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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
Q

what areas of the body do we assess for mobility & turgor?

A

anterior chest or forearm
DONT use back of hand

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26
Q

poor skin mobility indicates what?

A

edema

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27
Q

poor skin turgor indicates what?

A

dehydration

28
Q

what is skin tenting?

A

when the skin remains staying up and does not return back

29
Q

what are normal skin mobility & turgor findings?

A

skin should promptly return to place when released

30
Q

what characteristics do we assess for in lessions?

A

-color
-elevation
-pattern shape
-size
-location and distribution
-texture
-presence of exudate (drainage, not color & odor)

31
Q

ABCDE mnemonic for skin cancer

A

A: asymmetry
B: border
C: color
D: diameter
E: evolving

32
Q

what does it mean if a mole is larger than 6 cm?

A

could indicate cancer

33
Q

normal findings in older adult skin

A

-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
Q

normal healthy nail findings

A

pink, translucent, smooth, firm, well-rounded, convex, nail angle of about 160 degrees, and good adherence to nail bed

35
Q

what is clubbing in nails?

A

bulging of nail base leading to abnormal curvature of nail

36
Q

what is clubbing in nails associated with?

A

chornic hypoximia = chronic decreased oxygen levels

37
Q

how do we assess for clubbing?

A

flex fingers back to back and look for a diamond shape
-diamond shape = no clubbing

38
Q

what are some abnormal nail findings?

A

pitting, indents, and fungal infection

39
Q

normal hair findings in older adults

A

-decreased growth
-decreased in axillae & pubic
-increased facial hair in women
-decreased melanocytes -> leading to gray & thin hair

40
Q

normal nail findings in older adults

A

-growth rate decreases
-lack luster (dull)
-longitudinal ridges

41
Q

what is a pressure injury?

A

localized damage to the skin and or underlying soft tissue usually over a boney prominence or related to a medical device

42
Q

how do pressure injuries occur?

A

intense and/or prolonged pressure or pressure in combination with shear (when underlying tissue shifts)

43
Q

characteristics for those at risk for pressure injuries

A

microclimate, nutrition, perfusion, co-morbidities and condition of soft tissue

44
Q

what medical devices cause pressure injuries?

A

-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
Q

how often should we assess for pressure injuries?

A

assess at least once a shift and after turning and repositioning or removing medical devices look at side that you just turned

46
Q

stage 1 pressure injury

A

-non-blanchable erythema
-intact skin

47
Q

stage 2 pressure injury

A

-part thickness skin loss
-exposed dermis
-no sluff

48
Q

stage 3 pressure injury

A

-full-thickness skin loss to subcutaneous layer
-may have undermining or tunneling
-may or may not have sluff

49
Q

stage 4 pressure injury

A

-full-thickness skin and tissue loss to tendon, cartilage, or bones
-undermining or tunneling

50
Q

unstageable pressure injury

A

obscured full-thickness and tissue loss

51
Q

deep tissue injury

A

-persistent non-blanchable deep red, maroon, or purple discoloration
-can be intact or non-intact

52
Q

how can we see if a patient is a risk for a pressure ulcer? what risk assessment tool do we use?

A

Braden Scale

53
Q

does the braden scale prevent pressure ulcers?

A

no

54
Q

what if the braden scale score is low, what does it indicate?

A

a higher risk of developing pressure injuries, after completion you may look at what are the problem areas

55
Q

what are the six subscales for the braden scale

A

-sensory perception
-activity
-mobility
-moisture
-nutrition
-friction & shear

56
Q

what are some things that can be done to prevent pressure injuries?

A

-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
Q

what does hygiene affect?

A

comfort, safety, and well being

58
Q

what are some personal hygiene elements?

A

bathing, perineal care/incontinence care, hair care, oral hygiene, shaving, and foot and nail care

59
Q

does every individual perform hand hygiene the same?

A

no, every person is different

60
Q

what are some factors that influence hygiene practices?

A

-social practices
-personal preferences
-body image
-socioeconomic status
-health beliefs & motivation
-cultural variables
-physical condition

61
Q

what are different kinds of bed baths?

A

-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
Q

soap and water vs. disposable bed cloths

A

-soap and water are a reservoir for bacteria
&
-disposable bed cloths only clean external sites

63
Q

how should we properly care for dentures?

A

-keep dentures covered in water when not worn
-store in an enclosed LABELED cup at patient’s bedside

64
Q

what happens if an older adult showers with too hot water, harsh soap, and too frequently?

A

very dry flaky skin

65
Q

what happens if an older adult shampoos hair too much?

A

dry scalp and hair

66
Q

edentulous

A

no teeth and complete or partial dentures

nurs 222: funds (15 decks)

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