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133 Cards in this Set
- Front
- Back
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What are the 3 layers of skin?
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1) Epidermis
2) Dermis 3) Subcutaneous tissue |
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What are two things contained the epidermis? What function do they serve?
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Keratin= provides waterproofing
Melanin= provides color to skin |
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What type of glands are contained in the dermis layer of skin? What functions do they lend?
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Sebaceous glands= contributes oil to skin
Sweat glands= contributes sweat to skin |
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The ___________ layer supports the ____________ layer.
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dermis, epidermis
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What insulates the subcutaneous layer?
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fatty cells
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What is the largest organ in the body?
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Skin
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A skin assessment also includes:
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hair and nails
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T/F You can assess skin while performing other parts of the health assessment?
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True. While checking pulses, edema, or chit chatting with patient you can assess for lesions and their locations, the condition and characteristics of the skin, and for ulcers.
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What are 9 characteristics of skin?
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1) is it intact 2) color or discoloration
3) moist/dry 4) temperature 5) ecchymosis 6) oiliness/dryness 7) edema 8) elasticity/tenting 9) nutrition of patient |
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What are 5 functions of skin?
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1) Protection 2) Thermoregulator 3) Secretions 4) Sensation 5) Provides vitamin D 6) Electrolyte regulator
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What's thermoregulation balance?
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Heat production = heat loss
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As muscle activity goes up (exercise); ___________ _______ goes up.
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Generated heat
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Why is thyroxine output important?
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Because increased thyroxine levels lead to increased cell metabolism. This is called Chemical Thermal Genesis
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What's the normal body temperature?
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36-38 degrees Celsius.
96.8- 100.4 degrees Fahrenheit |
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How is the sympathetic nervous stimulated?
What happens? |
Norepinephrine and epinephrine
Cellular metabolism is increased. |
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A fever results in 2 things?
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Increased cellular metabolism and increased body temperature
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What occurs with decreased BMR?
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Decreased heat production
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Shivering leads to what?
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Increased heat production
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Shivering increases _______ ___________ by ____ times
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heat production; 45
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What are the 4 types of heat loss?
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1) Radiation
2) Conduction 3) Convection 4) Evaporation |
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What is radiation?
What is it affected by? |
Transfer of heat from one surface to another without direct contact
body surface area--the greater the surface area, the greater the heat loss |
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heat loss in fetal position is _________
heat loss in the standing position |
less than
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T/F heat loss and heat production can occur simultaneously?
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True
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Vasoconstriction leads to ________ heat loss
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decreased
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Vasodilation leads to __________ heat loss
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increased
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What is conduction?
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Heat transfers through direct contact
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What is convection?
Example? |
Transfer of heat by way of air current
A fan blowing air around; Cuisinart convection oven. |
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What is evaporation?
Example? |
Loss of heat via fluid evaporation
Sweating or water vapor in exhalation. |
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Who is most at risk for deficient thermoregulation?
Why? |
Infants and the elderly (>75 yr)
Decreased fat tissue, skin wasting, decreased nutritional diet intake, decreased activity, decreased thermoregulating efficiency. |
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As level of exercise increases, the body temperature __________?
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Increases
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Who is most affected by hormones? When is this group most affected?
What hormone is it linked specifically to? |
Females.
During ovulation and after menopause. "Hot flashes" teperature swing and sweats for 10-15 minutes. Progesterone |
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How does stress affect temperature?
Why does it affect temperature? |
Stress increases body temperature because stress stimulates the sympathetic nervous system.
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How does environment affect body temperature?
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The warmer the climate; the warmer the patient's body temperature.
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How does Circadian Rhythm impact body temperature?
How long might it take for a 3rd shift to adjust to 3rd shift? |
The highest temps. are from 8 pm to 12 am. The lowest are from 4 am to 6 am.
Up to a year. |
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What is pyrexia?
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It's a fever over 38 degrees Celsius 100.4 degrees Fahrenheit.
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What is a subnormal temperature?
What is a low grade fever? What is hyperpyrexia? |
temperature below normal
temperature above normal an extremely high temperature over 105.8 degrees Fahrenheit. |
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What are the 4 types of fevers?
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1) Constant/subtained 2) Intermittent 3) Remittent 4) Relasping
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A constant/substained fever is a body temperature that is __________ _______ __________.
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always above normal
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An intermittent fever is a that _______ and _____ _______ __ __________.
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spikes; then returns to normal
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A remittent fever is a fever that ______ _________ __________ __ _________.
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spikes without returning to normal
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A relasping fever _______ ______ _______ __ __ ____________ _________ __ __ __________ _____ __ _______.
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that spikes and returns to an acceptable temperature in a time over 24 hours.
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What are the 5 causes of a fever?
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1) Inflammatory response 2) Allergies
3) Infection 4)Cerebral/Neurological Injury 5) Drug/Blood reaction |
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Which part of the brain is known as the "body's thermostat?"
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The hypothalamus
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What's the important job of the hypothalamus?
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It's the body's thermostat. It controls the body's set temperature point.
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Where is the hypothalamus located?
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Between the cerebral hemispheres.
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What part of the brain controls heat loss?
What part of the brain controls heat production? |
anterior portion of the hypothalamus= heat loss
posterior portion of the hypothalamus=heat production |
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What happens if the there is a brain stem injury?
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The body temperature can climb and climb and climb up. Eventually it can "burn itself out" and lead to death.
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What are pyrogens?
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Fever producing bacteria that occur with infections
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The hypothalamus will raise the set temperature point when _____________.
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it is triggered by hormone-like substances
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What will the patient experience while experiencing pyrexia?
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chills
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How do WBCs affect body temperature?
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increases body temp
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How do chills affect body temperature?
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Increases body temperature. The shivering increases muscle activity.
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How does the body release heat?
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Vasodilation, sweating, breathing
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The physiological causes of a fever?
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hypothalamus pyrogens
WBCs chills heat release: through vasodilation, diaphoresis, afebrile |
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Symptoms of a fever?
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aches headaches
diaphoresis malaise patient is warm to touch patient feels cold delerium tachycardia tachypnea |
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Nursing diagnoses related to thermoregulation?
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Dehydration r/t.......
Ineffective thermoregulation r/t,,,,,,,,, Hypo-/Hyperthermia r/t........ Risk for imbalanced body temperature r/t........... |
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Nursing interventions for a fever?
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cooling blanket, ice bags, get cultures then give antibiotics, PRN pyretics, assess mental status, get VS, give oral fluids, change bed linens/clothing, frequent oral care, maintain I/O, patient to be on bedrest
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What is Malignant Hyperthermia
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hereditary condition of uncontrolled heat production occuring when susceptible persons receive anesthetic drugs. It's usually fetal.
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Why does malignant hyperthermia happen?
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The patient has a rxn to anesthetic given during surgery
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What happens when a patient experiences malignant hyperthermia during surgery?
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The surgery stops, a hypothermia blanket is put on them, the patient will wake up and feel the pain from surgery, 20 bottles of meds will need to be opened.
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What should a nurse do before a patient goes in for surgery?
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A nurse should perform a thorough patient hx prior to surgery. Ask if they or any family members have had any problems with anesthesia in the past. A blood test can be done for 8-10K--only 8 institutions perform the test in the US.
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What is Dantrolene used for?
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It is a medication that is used for malignant hyperthermia. It's expensive.
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How is the test for malignant hyperthermia perfomed?
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A biopsy of muscle tissue is needed.
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What is succinylcholine used for?
What condition does succinylcholine increase the risk for? |
Paralytic intubation.
Malignant hyperthermia. |
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What is a heat stroke?
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When a person is exposed to extremely high temperatures for extended periods of time causing the hypothalamus to malfunction.
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What precedes a heat stroke.
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Heat exhaustion.
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Who is most at risk for a heat stroke?
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Infants, the eldery, people suffering from cardiovascular disease, alcoholism, diabetes, or hypothyroidism, strenuously working people (construction, farmers, athletes)
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What medications make a person more susceptible to heat strokes?
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Phenothiazides, antihistamines, anticholinergics (Parkinson's disease), antiemetics (Phenergan), cogentin, diuretics, amphetamines, and beta-adrenergic receptor antagonists
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Signs and symptoms of a heat stroke?
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Flushed skin, not sweating, confusion, visual disturbances, muscle cramps, increased thirst, nausea, delirium, dry hot skin, low BP, high heart rate, temperature as high as 113.
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What can a heat stroke lead to?
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loss of consciousness, fixed pupils, and permanent neurological damage.
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How do you treat a heat stroke?
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Put the patient in a cooler environment, replace fluids and electrolytes. (Want isotonic soln if IV)
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What are the signs and symptoms of heat exhaustion
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profuse diaphoresis which leads to fluid deficits
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What are the types of hypothermia?
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Accidental: examples: fall into a cold body of water, lack of shelter, inadequately dressed.
Induced: example: surgerically induce for cardio. or neuro. surgeries. |
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What is hypothermia?
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heat loss during a prolonged exposure
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What are the signs and symptoms of hypothermia?
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decreased heart rate, decreased BP, cyanotic, cardiac dysrhythmias, lost level of consciousness, unresponsive to painful stimuli, clinical signs of death.
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At ______ degrees F, the body starts to shiver and patient's ___ levels _______ because the ______ are using ____ to ________ _____.
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95, O2, decrease, muscles, O2, generate heat.
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Why do they surgerically induce hypothermia?
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To reduce the O2 needs of the body.
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What causes frostbite?
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Ice crystals form inside cell d/t exposure to extreme cold. It's a localized freezing of the skin and subcutaneous tissues. It leads to permanent circulation and tissue damage.
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What are signs and symptoms of frostbite?
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Area appears white and waxy, area is firm to touch,and the patient lost sensation to the area.
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Which areas are prone to frostbite?
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earlobes, nose tip, fingers, toes
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How do you tx frostbite?
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gradually warm areas with a warming blanket or layers of clothing, get VS, put frostbitten person next to another person, support cardio. function, raise BP, protect injured tissue, and frequently assess temperature
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Fahrenheit to Celsius
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(F-32) x (5/9)
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Celsius to Fahrenheit
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[(9/5) x C] + 32
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How do antipyretic medications affect thermoregulation?
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They reduce fever by increasing heat loss
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Antipyretics include?
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Acetaminophen (Tylenol)
NSAIDS (salicylates like ASA, ibuprofen, naprosyn), corticosteriods |
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Which medication acts like an antipyretic but is not usually used to treat fevers?
Why isn't it used? |
Corticosteriods
Because it masks signs of infection |
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What are the indications of using an antipyretic?
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prevent shivering and to prevent using oxygen stores
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What is the classification of antipyretics?
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analgesic and antiinflammatories
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What are the indications to use antipyretics for?
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mild-moderate pain, inflammation, and fever
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What are the objectives need to be addressed when a patient has a fever?
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increase heat loss, decrease heat production, and prevent complications
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What are the side effects of antipyetics?
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GI bleed, nausea, vomiting, dizziness, flushing, drowsiness, epigastric distress, ringing in the ears.
corticosteriods mask s/s of infection. |
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How are antipyretics administered?
What's the usual dose? |
orally and rectally
Depends on the size and age of the individual. |
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Tylenol dose is usually _________?
Give ____ and/or ____ with _____? Why? |
325-600 mg q 4hrs PRN
milk, food, ASA or corticosteriods. In case you are concerned about GI bleed |
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Heat has what effects?
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It increases: circulation, cell metabolism, and blood flow. It promotes healing, vasodilation, and movement of waste products. It relieves muscle stiffness, and muscle spasms.
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Why should heat therapy be ceased after 45 minutes?
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Because the reflux vasoconstriction response that will ultimately decrease circulation.
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What's the result of continuous heat?
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epithelial cell damage that will lead to tenderness, edness, and blisters
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How often should check the site heat is applied to?
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every 10 minutes
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Cold has what effects?
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Vasonconstriction, diminishes pain and swelling, promotes blood coagulation, decreases cell metabolism, bacterial growth and oxygen needs of cells.
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Prolonged exposure to cold therapy leads to?
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inadequate blood flow and nutrients to tissue. 1st site is reddened, then area has blue-purplish mottlling with numbness and burning pain
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Cold should be applied for no longer than?
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Every hour because of the vasodilation reflux effect
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Examples of moist heat are?
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Warm soaks, warm bath, sitz bath (used for hemorrhoids, whirlpools, dampening the felt pad of a aquathermic pad
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Moist heat is good for?
What needs to be checked with moist heat? |
Hemorrhoids, episiotomy. rectal surgery, and vaginal inflammation.
Check water temp and add hot water if water cools. |
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Examples of dry heat are?
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Water bottles, hot packs, heating pad, hyperthermic blankets
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Contraindications of heat therapy?
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trauma if after 1st 24 hours, extensive blood loss, malignant tumor, erythemia , blisters, abdominal pain
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Contraindications of cold therapy?
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open wounds, hypersensitivity to cold, neuropathy, impaired circulation
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Contraindications to both heat and cold?
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Neurosensitivity, impaired mental status, impaired circulation, open wounds
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What condition is an examples of a condition that will impair circulation?
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PVD. Lack the ability to dissipate heat via circulation. Pt is at risk for tissue damage b/c of poor circulation and blood pooling.
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If you suspect a circulatory problem, what should you assess?
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Capillary refill, color of extremities, compare the color of left side of body to the right side of the body, touch patient's skin and palpate pulses.
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Why should heat and cold not be applied to an open wound?
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Cold= lessens blood flow and inhibits healing
Heat= increases blood flow and could lead to a hemorrhage |
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Guidelines for applying heat or cold include
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get a baseline, assess the pt for temp. sensitivity, heat/col tol., assess the area, explain th eprocedure, apply a barrier btwn device and skin, reassess q 15 minutes, remove at appropriate time, examine area and document response. Inspect equip. for frayed wires and exposed heating components.
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Other cautions to be aware of in heat or cold therapy?
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Age (young/old)
Renal Insuff./Failure Edema New tissue Abdominal pain Spinal injury |
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Developed neuropathies from renal insufficiencies or failure can?
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lower tolerance to heat or cold
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New tissue is ________________ to heat and cold therapy?
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More sensitive
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You should cautiously apply heat to abdominal pain or oral pain because?
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Abdominal pain may be sign of appendicitis and heat could cause appendix to rupture. Oral pain may be an abscess and applied heat would could sepsis.
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Why do the elderly have less tolerance for heat and cold?
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Thinner skin layers and wasting. They are more at risk for burns.
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Why should you be cautious with heat and cold therapy with a patient with a spinal injury?
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Because they have altered nerve pathways, decreased sensation, and decreased pain reception.
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When you palpate the skin you should assess what?
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dry/moist, smooth/rough, color of, edema present, intact/nointact, temperature of
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Preferred lighting to inspect skin in?
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Indirect light
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macule
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What is a papule?
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A palpable firm solid in skin <1cm
Examples: wart, pimple, |
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Palpule
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What's a plaque?
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A primary skin lesion that's palpable solid in skin that doesn't extend into lower skin layers and is >1cm
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What's a nodule?
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A primary skin lesion that's a solid, hard mass deeper in the dermis and between 0.5 - 2 cm
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What's a tumor?
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A primary skin lesion that's a solid, hard mass that extends through the subcutaneous tissue and is >2 cm. It has irregular borders.
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What's a cyst?
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A primary skin lesion that's encapsulated, semi-solid or fluid-filled it can be >1cm
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What's a vesicle?
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Circumscribed round or oval translucent mass that's <0.5 cm. Filled with sebaceous fluid or blood.
example= chicken pox, blisters, cold sores |
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Plaque
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Nodule
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Tumor
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Vesicules
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Bulla
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Pustule
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Wheal
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