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31 Cards in this Set

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What aspects of the skin should you assess?
color, odor, temperature, texture, turgor, edema, and any visible lesions.
What assessments should you perform if you find a lesion?
size, shape, color, distribution, texture, surface relationship, exudate, and presence of pain or tenderness.
What warning signs lead you to suspect a malignant lesion?
The warning signs of malignant lesions are as follows:
A–for asymmetry
B–for border irregularity
C–for color variation
D–for diameter >0.5 cm
E–for elevation above the skin surface
Identify the major functions of the skin.
The skin has five major functions:

Protection of the internal organs
Unique identification of an individual
Thermoregulation
Metabolism of nutrients and metabolic waste products
Sensation
What is the function of the stratum corneum, the outermost layer of the skin?
The stratum corneum serves as a barrier, which has three functions:

Restrict water loss
Prevent entry of fluids into the body
Protect the body against the entry of pathogens and chemicals
What is the function of the subcutaneous layer?
The subcutaneous layer, which is primarily connective and adipose tissues, has three functions:

Insulation
Protection
Reserve of calories in the event of severe malnutrition
What effect does aging have on skin?
As adults age, aging has the following effects on the skin:

The activity of the sebaceous and sweat glands diminishes resulting in drier skin.
The subcutaneous tissue layer thins, giving the individual a sharp angular appearance. Excess caloric intake and weight gain can offset this change of appearance.
The strong bond between the epidermal and dermal layers decreases as the dermal layer looses elasticity.
These changes make the skin prone to breakdown and slow the healing of a wound.
What effect does immobility have on skin?
Patients with impaired mobility often cannot reposition themselves, leading to pressure over bony prominences, which can lead to skin breakdown.
Identify the factors that affect skin integrity.
Eleven factors affect skin integrity:

Age
Mobility status
Nutrition
Hydration
Sensory status
Circulation
Medications
Exposure to moisture
Exposure to harmful microorganisms
Fever
Lifestyle
What nutritional components are essential to maintain skin?
Adequate intakes of five nutritional components are essential to maintain skin:

Protein
Calories
Fluid
Vitamin C
Minerals
Explain the difference between an acute and a chronic wound.
Acute and chronic wounds have different durations and causes.

Acute wounds are expected to be of short duration. Acute wounds may be intentional (surgical incisions) or unintentional (trauma).
Wounds are classified as chronic when they exceed the anticipated length of recovery. Chronic wounds include pressure, arterial, venous, and diabetic ulcers. These wounds are frequently colonized with bacteria, and healing is very slow because of the underlying disease process. A chronic wound may linger for months or years.
Describe the wound categorization system based on contamination.
Wounds are categorized based on four levels of contamination:

Clean wounds are uninfected wounds with minimal inflammation. They may be open or closed and do not involve the gastrointestinal, respiratory, or genitourinary tracts (these systems frequently harbor bacteria). There is very little risk of infection for these wounds.
Clean-contaminated wounds are surgical incisions that enter the gastrointestinal, respiratory, or genitourinary tracts. There is an increased risk of infection for these wounds, but there is no obvious infection.
Contaminated wounds include open, traumatic wounds or surgical incisions in which a major break in asepsis occurred. The risk of infection is high for these wounds.
Infected wounds are wounds with evidence of infection, such as purulent drainage or necrotic tissue. Wounds are considered infected when bacteria counts in the wound tissues are above 100,000 organisms per gram of tissue.
How does wound depth affect healing?
Wound depth is a major determinant of healing time. As wound depth increases, healing time also increases.
Describe four types of wound closures.
Adhesive strips (Steri-strips)
Sutures
Surgical staples
Surgical glue
Vacuum-assisted
Compression stockings
Identify five types of wound complication.
Five types of complications can occur with wounds:

Hemorrhage
Infection
Dehiscence
Evisceration
Fistula
Describe three signs of internal hemorrhage
Answers may include any three of the following signs of internal bleeding:

Swelling of the affected body part.
Pain.
Changes in vital signs.
A hematoma (a red-blue collection of blood under the skin). A hematoma often forms as a result of internal bleeding. The amount of blood in a hematoma varies. A large hematoma causes pressure on surrounding tissues. When the hematoma is located near a major artery or vein it may impede blood flow.
Differentiate between dehiscence and evisceration
Dihesence and evisceration have the following differences:

Dehiscence is the separation of one or more layers of the wound.
Evisceration is the total separation of the layers of a wound with internal viscera protruding through the incision.
What should be included in a wound assessment?
A wound assessment should include the following parameters:

The type of wound
The color of the wound and surrounding skin
The condition of the wound bed and surrounding skin
The color, consistency, amount, and odor of exudate or drainage
Pain or discomfort related to the wound or wound care
What is the preferred method of wound culture that may be performed by a registered nurse?
Needle aspiration of a wound is the preferred method for a culture obtained by nursing staff.
Identify the major interventions for preventing pressure ulcers.
The following major interventions prevent pressure ulcers:

Skin care
Adequate nutrition
Frequent position changes
Use of therapeutic mattresses and cushions
Patient and family teaching
Identify the objectives of nursing interventions for red, yellow, and black wounds
Nursing interventions have the following objectives for wounds:

Protect a red wound
Cleanse a yellow wound
Debride a black wound
Describe the four types of wound debridement.
The four types of wound debridements are sharp, mechanical, enzymatic, and autolysis:

Sharp debridement is the use of a sharp instrument, such as scalpel or scissors, to remove devitalized tissue.
Mechanical debridement may be performed via the use of wet-to-dry dressings, hydrotherapy (whirlpool), or lavage.
Enzymatic debridement is the application of a topical enzymatic agent to the wound.
Autolysis is the use of an occlusive moisture-retaining dressing and the body's own mechanisms for ridding itself of necrotic tissue.
Identify the purposes of a wound dressing
The primary purposes of dressings are as follows:

Protect from contamination and heat loss
Aid hemostasis
Absorb drainage
Debride the wound
Splint the wound site
Prevent drying of the wound bed
Keep the surrounding tissue dry and intact
Provide comfort to the patient
What is the effect of adding moisture to heat or cold treatments?
The addition of moisture amplifies the intensity of the treatment
For how long should heat or cold be applied to an area?
Heat or cold should be applied intermittently, leaving on for no more than 15 minutes at a time to avoid tissue injury.
What precautions should you take before using heat or cold therapy?
The following precautions should be taken before heat or cold therapy:

Avoid direct contact with the heating or cooling device. Cover the hot or cold pack with a washcloth, towel, or fitted sleeve.
Apply hot or cold intermittently, leaving on for no more than 15 minutes at a time in an area. This helps prevent tissue injury (e.g., burns, impaired circulation). It also makes the therapy more effective by preventing rebound phenomenon: At the time the heat or cold reaches maximum therapeutic effect, the opposite effect begins.
Check the skin frequently for extreme redness, blistering, cyanosis (turning blue) or blanching. When heat or cold is first applied, the thermal receptors react strongly and the person feels the temperature intensely. Over about 30 minutes, the receptors adapt to the new temperature, and the person notices it less. Caution clients not to change the temperature when this occurs because this can cause tissue injury.
Normal Variants of Skin Color
Capillary hemangiomas – Milia
“Cradel cap”
Mongolian spots
Port wine stains
Acne
Wrinkles
skin tags
Striae
Skin Color Variations
Pallor
Cyanosis
Erythema
Ecchymosis
Jaundice
Petechiae
assessment of hair, skin and nails
Inspection
Palpation
Olfaction
Color
Temperature
Moisture
Texture
Skin Lesions
Macule - Flat & colored- i.e. freckle, petechiae, birthmark, Mongolian spot
Papule - Elevated & raised, but superficial – i.e. include: mole
Vesicle - Elevated & filled with fluid – i.e. blister, burns, chickenpox, herpes, herpese zoster follows a nerve
Nodule - Elevated & firm – i.e. wart, lipoma (fatty cyst)
Tumor -Elevated & deep – i.e. breast mass, epithelioma
Wheal - Elevated, superficial, with localized edema – i.e. include insect bite, hives, PPD test, hives = urticaria.
Pustule - Elevated & filled with pus – i.e. acne, foliculits, impetigo
Secondary Lesions
Ulcer -Irregularly shaped with loss of tissue
Crust -Elevated, rough texture with dried exudate
Scale - Shedding dead skin cells
Atrophy - Thinning of skin with transparent appearance
Scar - Fibrous tissue at site of injury, trauma or surgery. Have patients cover their chest scars when coughing.
Keloid - Raised and irregular scar due to excess collagen formation
Excoriation - Superficial abrasion, diaper rash.
Fissure - Linear break in the skin of varying depths