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nurs 222: funds > week 7 > Flashcards

week 7 Flashcards

1
Q

what assessment techniques do we use for the skin?

A

inspection & palpation

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2
Q

elements of skin assessment

A

color & tone, temperature, moisture, texture, thickness, integrity, boney prominences, mobility, turgor, and lesions

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3
Q

what is skin tone?

A

underlying skin color determined by amount of melanin

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4
Q

what should we look for in skin color?

A

notice any widespread or localized color changes

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5
Q

what are some abnormal skin color characteristics? (4)

A

-erythema (redness)
-cyanosis (bluish) = low oxygen
-pallor (white)
-jaundice (yellow) = possible liver failure

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6
Q

do we use the front or back of hand to palpate skin temperature?

A

back (dorsa) of hands

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7
Q

do we palpate skin temperature bilaterally?

A

yes!

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8
Q

is skin temperature assessed on the upper extremity, lower extremity, or both?

A

both upper and lower

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9
Q

what are normal findings for skin temperature?

A

warm, temperature equal bilaterally

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10
Q

what do we assess for with skin moisture? (4)

A

-dullness = dehydration
-dryness = common in renal pts
-crusting & flaking
-excessive moisture = maceration, moisture for too long which can ulcerate quickly

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11
Q

diaphoresis

A

excessive or abnormal sweating

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12
Q

hypoglycemic

A

blood pressure decreased with major diaphoresis

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13
Q

what parts of the hand do we palpate for skin texture?

A

palms of hands or fingertips

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14
Q

what do we assess for in skin texture? (4)

A

-smoothness/roughness
-thinness/thickness
-tightness/suppleness
-induration = areas of hardness or softness

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15
Q

if an area of skin is hard and warm then what does that indicate?

A

inflammation

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16
Q

what are considered boney prominences

A

any point on the body where the bone is immediately below the skin surface

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17
Q

what is erythema?

A

redness of the skin due to congestion of the capillaries

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18
Q

what will erythema look like on a pale, ivory, beige skin color?

A

red, bright pink

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19
Q

what will erythema look like on a very dark-skinned individual?

A

difficult to see
-purplish tinge or darkened area
-palpate for increased warmth with inflammation, taut skin, and induration = pressure injuries

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20
Q

what is a normal finding for blanching in areas of redness?

A

blanchable redness

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21
Q

what does non-blanchable redness indicate

A

1st stage of pressure ulcer development

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22
Q

what is mobility?

A

the ease of the skin to rise

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23
Q

what is turgor?

A

the ability to return to place promptly when released

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24
Q

what is skin mobility & turgor assess for?

A

elasticity of skin and hydration status

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25
what areas of the body do we assess for mobility & turgor?
anterior chest or forearm *DONT use back of hand*
26
poor skin mobility indicates what?
edema
27
poor skin turgor indicates what?
dehydration
28
what is skin tenting?
when the skin remains staying up and does not return back
29
what are normal skin mobility & turgor findings?
skin should promptly return to place when released
30
what characteristics do we assess for in lessions?
-color -elevation -pattern shape -size -location and distribution -texture -presence of exudate (drainage, not color & odor)
31
ABCDE mnemonic for skin cancer
A: asymmetry B: border C: color D: diameter E: evolving
32
what does it mean if a mole is larger than 6 cm?
could indicate cancer
33
normal findings in older adult skin
-uneven skin pigmentation -loss of elasticity -epidermis thins & flattens -dermis thins & flattens -loss of elastin, collagen, and subcuataneous fat -decreased # of sweat & sebaceous glands -decreased skin vascularity & increase in fragility
34
normal healthy nail findings
pink, translucent, smooth, firm, well-rounded, convex, nail angle of about 160 degrees, and good adherence to nail bed
35
what is clubbing in nails?
bulging of nail base leading to abnormal curvature of nail
36
what is clubbing in nails associated with?
chornic hypoximia = chronic decreased oxygen levels
37
how do we assess for clubbing?
flex fingers back to back and look for a diamond shape -diamond shape = no clubbing
38
what are some abnormal nail findings?
pitting, indents, and fungal infection
39
normal hair findings in older adults
-decreased growth -decreased in axillae & pubic -increased facial hair in women -decreased melanocytes -> leading to gray & thin hair
40
normal nail findings in older adults
-growth rate decreases -lack luster (dull) -longitudinal ridges
41
what is a pressure injury?
localized damage to the skin and or underlying soft tissue usually over a boney prominence or related to a medical device
42
how do pressure injuries occur?
intense and/or prolonged pressure or pressure in combination with shear (when underlying tissue shifts)
43
characteristics for those at risk for pressure injuries
microclimate, nutrition, perfusion, co-morbidities and condition of soft tissue
44
what medical devices cause pressure injuries?
-nasal cannula -feeding tubes -oxygen max -catheter (lying on tubing) -compression devices (must be take off at least once a shift) -TED stockings (must be smooth, stretched out, and no bunching)
45
how often should we assess for pressure injuries?
assess at least once a shift and after turning and repositioning or removing medical devices look at side that you just turned
46
stage 1 pressure injury
-non-blanchable erythema -intact skin
47
stage 2 pressure injury
-part thickness skin loss -exposed dermis -no sluff
48
stage 3 pressure injury
-full-thickness skin loss to subcutaneous layer -may have undermining or tunneling -may or may not have sluff
49
stage 4 pressure injury
-full-thickness skin and tissue loss to tendon, cartilage, or bones -undermining or tunneling
50
unstageable pressure injury
obscured full-thickness and tissue loss
51
deep tissue injury
-persistent non-blanchable deep red, maroon, or purple discoloration -can be intact or non-intact
52
how can we see if a patient is a risk for a pressure ulcer? what risk assessment tool do we use?
Braden Scale
53
does the braden scale prevent pressure ulcers?
no
54
what if the braden scale score is low, what does it indicate?
a higher risk of developing pressure injuries, after completion you may look at what are the problem areas
55
what are the six subscales for the braden scale
-sensory perception -activity -mobility -moisture -nutrition -friction & shear
56
what are some things that can be done to prevent pressure injuries?
-turning & repositioning every 2 hours -HOB @ 30 degrees (higher we sit up the more we will have shearing) -pillows & waffle mattress -moisture barrier cream -avoid adult diapers (plastic retains heat & moisture) -frequent assessment
57
what does hygiene affect?
comfort, safety, and well being
58
what are some personal hygiene elements?
bathing, perineal care/incontinence care, hair care, oral hygiene, shaving, and foot and nail care
59
does every individual perform hand hygiene the same?
no, every person is different
60
what are some factors that influence hygiene practices?
-social practices -personal preferences -body image -socioeconomic status -health beliefs & motivation -cultural variables -physical condition
61
what are different kinds of bed baths?
-complete bed bath or shower -partial bed bath -soap and water vs. disposable bed bath cloths -chlorhexidine gluconate (CHG) = mouthwash -perineal care/incontinence care/foley care
62
soap and water vs. disposable bed cloths
-soap and water are a reservoir for bacteria & -disposable bed cloths only clean external sites
63
how should we properly care for dentures?
-keep dentures covered in water when not worn -store in an enclosed LABELED cup at patient's bedside
64
what happens if an older adult showers with too hot water, harsh soap, and too frequently?
very dry flaky skin
65
what happens if an older adult shampoos hair too much?
dry scalp and hair
66
edentulous
no teeth and complete or partial dentures

nurs 222: funds (15 decks)

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