/close
Urethra - female is shorter
Kidneys and ureters
Maintain composition and volume of body fluids
Filter and excrete blood constituents not needed, retain those that are
Excrete waste product
How kidneys and ureters excrete waste product
The nephrons maintain and regulate fluid balance through the mechanisms of selective reabsorption and secretion of water, electrolytes and other
Urine from nephrons empties into the kidneys
Bladder
Smooth muscle sac innervated by ANS
Serves as temp reservoir for urine
Composed of three layers called detrusor muscle
Sphincter guards opening between it and urethra
Layers of bladder
Inner longitudinal layer
Middle circular layer
Outer longitudinal layer
Urethra
Conveys urines from the bladder to the exterior
Males function in excretory and reproductive
No portion of female is external to body
Process of emptying the bladder
Detrusor muscle contracts, internal sphincter relaxes, urine enters posterior urethra
Muscles of perineum and external sphincter relax
Muscle of abdominal wall contracts slightly
Diaphragm lowers, micturition occurs
Factors affecting micturition
Dev considerations
Food and fluid intake
Psychological variables
Activity and muscle tone
Pathologic conditions
Medications
Toilet training
Usually 2-3 years old
Enuresis
Not being able to control pee
Nocturial enuresis: bed wetting
Effecting of aging on voiding
Nocturia
Increased frequency
Urine retention and stasis
Voluntary control affected by physical problems
Diseases associated with renal problems
Congenital urinary tract abnormalities
Polycystic kidney disease
Urinary tract infection
Urinary calculi
Hypertension
Diabetes mellitus
Gout
Connective tissue disorders
Diuretics and Urine production and elimination
Prevent reabsorption of water and certain electrolytes in tubules
Cholinergic medications and Urine production and elimination
Often for heart
Stimulate contractions of detrusor muscle, producing urination
Analgesics/tranquilizers and Urine production and elimination
Suppress CNS, diminish effectiveness of neural reflex
Don’t know when they have to pee
Anticoagulants and urine color
Red urine
Diuretics and urine color
Pale yellow urine
Pyridium and urine color
Orange to orange-red urine
Antidepressant amitriptyline or B-complex vitamins and urine color
Green or blue green urine
Levodopa and urine color
Brown or black urine
Assessment of kidneys
Palpation of kidneys is usually performed by an advanced health care practitioner as part of a more detailed assessment
Assessment of urinary bladder
Palpate (can’t on empty bladder) and percuss or use bedside scanner
Assessment of urethral orifice
Inspect for signs of infection, discharge, or odor
Assessment of skin for urinary function
Assess for color, texture, turf or and excretion of wastes
Urine assessment
Assess for color, odor, clarity, and sediment
Polyuria
A person pees a lot
Anuria
Person who doesn’t pee at all
Oliguria
Person who does not pee enough
Ex: 200 mL in 24 hours
Normal urine output
2000 mL out in 24 hrs
Minimum 800 mL
Measuring urine output
Ask patient to void in bedpan, urinal or specimen container
Put on gloves, pour into appropriate measuring device
Place the calibrated container on a flat surface and read at eye level
Note amount of urine voided and recorded on the appropriate form
Remembers for urine specimens
Routine urinalysis
*aseptic technique
Clean catch or midstream
Sterile specimens from indwelling catheters (don’t take from bag)
Urine specimen from a urinary diversion (appliance and out abdominal)
24hr collection - must refrigerate after 1hr no good
Point of care urine testing
Color, clarity, keatones (diabetes), blood, concentration
Diabetes and UTIs
More susceptible b/c of keatones (sugar) in urine
Reasons for catheterization
Relieving urinary retention
Prolonged patient immobilization
Obtaining sterile urine specimen
Accurate measurement of urinary output in critically ill
Assisting in healing open sacral or perineal wounds in incontinent patients
Emptying before, during or after surgery and diagnostic exams
Improved comfort for end of life care
Transient incontinence
Appears suddenly and lasts 6 months or less
Mixed incontinence
Urine loss with features of two or more types of incontinence
Overflow incontinence
Overdistention and overflow of bladder
Functional Incontinence
Caused by factors outside the urinary tract
(Can’t get to bathroom b/c lose of function)
Ex: need walker
Reflex incontinence
Emptying of the bladder without sensation of need ro void
Total incontinence
Continuous, unpredictable loss of urine
Stress Incontinence
Involuntary loss of urine related to an increase in intra-abdominal pressure
Ex: laughing or scared
Breasts
Paired mammary glands
Produce and store milk that provides nourishment for newborns
Aid in sexual stimulation
Anatomy of breast
Nipple, Areola
Montgomery glands
Four quadrants
Glandular, fibrous, and fatty tissue, major axillary lymph nodes
Most common cancer in women
Breast cancer
Breast exam preparation
Client sitting in an upright position arm behind head
Expose both breasts **
Inspect and palpate: encompass whole breast and tale of Spence (armpit)
Retraction and dimpling on breast exam
Signs of tumors
Palpation of breasts
Texture and elasticity
Tenderness and temp
Masses: loco, size, shape, mobility, consistency, tenderness
Milky discharge only normal when pregnant
Mastectomy/lumpectomy sites
Gynecomastia
Enlarging of male breast
Peau d’orange
Boob peeling from swelling
Piaget disease
Can cause redness, drying of nipples and skin around
Retracted nipple and dimpling
Signs of cancer
Mastitis
Red, swelling, heat, tenderness
Can happen when breastfeeding
Cancerous tumors vs benign breast disease
Cancerous don’t move and are fixed
Benign come and go with time of month
Expected changes in aging females breasts
Decrease in size
Decrease in firmness
Glandular tissue decreases and fatty tissue increases
Rhinitis
Nasal passage inflammation
Causes congestion and runny nose
Sizes of head
Microcephalic
Macrocephalic
Measure each well child visit until 3
Hirsutism
Excessive hair growth
Polycystic ovary syndrome can case
TMJ
Temporal mejibular joint syndrome
Can hear jaw popping when opening or closing
Sinuses assessment
Transilluminate - pen light should “shine through”
Palpation
Percussion - if dull is infected
Thrush
White film on tongue
Can be caused by antibiotics or weak immune system
Cobblestoning
Pink and white patterning of healthy tonsils
Tonsil grading
Want +1
+2 is a little inflammation but not bad
+3 is a worse
+4 is infection
Uvula
Should move up when patient says ahhhh
Luekaplakia
Lesions, ulcers and nodules
Slernocleidomastoid
Neck muscle that connects skull to sternum and clavicle
Trapezius
Large muscle in back of neck that helps with balance and movement
Salivary Glands
Parotid
Submandibular
Sublingual
Neck exam
Evaluate range of motion
Stenocleidomastoid
Trapezius
Scalene
Lymph nodes assessment
Size shape consistency definition mobility and tenderness
Exophthalmos
Bulgin of the eyes
Goiter
Lump in thyroid
Could be iron deficiency, inflamed, meds, prego, radiation exposure
Anterior thyroid exam
Use pads of fingers of one hand to find thyroid
Cricoid cartilage, then move inferiorly to find the isthmus
Work laterally between trachea and sternocleidomastoid muscle to feel one thyroid lobe for masses
Ask to swallow
Thyroid should move superiorly
Feel for masses as swallow
Repeat for other lobe
Posterior thyroid exam
Reach around from behind and follow same steps as anterior
Auscultation of thyroid
Listen for bruits using diaphragm if gland is enlarged
Anuria
Failure of the kidneys to produce urine
Bacteriuria
Condition that occurs when bacteria enters the bladder during catheterization, or when organisms migrate up the catheter lumen or the urethra into the bladder
Bacteria in the urine
Bladder scan
Noninvasive portable tool for diagnosing, managing and treating urinary outflow dysfunction
Dysuria
Painful urination
Hematuria
Blood in the urine, if present in large enough quantities urine may be bright red or reddish brown
Ileal conduit
Urinary diversion in which the ureters are connected to the ileum with a stoma created on the abdominal wall
Micturition
Process of emptying the bladder, urination, voiding
Oliguria
The production of abnormally small amounts of urine
Polyuria
Production of abnormally large volumes of dilute urine
Pyuria
The presence of pus in the urine, typically from bacterial infection
Specific gravity
A characteristic of urine that can be determined with manufactured plastic strips or an instrument called a urinometer or hydrometer
Stress incontinence
State in which the person experiences a loss of urine of less than 50 mL that occurs with increased abdominal pressure
Urinary diversion
Surgical creation of an alternate route for excretion of urine
Areola
Darkened area surrounding the nipple
Breast clock
Method of describing the location in terms of time zones on the clock
Cysts
Sac containing liquid/semisolid substance
Dimpling
Retraction
Nipple retraction
Being drawn or pulled back
When copper’s ligaments are invaded by Ca, becomes fibrotic, pulls back skin over lesion -> dimpling
Nodules
Small mass of tissues in the form of swelling, protuberance
Peau d’Orange
Orange peel consistency to the skin
Peau d’Orange
Orange peel consistency to the skin
Pendulous
Hanging loosely (breasts)
Tail of Spence
The area extending into axillae from the upper outer quadrant of the breast
Alopecia
Hair loss
Canthus of eye (inner and outer)
Points where lower and upper lids meet
Caries
Cavities, decay of teeth
Cerumen
Wax in the external ear cancels, consisting of a heavy oil and brown pigment
Cheilosis
Ulceration of the lips
Edentulous
Without teeth
Gingiva
Gums
Gingivitis
Inflammation of the gingivae or gums
Glossitis
Inflammation of the tongue
Halitosis
Offensive breath
Nares
Nose openings
Pediculosis
Infestation with lice
Periodontal disease
Destruction of tooth supporting structure, degeneration of the dental periosteum (tissues) and bone
Plaque
Gummy mass of microorganisms on and around teeth
Sordes
Accumulation of foul, brown crust on teeth and mucous membranes
Stomatitis
Inflammation of the oral mucosa
Tartar
Hard deposit on the teeth near the gum line formed by plaque buildup and dead bacteria
Decubitus
Pressure ulcer, bedsore, area where skin tissue is destroyed, old term
Dermis
Layer under epidermis, contains blood and nerves
Diaphoresis
Profuse sweating
Ecchymosis
Larger, irregularly formed hemorrhage area on skin
Erythema
Redness of the skin
Hematoma
Mass of blood
Ischemia
Deficiency of blood in area
Jaundice
Yellowing of skin
Lentigo
Brown macula age spot
Lesion
Pathologically altered skin
Maceration
Process of softening a solid by steeping in fluid and sloughing of skin when wet for a long periods of time
Macula
Small, flat area on skin
Necrosis
Death of cells
Pallor
Paleness of skin
Papula
Small, raised area of the skin
Petechia
Small, red/purple hemorrhagic pin-point spots on skin, from capillary bleeds
Purpura
Red or purple spots as a result of minute hemorrhages within skin
Bigger then petechia
Pustule
Elevation of skin filled with purulent material
Striae
Lines or bands elevated above or depressed below surrounding tissue or differing color + texture
Vesicle
Serous, small, fluid filled area on skin
