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56 Cards in this Set
- Front
- Back
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Pressure area involves epidermis, dermis, & subq tissue, bone & other support tissue; resembles a massive crater w/hidden areas of adjacent tissue.
Describes what stage pressure ulcers? |
stage IV
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What does the dermis contain?
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nerve fibers, blood vessels, sebaceous glands, sweat glands, & hair follicles
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What does the epidermis shield against?
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shields underlying tissue against water loss, injury & prevents entry of microorganism
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What are the 3 layers of the skin?
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epidermis, dermis, sub-q tissue
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What are the 5 functions of the skin?
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protects, secretes, excretes, regulate temp, & is a sense organ
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What causes a change in hair color or condition?
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a lack of hormones & nutrients to the hair follicle
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What 6 factors can affect hair characteristics?
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hormonal changes, emotional stress, physical stress, aging, infection, certain illnesses
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oral mucosa is normally....
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light pink & moist
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What does disease cause in nails?
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changes in the shape, thickness, & curvature of nail
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What are nails?
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they are epithelial tissues that grow from the root of the nail bed, located in the skin at the nail groove
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What does sub-q tissue do?
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insulates & cushions the skin
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What is the nurse's responsibilities in oral hygiene?
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maintenance & prevention
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What does the buccal cavity consist of?
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lips surrounding the opening of the mouth, the cheeks running along the side walls of the cavity, the tongue & its muscles, & the hard & soft palate
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A normal healthy nail is...
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transparent, smooth, convex, w/a pink nail bed & translucent white tip
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Nasal mucosa is normally...
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pink,clear & w/o discharge
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What do you inspect the nares for?
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signs of inflammation, discharge, lesions, edema, & deformity
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When assessing external ear structures, what is the nurse most concerned with?
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the presence of accumulated cerumen or drainage on the ear canal, local inflammation, or pain
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Normal external eye structures are...
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conjuctivae are clear & not inflamed, eyelid margins are in close approximations w/the eyeball, lashes are turned outward, lid margins are w/o inflammation, drainage or lesions, eyebrows should not have flaking skin
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A nursing daignosis is accurate only if...
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you select the appropriate related factors, which influence the nursing therapies chosen
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Skin is broken & there is superficial skin loss involving the epidermis alone or also the dermis. Resembles a blister.
Describes what stage pressure ulcers? |
stage II
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What are medicated baths?
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relieve skin irritation & create an antibacterial & drying effect
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What is a sitz bath for?
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cleanses & reduces pain & inflammation of perineal & anal areas
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Proper oral hygiene does what?
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prevents inflammation & infection & promotes comfort, nutrition, & verbal communication
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Why are the accessory muscles used on breathing?
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They are used to facilitate inspiration in cases of acute & chronic airway obstruction or atelectasis.
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List the 5 abnormal chest configurations & causes.
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Barrel chest- hyperinflation;emphysema
Kyphosis- loss of resiliency & a loss of skeletal muscle |
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What does COLDSPA stand for?
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Character
Onset Location Duration Severity Pattern Associated Factors |
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What are the abnormal shapes of nail & what does it mean when nails are incorrectly shaped?
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early & late clubbing- hypoxia
spoon nails- anemia beaus lines- acute illness pitting- psoriasis paronychia- local infection |
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What is he function of nails?
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to protect the distal ends of the fingers & toes
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What is the function of the nasal hair, eyelashes, & eyebrows?
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filters dust & other airborne debris
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Pressure are involves epidermis, dermis, & subq tissue. The ulcer resembles a crater.
Describes what stage of pressure ulcers? |
stage III
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What is the subcutaneous tissue, where is it located, & what is its main function?
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It is a loose connective tissue containing fat cells, blood vessels & nerves that merges w/ the dermis. Assists w/heat regulation. Contains vascular pathways for the supply of nutrients & the removal of waste products from the skin.
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What 3 layers is the skin composed of?
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Epidermis
Dermis Subcutaneous Tissue |
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What does the appearance of the skin,hair & nails provide the nurse with?
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data that may reveal local or systemic problems, alterations, or trauma in clients self-care activities or disease/infection. Also provides data r/t health maintenance, hygiene, exercise, nutrition & occupation.
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Name the key points to remember when inspecting skin,hair & nails.
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Inspect skin color, temp, moisture, & texture
check skin integrity be alert for skin lesions evaluate hair condition, loss or unusual growth note nail bed condition & capillary refill |
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What are the steps in analysis of data?
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Identify
Cluster Group Look Refer Nursing Diagnosis |
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Name what will need to be documented on skin lesion.
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Note color, shape & size; location, distribution & configuration
Measure lesion fungal- shine a wood's light on the lesion |
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What are the types of vascular skin lesions?
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petechia
ecchymosis hematoma cherry angioma spider angioma telangiectasis |
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Name normal assessment findings for the skin.
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evenly colored skin, slight/none skin odor, intact & no reddened skin areas; skin lesions are normal; smooth & even skin texture;moist to dry; warm & good skin turgor
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What does it indicate when nails are an abnormal color?
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pale/cyanotic- hypoxia/anemia
splinter hemorrhages- trauma yellow- fungal infections/psoriasis |
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What does thickened nails often indicate?
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decreased circulation
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What is the best light for examining skin?
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sunlight
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What does ABCDE stand for?
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Asymmetry
Borders Color Diameter Elevation |
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How does steroid therapy affect the skin?
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causes the skin to be very thin
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Where do you assess for jaundice?
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Sclera, oral mucosa, palms & soles
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Explain the difference between central & peripheral cyanosis.
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Central cyanosis results from a cardiopulmonary problem & can be seen in the oral mucosa
Peripheral Cyanosis is a local problem resulting from vasoconstriction. |
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What are normal skin lesions?
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striae
moles freckles birthmarks healed scars |
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Skin is unbroken but appears red; no blanching when pressed.
Describes what stage of pressure ulcers? |
stage I
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What are the 2 categories of baths?
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cleansing & therapeutic
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What is the function of scalp hair?
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protective covering
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Name the different breathing patterns.
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normal
tachypnea bradypnea hyperventilation hypoventilation cheyne-stokes biot's |
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List the normal breath sounds.
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brochial
bronchovesicular vesicular |
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What causes crepitus?
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occurs when air passes through fluid or exudate
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What causes fremitus?
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caused by vibrations of air in the bronchial tubes transmitted to the chest wall
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What is the normal diaphragmatic excursion & how do you measure it?
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excursion should be equal bilaterally and measure 3-5 cm in adults
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List adventitious breath sounds.
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fine crackles, coarse crackles, pleural friction rub, wheeze, strider, rhonchi, pulomary edema
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List the different colors of sputum & what it indicates.
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yellow/green= bacterial or fungus
white,mucoid,clear= viral, common cold,bronchitis rust= TB, pneumonia red= respiratory pink, frothy= exposure to irritants, chronic bronchitis, pulmonary abcess |
