Test #7 Study Guide

Question 1

How do you document pressure ulcers/injuries?

Answer 1

Date, time, site, stage, blanching and intervention performed. As the pressure ulcers heals continue documentation as notated above along with the PUSH tool to demonstrate healing.

Question 2

What are pressure ulcers/injuries risk factors?

Answer 2

Confinement, immobilization, incontinence, malnutrition, decreased LOC, confusion, DM, dehydration, edema, excessive sweating and extreme age.

Question 3

What are ways to prevent pressure ulcers/injuries?

Answer 3

Pressure relief, padding, positioning, use of pressure relief devices, adequate nutrition (protein, hydration), excellent skin care: clean, dry and moisturized

Question 4

What are some nursing interventions for skin tears?

Answer 4

Clense with sterile saline water, debride, approximate, steri-strips and dress with non adhering dressing, provide medication as prescribed (ie. Antibiotics)

Question 5

What are some special considerations to prevent pressure ulcers in an elderly patient?

Answer 5

Keep skin clean, dry and moisturized, frequent repositioning, prevent skin shearing, be cautious with skin( thin tears easy), keep nurished and hydrated, ambulate.

Question 6

What are diagnostic test for skin conditions?

Answer 6

All done diagnosed by a professional doctor.
Fungus: Microscopic examinations of skin scrapings
Skin Cancer: examinations of skin, biopsy and pathology results
All other skin conditions are diagnosed by physical examination of skin, review of medical history

Question 7

Basal Cell Carcinoma

Answer 7

growth or sore that doesn’t heal, a skin-colored bump that’s translucent, or a white, waxy, scar-like lesion without a clearly defined border most commonly seen in the face and the trunk.

Question 8

Squamous Cell Carcinoma

Answer 8

a firm bump, flat sore, or raised area on the skin. It can appear as a rough, scaly patch, wart-like growth, or sore that won’t heal

Question 9

Malignant Melanoma

Answer 9

Changes in the size, shape, color, or feel of a mole or skin lesion. It is the least common, but most dangerous because it can lead to death if not treated. Genetic predisposition.

Question 10

Superficial Spreading Melanoma

Answer 10

on the surface, that usually starts as a dark spot with irregular edges, often on a sun-exposed part of the body.

Question 11

Nodular melanoma

Answer 11

a firm, raised, discolored growth on your skin that may look like a blood blister, that grows downward through the skin that can lead to a formation of a nodule.

Question 12

Lentigo Malignant Melanoma

Answer 12

a flat, tan, or brown patch with an uneven border. It can also look like a freckle that changes in size, shape, or color.

Question 13

How to monitor for skin cancers

Answer 13

Have yearly skin checks, if a new mole, or u healing lesion appears get it checked ASAP, watch for uneven borders, changing moles.

Question 14

Dermatitis types

Answer 14

Contact: allergic response due coming in contact with something
Atopyc: eczema
Stasis: rash due to venous stasis
Seborrheic: crusty yellow build up in scalp,ears, neck

Question 15

Dermatitis s+s

Answer 15

Itching

Question 16

Dermatitis treatment

Answer 16

Contact: avoid touching irritant, antihistamine, corticosteroid.
Atopic: avoid soaps or other irritants (creams, ointments), antihistamines, medicated creams.
Stasis: compressir stockings, medicated creams, treat underlying cause
Seborrheic: self care, medicated shampoos

Question 17

Dermatitis patient education

Answer 17

Avoid irritants, do not take long hot showers, trial and error to identify self care products that do not irritate skin, Do not rub skin to dry, pat dry instead.

Question 18

Stage I pressure ulcer

Answer 18

A non blanchable, intact area of the skin that is reddened, deep pink or mottled

Question 19

Stage II pressure ulcer

Answer 19

Partial thickness skin loss involving the epidermis, or dermis, or both, blistered or abraded or has a shallow crater. The area surrounding the damaged skin is reddened and probably will feel hot or warmer than normal

Question 20

Stage III pressure ulcer

Answer 20

The skin is ulcerated. There is a crater-like ulcer, and the underlying subcutaneous tissue is involved in the destructive process. The ulcer may or may not be infected. Bacterial infection is almost always present at this stage, however, and accounts for continued erosion of the ulcer and the production of drainage

Question 21

Stage IV pressure ulcers

Answer 21

deep ulceration and necrosis involving deeper underlying muscle and possibly bone tissue. The ulcer can be dry, black, and covered with a tough accumulation of necrotic tissue, or it can be made up of wet and oozing dead cells and purulent exudates. Depth can’t be determined

Question 22

Prevention and Treatment for skin cancer?

Answer 22

Prevention: wear sunscreen/sunblock, UV protective clothing, stay out of sun during peak sunlight hours, wear hats, get yearly skin checks.
Treament: Removal of lesion, chemotherapy, radiation.

Question 23

Acne s+s

Answer 23

uninflamed blackheads to pus-filled pimples or large, red, and tender bumps.

Question 24

Acne types

Answer 24

Acne vulgaris: during puberty
Acne rosacea: during adulthood 30- 50 yo look like ruptured veins or spiderveins

Question 25

Acne treatment

Answer 25

Treatment: retinol A, Benzoyl peroxide: lots of acne face washes, azelaic acid, antibiotics.Accutane should only be used for severe cystic acne resistant to other treatment, cystic acne are going to be big and painful acne Photodynamic therapy: can be used for severe acne, and skin cancers. Dermabrasion: removal of first layer of skin, watch out for infection, do not perform on regular basis.

Question 26

Acne patient teaching

Answer 26

Wash hands before caring for acne
Wash face
Do not pop pimples
Diet, hydration

Question 27

Psoriasis s+s

Answer 27

Noncontagious, chronic, inflamed, edematous skin lesions covered with white flaking scales that can cause itching and pain.

Question 28

Psoriasis treatment

Answer 28

Mild cases: keep moist with good moisturizing lotion
Tar preparations: ie. Medicated shampoo
Antimetabolites: methotrexate is most common, injections remicade: they keep skin from over proliferatin, it stops it from overgrowing.

Question 29

Psoriasis patient teaching

Answer 29

Keep skin moist and pliable, do not dry out. Use humidifiers, if skin is dry.
Be cautious to prevent injury, which can increase psoriasis growth

Question 30

Steven- Johnson-Syndrome s+s

Answer 30

Allergic reaction with skin manifestations. Fever, sore throat/mouth, fatigue, burning eyes, widespread skin pain, a rash that spreads, blisters, shedding of skin
Commonly caused by: Anticonvulsants carbamazepine (Tegretol) and phenytoin (Dilantin), the antimalarial med: sulfadoxine–pyrimethamine (Fansidar), and the antibiotic trimethoprim–sulfamethoxazole (Bactrim, Septra)

Question 31

Steven-Johnson-Syndrome treatment

Answer 31

First action if this is suspected: Discontinue the drug causing this.
Provide supportive care. Medical Emergency!
Provide wound care. They will need wound care.

Question 32

Steven-Johnson-Syndrome patient teaching

Answer 32

Remember medication that caused this reaction add it to allergy list, recovery may take months, ways to cleanse mouth. Therapy to prevent weakness and contractures due to being in bed., rest.

Question 33

Cellulitis s+s

Answer 33

Swollen, red, hot skin caused by infection of the dermis and subcutaneous tissue
Furuncles: boils infected nodule turnes red that turns into a large tender cyst(Whitehead like nodule)
Carbuncles: group of furuncles.

Question 34

Cellulitis treatment

Answer 34

Warm compresses, Incision and drainage ,if really big. Systemic antibiotics, depending on severity.

Question 35

Cellulitis patient teaching

Answer 35

Rinse well after bathing, avoid cosmetics on affected areas, use clean washcloths and linens.

Question 36

Hepres simplex s+s

Answer 36

HSV-1: lesion on lip, nares- often called ”cold sores”
HSV-2: lesions on perineal area

Question 37

Herpes simplex treatment

Answer 37

Topical and oral Zovirax, Famvir, Valtrex
Abreva-OTC. Tincture of benzoin or spirits of camphor – dry lesions and aids in healing

Question 38

Herpes simplex patient teaching

Answer 38

Good personal hygiene
Prevent spread
Reduce stress
Sunscreen for lips I herpes

Question 39

Herpes zoster (shingles) s+s

Answer 39

Aching or discomfort along the nerve pathway, very painful localized blisters

Question 40

Herpes zoster (shingles) treatment

Answer 40

Symptomatic treatment, oatmeal baths, no overheat, it will spread if overheated
Antibiotics, Zovirax, Famvir, Valtrex,
Systemic corticosteroids

Question 41

Herpes zoster (shingles) patient teaching

Answer 41

Cold compresses, calamine lotion, and Rest and adequate nutrition. Imagery, deep muscle relaxation, or use of distraction activities. Isolation during active phase, before lesions crust over.

Question 42

Fungal infection types

Answer 42

Tinea pedis (athletes foot)
Tinea cruris (jock itch)
Tinea of the scalp (ringworm)
Tinea barbae (barbers itch)
Moniliasis (thrush)
Onychomycosis (nail fungus)

Question 43

Fungal infection treatment

Answer 43

Topical medicated ointments, antifungals, tea tree oil Vicks vaporub