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PN Exam 9 Class #89
Ch 53-55 MS
| Question | Answer |
|---|---|
| What is the Integumentary system and what does it do? | It is skin, hair, nails, scalp and mucous membranes. It is the protective layer of our bodies defending against pathogens that may be potentially harmful, the body's first line of defense. Skin is an organ. |
| What are the 3 layers of skin tissue? | 1. Epidermis- outermost layer 2. Dermis- middle layer 3. Hypodermis- bottom layer |
| What is the layer of the epidermis that primarily defends against infection? | The stratum corneum: it is the outermost layer of skin cells. |
| How are skin cells replaced? | By skin cells underneath, the lower new layers push old layers up until they fall off. |
| What gives skin and hair its coloring? | Melanin |
| What are mutagenic UV rays capable of doing? | Damaging the DNA in cells and causing mutations that can result in malignancy (cancer). |
| What substance in the dermis gives the skin its strength? | Extensive Collagen Fibers. **Also provides elacticity. |
| What does the Hypodermis do for the body? | It is mainly composed of areolar and adipose (fat): gives body insulation. |
| What are the 3 main glands in the skin? | 1. Eccrine glands 2. Apocrine glands 3. Sebaceous glands |
| What is an Eccrine gland? | Glands that produce sweat, found concentrated on hands, feet, forehead, and torso. Helps maintain and regulate body temp. |
| What is an Apocrine gland? | Contain a duct to the hair follicle that Produce scent that responds to stress and sexual stim. |
| What is an Sebaceous gland? | Open into the hair follicle and secrete an oily substance called SEBUM that helps lubricate skin and hair. |
| What is most important to remember when assessing skin? | It can visibly communicate a patient's health. |
| What method should be used if there is a skin issue? | The WHATS UP method Where is it? How does it feel? Aggravating and Alleviating factors? Timing? Severity? Useful other data? Patient's Perception? |
| What are some changes that occur in an aging Integumentary system? | 1. Gray and thinning hair 2. Thin skin, slower to heal 3. Wrinkles develop 4. Temperature becomes harder to regulate 5. Skin becomes dry |
| What are some questions to ask during data collection for the integumentary system? | 1. History 2. Risk Factors 3. Hair 4. Nails 5. Medications 6. Exposures |
| Examination of the skin includes? | 1. Entire skin area 2. Hair 3. Nails 4. Scalp 5. Mucous Membranes |
| What is Erythema? | Redness |
| What might thick nails indicate? | Fungal Infection |
| When caring and assessing an older patient's feet, what are some things to focus on? | 1. Redness and breakdown on bony prominences 2. Inspect for dryness and cracking 3. Inspect between toes 4. Look for calluses 5. Thick toenails 6. Palpate pulses for circulation 7. Patient sense to touch |
| When cleaning feet? | Thoroughly dry feet especially between toes, do not apply lotion to toes. |
| Diabetic feet? | Always inspect with patient's shoes off. |
| What is a Punch Biopsy? | Uses a small, round cutting instrument, called a punch, to cut a cylander-shaped plug of tissue for a full-thickness specimen. |
| What are the steps in culturing a wound? | **1. Clean the wound well! Use sterile saline to remove excess drainage and debris from the wound. 2. Using a sterile calcium alginate swab in a rotating motion, swab wound and wound edges 10 times. 3. Do NOT swab over eschar or slough 4. Place swab in cu |
| What does a Wood Light Examination do? | Uses UV rays to detect a fluorescent materials in the skin and hair present in certain diseases such as TINEA Capitis (ringworm). |
| What is the purpose of Wet Dressings? | To decrease inflammation, cleanse a dry wound, and promote drainage of infected areas. |
| Wet dressing must not be prescribed for more than? | 72 hours **No more than 1/3 of the body should be covered in wet dressings at a time. |
| What is Balneotherapy? | Therapeutic bath: Is useful in applying medications to large areas of the skin, as well as for debridement, or removing old crusts; for removing old medications; and to relive itching and inflammation. |
| When using tar Balneotherapy what should you remember? | Keep he room well-ventilated: tars are volatile. |
| What are Antipruretics? | Anti-itching meds. |
| How are Ointments and Creams applied? | With a gloved hand or wooden tongue depressor. |
| What are Powders used for? | Moisture absorption and reducing friction: zinc, oxide, talc, cornstarch bases. **Avoid use with individuals who have breathing problems. |
| What are Pastes used for? | Inflammatory disorders |
| What are Topical Corticosteroids used for? | Reduce or relieve pain and itching by decreasing inflammation, use them sparingly and according to package directions. |
| Why should wet dressings and ointments only be applied to affected areas? | They can cause maceration of good/ healthy skin. Plastic wrap dressings and other occlusive dressings should be removed for and least 12 out of every 24 hours: this prevents skin atrophy. |
| What are Hydrocolloid dressings used for? | AKA DuoDERM, and Tegaderm: help protect areas exposed to pressure and treat pressure injuries in early stages. |
| What should be used to cover a skin tear? | **Nonadherent dressing, such as Xeroform and wrapped in gauze. |
| What are Balnetar, Polytar, and Neytrogena T/Gel considered? | Tar Therapy |
| Where are Melanin Granules located? | The base of the hair shaft |
| What is another term for Atarax? | Hydroxyzine CHL |
| What is the category of Vistaril? | Antihistamine |
| What color is a sign of infection? | Yellow/green |
| What are bed sores caused by? | Ischemia to tissue, lack of O2 |
| What factors aggravate Psoriasis? | Strep infections, Sunburn, and Excessive Alcohol |
| What is the lesion type associated with Psoriasis? | Plaque |
| Herpes are what type of Lesion? | Vesicles |
| Acyclovir is used for what? | Herpes |
| What is Basal cell carcinoma? | Most common skin cancer. often 100% treatable |
| How quickly do Scabies die after treatment? | 24hrs |
| What sign is specific to Scabies infestation? | Small itchy red squiggly lines. |
| Faruncle and Carbuncles are? | Bacterial infections, often Staph. |
| Most fluid loss after a burn occurs when? | 12hrs after |
| What are some burn side effects? | 1. Curling Ulcer 2. Fluid Deficit 3. Contractures **4. Infection |
| What are 3 common corticosteroids? | 1. Accutane- Acne treatment 2. Zovirax- Antiviral Herpes Treatment 3. Diflucan- Antifungal |
| Who should you NOT give Diflucan to? | Anyone who has Renal Impairment or Liver Disease. |
| What are 2 main things to remember and teach about Antibiotic use? | 1. Finish the prescription regardless of feeling better. 2. Avoid heating pads on top of antibiotic ointments. |
| How can you help prevent patient's from scratching? | 1. Cut their nails 2. Antipruretics (anti-itch) 3. Antihistamines |
| What should you remember when applying Zovirax? | Wear Gloves! (it treats herpes) |
| What are Hydrocolloid dressings used for? | Low moisture wounds, they keep air off and moisture in wound. |
| How quickly can pressure ulcers injuries begin forming? | 20-40 mins of constant pressure |
| What can you teach to patient's to Maintain Mobility? | 1. Shift weight every 15 mins when sitting or lying 2. Provide active or passive ROM 3. Turn every 2 hours **4. HOB no higher than 30 degrees 5. Reposition every hour when in a chair (Avoid the use of Donut shaped cushions) |
| What are the best practices for skin care in patients at long-term and acute settings? | 1. Assess risk factors 2. Avoid frequent bathing 3. Use oil-soluble moisturizers for dry skin 4. Protection against exposure to urine or stool 5. Cleaning moist areas (between toes, under folds, under boobies) |
| What are the best wounds for healing? | Beefy red wounds |
| What is the three color system for pressure injuries? | 1.Black wounds indicate necrosis (dead tissue) 2. Yellow wounds have Slough (a layer of dead tissue, may be infected) 3. Red wounds are pink or red = healing stage |
| How do you heal a pressure injury? | Remove the area from any pressure. |
| What are the 4 main types of Debridement? | 1. Mechanical 2. Enzymatic 3. Autolytic 4. Surgical- nurses do not do surgical |
| What is Eschar? | Black or brown hard scab or dry crust, or thick, black, leatherlike tissue that forms from necrotic tissue. |
| What is Mechanical Debridement? | Scissors and forceps are used to remove dead tissue. |
| How do wet-to-dry dressings work? | They are applied wet DIRECTLY to the wound (avoid healthy tissue), and connect to the tissue as they dry. When they are removed, it removes the dead skin along with the dressing. |
| What is Enzymatic Debridement? | Enzymatic topical enzyme is applied, , the nthey selectively digest necrotic tissue. Again, avoid any contact with healthy tissue. |
| What is Autolytic Debridement? | The use of a synthetic dressing or moisture-retentive dressing over the injury, eschar then self-digests .Hence, this method is not used for infection, for it could exacerbate it. |
| What do pressure injuries result from? | Results from tissue anoxia. Can begin to develop within 20-40 mins of unrelieved pressure on the skin. |
| What are other causes for pressure injuries? | Pressure from a tight splint or cast, traction, or other device. |
| Who is at risk for pressure injuries? | Individuals who are immobile, have decreased circulation, or have impaired sensory perception or neurological function. |
| In order to help patient's maintain mobility what are some things to remember? | 1. Shift their weight every 15 mins if possible when sitting or lying down. 2. Provide frequent PROM or AROM and turn at least every 2 hours. 3. When side positioning, place the HOB no more than 30 degrees. 4. When seated, Re position at least every hour. |
| Should you use a donut shaped cushion? | No, this can actually promote ischemia, instead of promoting circulation. |
| What is the area of a wound that should be cleaned first? | Always move irrigation from the most clean area, to most dirty (this helps prevent recontamination). |
| Wounds heal most quickly in what environment? | a moist environment with minimal bacterial colonization and a healing temp. this takes 12hrs to occur after the wound is covered with an occlusive dressing. |
| What are the 4 Pressure injury stages? | Stage 1: skin is still intact, but the area is red and does not blanch when pressed. Stage 2: Partial-thickness skin loss with exposed dermis. Stage 3: Full-thickness skin loss with visible fat showing. Stage 4: Full-thickness skin loss with exposed musc |
| What are the 2 other categories of pressure injuries? | 1. Unstageable: Full-thickness skin and tissue loss is hidden by slough or eschar so the depth cannot be evaluated. 2. Deep Tissue Injury: Intact or non-intact skin area with persistent, non-blanchable, dark red-maroon-purple discoloration. |
| What is Dermatitis? | Inflammation of the skin. |
| How should the patient avoid dermatitis irritation to the skin? | Avoid allergens, irritants, and excessive heat and dryness and by controlling perspiration. Baths should be short in tepid water. only use mild superfatted soaps. Lubricate dry skin. Prevent itching and scratching as much as possible. |
| What are the main clinical manifestations of Dermatitis? | Itching and rashes or lesions. |
| How can itching or pruritis be managed/ relieved? | By antihistamines, analgesics, and atipruritic medication as ordered. |
| What can be used to suppress inflamation? | Steroids such as hydrocortisone or methylprednisone. |
| What is Psoriasis? | A chronic inflammatory skin disorder in which the epidermal cells proliferate abnormally fast. ** Epidermal cells shed every 4-5 days. |
| Psoriasis is what in nature? | Autoimmune: T cells attack healthy cells causing an increase in skin cell, T cell, and white cell production. Characterized by exacerbations and remissions. |
| What are occlusive dressings commonly used for? | To enhance penetration of medications. |
| What is Herpes Simplex Virus (HSV)? | A common viral infection that tends to recur repeatedly. |
| What are the 2 types of Herpes Simplex? | Type 1 virus: occurs above the waste and causes a fever blister or cold sore. Type 2 virus: occurs below the belt and causes genital herpes. |
| How do you prevent Herpes Simplex? | 1. Avoid sharing contaminated items such a toothbrushes, lipsticks and drinking glasses. 2. Use sunscreen especially on the lips to prevent outbreaks and irritation. |
| What is Herpes Zoster? | Shingles, an acute inflammatory and infectious disorder that produces a painful vesicular eruption of bright red edematous plaques along the distribution of nerves from one or more posterior ganglia. |
| What is Herpes Zoster caused by? | The same virus that causes chickenpox. |
| How do you prevent Herpes Zoster? | 1. Varicella Vaccine (Verivax)- for children and adults who have not had chickenpox. 2. Zostavax- recommended for all patients over age 60 who have had chickenpox. |
| What is Dermatomycosis? | A fungal infection of the skin. **Tinea is the term used to describe fungal skin infections. |
| What is Tinea Pedis? | Common fungal infection, mostly seen on feet. Types: 1. Interdigital 2.Chronic Hyperkeratonic 3. Inflammatory/Visicular 4. Ulcerative |
| How is Tinea Pedis treated? | 1. Apply topical antifungal agents 2. Use wet or vinegar dressings when ordered 3. Teach to keep feet dry, dry between toes, wear cotton socks, **Wear water shoes in public bathrooms. |
| What are normal characteristics of skin? | Skin is intact, with no abrasions, and is smooth, dry, well hydrated, and warm. Skin turgor is firm and elastic. |
| What is a Papule? | Palpable solid raised lesion that is due to superficial thickening in the epidermis. Ex Ringworm, warts, moles. |
| What is a Vesicle? | A small blisterlike raised area of the skin that contains serous fluid. Ex. Poison ivy, shingles, chickenpox. |
| What is a Wheal? | Round, transient elevation of the skin caused by dermal edema and surrounding capillary dilation; white in center and red in periphery. Ex. Hives, insect bites. |
| What is a Pustule? | Small elevation of skin or vesicle that contains lymph or puss. Ex. Impetigo, scabies, acne. |
| What is Plaque? | A patch or solid, raised lesion on the skin or mucous membrane. |
| What is a Cyst? | A closed sac or pouch which consists of semisolid, solid or liquid material. Ex. Sebaceous cyst. |
| When scraping scales for a culture, how should you position the patient? | So that the skin lesion is vertical. Place the slide against the skin below the lesion. Wear gloves during and perform hand hygiene. |
| What are the S/S of Impetigo Contagiosa? | Rash appears as oozing, thin-roofed vesicle that rapidly grows and develops a honey colored crust; crusts are usually easily removed and new crusts appear; lesions heal in 1-2 wks if allowed to dry. Rash is contagious until all lesions are healed. |
| What is Scabies? | A contagious skin disease caused by the mite Sarcoptes Scabiei, resulting from contact with another infected host or clothes. |
| What do Scabies do? | The parasite borrows into the superficial layer of the skin. These burrows appear as short, wavy, brownish black lines. |
| What are some common skin tendencies in people from different cultures? | 1. African Americans: have a greater chance of developing Keloids, the men may have facial hair that curls back into itself. 2. Dark-skinned people have a tendency for birthmarks/ mongolian spots. 3. Freckles are most common in fair skins. |
| What is a Keloid? | A benign growth of fibrous tissue (scar formation) at the site of trauma or surgical incision. often, occurs on the torso. |
| Treatments for Keloids include? | Compression therapy, corticosteroid injections into lesions, excision, and laser therapy. |
| What is Basal cell carcinoma? | The most common type of skin cancer. Tumor is most often seen on sun exposed areas of the body. Looks like a small pearly papule with a rolled and waxy edge. |
| What is Malignant Melanoma? | Malignant growth of pigment cells. Highly metastatic, this skin cancer has the highest mortality rate. It appears dark brown or black and has irregular shaped edges. |
| What are the characteristics that should be reported for skin lesions? | 1. Assymetrical shape 2. Irregular or poorly defined border 3. Variable color 4. Diameter larger than a pencil eraser 5. Changing appearance |
| What kind of skin protection should be used to prevent skin cancer and UV damage? | Sunscreen with an SPF of at least 15 or more and wear sun protective clothing like hats, sunglasses, and long sleeves. |
| What are 5 things to remember with skin damage from burns? | 1, Temp of burning agent 2. Burning agent itself 3. Duration of exposure. 4. Conductivity of tissue. 5. Thickness of the involved dermal structures. |
| What is the severity of a burn injury is determined by? | 1. Depth of tissue destruction 2. Percentage of body surface area injured 3. Cause of burn 4. Age of patient 5. Related injuries 6. Medical History 7. Location of burn wound |
| What are the 3 classifications of burn depth? | 1. Partial thickness (superficial) 2. Partial thickness (deep) 3. Full thickness |
| In an emergency situation what is the first part of the ABC's? | Airway always comes first! |
| What is an Escharotomy? | Relieves pressure from the skin on the circulatory system underneath. It is a linear excision through the eschar to the superficial fat that allows for expansion of the skin and return of blood flow to the heart or chest expansion. |
| What should a nurse remember before assisting with an Escharotomy? | To provide adequate padding of the bed because the procedure can be accompanied by copious amounts of drainage. ** Check for return of distal pulses. |
| What do Biological dressings help with? | Wound healing, and stimulate Epithelialization. These dressings may be used as donor site dressings to manage a partial-thickness burn, or to cover a clean excised wound before autografting. |
| What is an Autograft? | A skin graft from the patient's unburned skin that is placed on the client. |
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merelisen3
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