1 Fundamentals - Skin Integrity + Hygiene

Front 1

what is the first line of protection, it is considered an organ and helps with protection, sensation, temperature, vitamin D and body image

Back 1

Skin

Front 2

what is another word for decubitus ulcer?

Back 2

pressure ulcer

Front 3

signs that can be measured, inspection and palpation, are called

Back 3

objective

Front 4

symptoms such as general health changes and pain, puritus, is called

Back 4

subjective

Front 5

what do you look for when INSPECTING?

Back 5

Color
Vascularity

Front 6

pallor , cyanosis, jaundice are what colors respectively?

Back 6

pale, blue, yellow

Front 7

vascularity deals with

Back 7

blood vessels

Front 8

a bruise, black and blue

Back 8

ecchymosis

Front 9

a rash, red dots

Back 9

petachaie

Front 10

collection of blood under the skin

Back 10

hematoma

Front 11

what is the first line of protection, it is considered an organ and helps with protection, sensation, temperature, vitamin D and body image

Back 11

Skin

Front 12

what is another word for decubitus ulcer?

Back 12

pressure ulcer

Front 13

signs that can be measured, inspection and palpation, are called

Back 13

objective

Front 14

symptoms such as general health changes and pain, puritus, is called

Back 14

subjective

Front 15

what do you look for when INSPECTING?

Back 15

Color
Vascularity
Lesions

Front 16

pallor , cyanosis, jaundice are what colors respectively?

Back 16

pale, blue, yellow

Front 17

vascularity deals with

Back 17

blood vessels

Front 18

a bruise, black and blue

Back 18

ecchymosis

Front 19

a rash, red dots

Back 19

petachaie

Front 20

collection of blood under the skin

Back 20

hematoma

Front 21

when inspecting for lesions you must consider

Back 21

size
shape
depth
drainage
color
elevation
borders

Front 22

a wound is measured in

Back 22

millimeters

Front 23

when using Palpation, you feel for

Back 23

temperature
moisture.dryness
turgor
edema
texture

Front 24

elasticity test by clavicle - pinch gently to test, skin should return back into place

Back 24

turgor

Front 25

swelling is also known as

Back 25

edema

Front 26

when inspecting Nails , palpate for capillary refill on a pink nail bed- what is capilarry refill?

Back 26

push in nail bed
less than 4 seconds
for capillary to refill

Front 27

when inpsecting Hair/Scalp, inspect for

Back 27

color, evenly distributed, no alopecia which is baldness

Front 28

your patient has lower elasticity, thinner, medications are increasing , need for circulation and nurtrition...what lifespan change is he in

Back 28

aged

Front 29

your patient has jaundice and slight acne, this lifespan stage is

Back 29

newborn

Front 30

area of tissue ischemia or cellular necrosis is called

Back 30

pressure ulcers

Front 31

what occurs when capillary blood flow is obstructed by pressure?

Back 31

tissue ischemia

Front 32

pressure ulcers are most likely to occur due to friction and shearing forces in what areas

Back 32

sacrum
lower back/cosack

Front 33

name some risk factors for
pressure ulcers

Back 33

immobility
nutrition
moisture
mental status
age
poor circulation

Front 34

formation of a pressure ulcer is affected by these two things

Back 34

duration and amount
of pressure

Front 35

what occurs when pressure is relieved and skin heals without tissue damage

Back 35

Reactive Hyperemia

Front 36

Stage of pressure ulcer where skin is broken, blister and a partial thickness skin loss (abrasion)

Back 36

stage 2

Front 37

Stage of pressure ulcer where Skin is intact with persistant redness or purplish hue.

Back 37

stage 1

Front 38

Stage of pressure ulcer with full thickness skin loss, deeper ulcer

Back 38

stage 3

Front 39

Skin is Intact ONLY in what stage

Back 39

stage 1

Front 40

Stage of pressure ulcer where ulcer has caused extensive damage to muscle , bone, tissue damage and sinus tracts are likely . Full thickness skin loss, need wound therapy for months

Back 40

stage 4

Front 41

What risk factor for pressure ulcer development are you reducing by instructing the patient to use the overbed trapeze...this is not used with elderly.

Back 41

Friction

Front 42

what two ways can you asess an ulcer/sore

Back 42

REEDA
COCA

Front 43

what does REEDA stand for when assesing pressure ulcers

Back 43

Redness
Edema (Sweling)
Ecchymosis (bruising)
Drainage
Approximation

Front 44

What does COCA stand for

Back 44

Color
Odor
Consistency
Amount

Front 45

if you come across a legion while inspecting and palpating all skin surfaces, you must note

Back 45

Characteristics

Front 46

your patient has an area blanching of the skin over the area under pressure (turns lighter in color, ischemia) with persistant redness (erythema) and bluish or purple tones of skin...you would diagnose your pt with

Back 46

pressure ulcer

Front 47

What stage is the deepest extensive ulcers needing wound therapy for months, diabetics may lead to amputation

Back 47

stage 4

Front 48

give an example of a short term patient goal and describe why its a good goal

Back 48

The PT will walk 10 feet today.....the goal MUST be measurable.

Front 49

what is a clinically validated tool that allows nurses and other health care providers to reliably score a patient/client's level of risk for developing pressure ulcers.

Back 49

The Braden Scale

Front 50

Nursing Interventions for Skin - when you see yellow skin you must

Back 50

clean it

Front 51

when skin is black gray, necrotic tissue must be __________

Back 51

removed, so healing can take place

Front 52

your pt has warm , dry, pink , intact skin... is this diagnosis a normal and correct way to document findings

Back 52

yes

Front 53

name the stage of pressure ulcer

sinus tracts have developed

Back 53

stage 4

Front 54

name the stage of pressure ulcer

the skin is in tact

Back 54

stage 1

Front 55

the ulcer is superficial like a Blister

Back 55

stage 2

Front 56

there is partial thickness skin loss of epidermis

Back 56

stage 2

Front 57

there is Full thickness skin lost

Back 57

stage 4

Front 58

what is called when you reduce blood viscosity (thickness)

Back 58

vasodilation

Front 59

vasodilation , reduced muscle tension, increased tissue metabolism and capillary permeability are psychological effectrs of ______

Back 59

heat therapy

Front 60

examples of HEat therapy are

Back 60

warm moist compresses
warm soaks
stiz bath
hot packs
aquathermia k pad
electric heating pads

Front 61

exmples of cold therapy are

Back 61

cold soaks
ice bag collar
cold packs
cold moist compresses

Front 62

Cold Therapy should be left for intervals of 20-30 minutes or what will occur

Back 62

rebound effect

Front 63

your pt has a had a muscular injury, abdominal cramping- what therapy would be good for him

Back 63

hot threapy

Front 64

your pt had a stroke and a rising high temperature, what therapy would be good for him

Back 64

cold therapy

Front 65

a schedule for hygiene care is

Back 65

AM
PRN - as needed
HS hour of sleep
before meals
after toileting
judgement

Front 66

what is used to prevent thrombosis (blood cloths) in lower extremeties to promote and stimulate circualtion

Back 66

anti embolic stockings

Front 67

helps to force blood in the superficial veins of the legs into deeper veins to rpevent stagnation and pooling of blood and maintain venous return to the heart

Back 67

anti embolic stockings

Front 68

Do you massage legs when anti embolic stockings are on?

Back 68

NO

Front 69

Wheels locked and bed in a low position is good bed safety

t/f

Back 69

true

Front 70

Elastic Stockings are also known as

Back 70

TEDS stockings