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28 Cards in this Set
- Front
- Back
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Integument Level 1 assessment
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SKIN:
-Intergrity -temperature -Lesions -turgor -pigment -Perspiration -Sensitivity (pain) SCALP: -smooth -moist -clean HAIR: -Clean -Distribution NAILS: -nail beds pink -beds firm and smooth |
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Behaviors related to insect sting
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Itching- Pruritis
Redness-Erythema Swelling-Edema -Wheal: from the sting will have a white central spot Tenderness on Palpation Warm to the touch |
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Interventions related to insect sting
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-tepid bath/compresses
-remove stinger -apply cortisone/antihistamine cream -elevate area -decrease scratching -cleanse area to avoid infection -teach prevention (no perfume, no bright flowery clothes, wear shoes always -keep area clean and dry |
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Therapeutic baths
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-saline
-oatmeal -cornstarch -NA bicarb -K+ permanganate |
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Infections of Skin:
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-Tinea capitis
-corporis -cruris -pedis -impetigo -folliculitis -cellulitis |
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Infections of Skin Interventions
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-Standard precautions
-Isolate infected from susceptible others -maintain careful hand washing after care -avoid unnecessary close contact -appropriate disposal of dressings etc.. -teach hygienic care -Medication administration-protect, soothe, cleanse, RX organisms |
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Skin lesions
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-contact dermatitis
-atopic dermatitis (eczema) -seborrheic dermatitis (cradle cap) -dry skin -scabies -sunburn -nevi -diaper rash -abrasions |
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Antibodies: IgG
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-largest component of the total immunoglobulins
-only one that can cross the placenta to give newborns passive acquired immunity |
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Antibodies: IgA
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-primary defense for disease in mucosal membranes
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Antibodies: IgM
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-largest immune globulin
-responsible for primary immune response -forms antibodies to ABO blood antigens |
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Antibodies:IgE
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-causes symptoms of allergic reaction (triggers histamine)
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Antibodies: IgD
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-present of lymphocytes surface
-roles in helping differentiate B Lymphocytes |
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Cell Mediated Immunity
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-immunity against intracellular pathogens
-Fungal infections -transplanted tissue -tumor cells -hypersensitivity reactions |
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Effects of Aging on immune system:
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-decrease cell-mediated reactions
-thymus size decreases -decrease response of T and B cells -decrease in primary and secondary antibodies -increase in tumors and susceptibility to infection |
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Lymphocytes: B-cells
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-make antibodies from plasma cells
-immediate reaction -make memory cells |
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Lymphocytes: T-cells
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-no antibodies
-release cytokines, activate B-cells and NK cells -CD-4: are Helper-T cells that release lymphokines to attract neutrphils (regulate cell-mediated and humoral responses) (hyperactivity causes allergies and autoimmune responses) -CD-8: Killer-T cells that attack antigens on cell membranes of pathogens and release cytotoxic substances that kill the pathogen (hyperactivity causes tissue damage) |
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Hypersensitivity Responses
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-Type 1: allergic, IgE mediated reactions (uses on mast cells)
-Type 2: Cytotoxic, antibody mediated (eg. Transfusion) -Type 3: Immune Complex, autoimmune disease -Type 4: delayed hypersensitivity, T-cell mediated (TB test, poison ivy) |
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Factors Effecting Bowel Elimination
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-Age
-Meds -Exercise -Medical Condition -Diet -Lifestyle/patterns -stress |
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Characteristics of the Outcome
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-Shape
-Odor -Frequency -Content -Amount -Color -Consistency |
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Constipation
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-hard stools
-difficulty passing stool -painful -long durations between stools |
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Diarrhea
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-lots of stool
-loss of control -large number of eliminations -watch for dehydration |
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Flatulence
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-caused by food or carbonation
-avoid causes -drink from a straw |
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Hemmorrhoids
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-caused by pressure
-vericose veins in anal area -can be due to occupation (inner or outer) |
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Imperforate Anus
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-in newborns when the opening to the anus is missing or blocked
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Incontinence
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-inability to control defication/urination
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Fecal Impaction
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-stool not moving (may be deficating liquid stool because it is getting around blockage)
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Encopresis
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-repeated, involuntary elimination of stool in inappropriate places(in school age children who are potty trained)
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Urinary Disruptions
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-Nocturia (going 2 or 3 times a night)
-Enuresis (bed wetting) -UTI -Urinary Frequency -Urgency -Incontinence (stress, urge, iatrogenic, functional, mixed) |
