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65 Cards in this Set

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These are functions of what: Prevents loss of body fluids, protects deeper tissues from pthogenic organisms, noxious chemicals, and short-wavelength ultraviolet radiation, helps regulate body temperature, provides locatioons for sensory reception of touch, pressure, temperature, pain, wetness, tickle,etc, assists in vitamin d synthesis and plays a minor excretory role?
Skin
How should you palpate the temperature of the skin?
with the back of the hand
Where should you assess skin turgor?
sternum or under the clavicle
On dark colored patients where should you assess the skin?
soles of feet and white part of the eye
These are a sign of what: bluish grey skin tone of nail beds, ear lobes, lips, mucous membranes, palms and soles. Dark skinned patients: ashen or gray color conjunctive of eye, mucous membranes and nail beds and hypoxemia?
cyanosis
This is a sign of what: dark red, purple, yellow or black tone, can be from anticoagulant therapy, clotting disorders, or trauma.
Ecchymosis or bruise
This is a reddish tone of skin, dark skin- deeper brown or purple skin tone. Can be from Polycythemia, localized infection or burns
Erythema
This is a yellow color of sclera, fingernails, palms of hands, mucous membranes. Dark skin- yellowish-green color, sclera of eye and dark yellow urine and will have high billirubin levels. Can be from hepatic disease.
Jaundice
Decreased hair growth may indicate what?
decreased circulation
Patchy baldness with breakage of hair shaft at surface can be from what?
Alopecia areata or ringworm
What is hair loss from wearing tightly bond hairstyles?
traction alopecia
What is hair loss from habitual pulling caused by OCD?
Trichotillomania
What is excessive hair from hormonal dysfunction, hereditary factors or certain medications? May have altered hair color, possible malnutrition, pernicious anemia, or nerve injury
Hirsutism
Dry, brittle hair may indicate malnutrition, or what?
hypothyroidism
Increased silkiness and thinning if the hair may indicate what?
hyperthyroidism
Scaling or Scalp eruption may indicate ______ or seborrheic dermatitis.
psoriasis
Curvature of the nail should be convex with an angle of about ___ degress between the nails and skin at the nail base.
160
What can cause brittle, thinning, peeling nail plates?
nutritional or circulatory deficiences or damage from external chemicals
What can cause cracks or fissures in nails?
malnutrition
White nail plates can indicate ______.
hypoalbuminemia
Pale nail plates can indicate what?
Anemia
Greenish-black nail plates can indicate what?
Fungal or bacterial infection (pseudomonas)
Yellow nail plates can be from psoriasis, respiratory disease,____ _____, staining from nail polish
cigarette smoking
Spoon shaped(concave) nails would indicate what?
iron deficiency
Poor adhesion of nails to nail bed or pitting nail plate can indicate what?
psoriasis
Clubbing is an indicator of what?
Cardiopulmonary disease
_______ hemorrhages of nail bed can be from endocarditis, psoriasis, or trauma.
Splinter
What is slightly raised tan to black, warty lesions, covered with a greasy crust that leaves a raw pulp when removed?
Seborrheic keratosis
What is a small tumor that consists of blood or blood vessels and are normal of age thirty and older?
Cherry angiomas
What is loss of hair?
Alopecia
This is a common assessment abnormality- tumor of blood or lymph vessel?
angioma
This is a white depigmented area of skin, can occur when someone has skin issues and can be caused by constant application of medicine to one area.
Vitligo
What are visible dilated superficial cutaneous small blood vessels, seen with alcoholics and steroid users?
Telangiectasia
What is increased prominence of superficial veins?
Varicosity
Where would you assess a dark-skinned patient for Jaundice?
Hard palate for yellow discolorization
What diagnostic test is performed using a small circular instrument or punch ranges from 2-6 mm. Plug of tissue is removed and may be closed with 1-2 stiches. Local anesthetia is used.
Punch biopsy
What test is removal only of the portio of the skin that is raised? Local anesthesia is used, scapel is moved parallel to the skin, and no suturing is necessary?
Shave biopsy
What is the removal or entire lesion such as larger or deeper specimens (moles), sutures are used and patients must be taught about wound care and infection prevention?
Excisional Biopsy
What test is for allergy testing, they inject small amounts of allergin to skin?
Patch test
A localized area of tissue necrosis caused by unrelieved pressure that occludes blood flow to the tissues, generally found over bony prominence, and formally called ________ ulcers, pressure sores or bed sores. They are caused by friction, shearing force, excessive moisture, and or pressure.
Decubitus
What is the most common scale for prediction the need for intervention of pressure ulcers?
BRADEN SCALE
_____ may be more important than a single score when predicting pressure ulcer risk.
Trending
________ increase skin fragility , edema, and decrease healing all of which can increase risk of developing pressure ulcers.
Corticosteroids
What pressure ulcer stage is this- an observable pressure related alteration of intact skin
May be warmer or cooler than adjacent skin; may have a firm or boggy feel(like a tomato); patient may report pain or itching in the area; persistent redness in light skinned individual, persistent red, blue or purple hues in darker skinned individuals; and "non-blanchable" erythema
Stage I
What is a condition in which a "red spot" appears on the skin from pressure. This spot will blanch out, which indicates that the tissue will recover is the pressure is removed and differentiates from stage I ulcer (which is persistant redness)?
Reactive Hyperemia
What stage of pressure ulcer is partial thickness skin loss involving epidermis and or dermis. Can be superficial, presents clinically as an abrasion, blister, shallow crater. May look like a skin tear (like you peeled tope of blister off)?
Stage II
What stage of pressure ulcer is full thickness skin loss, involves damage of SQ tissue that may extend down to, but not through the underlying fascia around the muscle, clinically presents as a deep crater, may or may not exhibit undermining of adjacent tissue.
Stage III
What pressure ulcer stage is full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone or supporting structure? May include tendons or joint capsule and have undermining and sinus tracts?
Stage IV
What are long extensions of the ulcer under the surrounding skin and tissues, may extend some distance from the visible wound, and overlying skin may look fairly "normal".
Sinus tracts
Staging of the ulcer cannot be done until the wound bed can be seen, so if any ______ (thick, dark scab like material) is present it must first be debrided.
Eschar
_____ tissue may also cover the wound bed, so it must be debrided prior to staging.
Necrotic
What is the best cleaner for pressure ulcers, applied with a 35 mL or bigger syringe with 19 gauge angiocath to clean wound out so you don't apply too much pressure?
Normal room temp saline
Why should you avoid cytotoxic cleaners such a Dakin's solutin or betadine?
These solutions kill new cells
When is the only time debridement is not used on a pressure ulcer?
dry, stable eschar covered heels. These are treated by keeping them pressure free and they will heal from the inside out.
What are the three types of debridement, choice is based upon patient condition, goals of therapy, and available clinical expertise?
sharp, mechanical, and or autolytic
What kind of debridement is a surgical prodedure, generally done in the OR and may require general anesthesia (some patients may not be candidates for general anesthesia); can also be done under sterile conditions at the beside by physician or specially trained RN or PT; it is often used when there is an infection present?
Sharp debridement
What kind of debridement is done with application of wet-to-dry dressings; this dressing is applied in contact with the necrotic tissue, dries into that tissue, and then pulls bits of the tissue away as it is removed from the wound. Key is to get the dressing material we enought to get "into" the necrotic tissue, but not so wet that it will not dry between dressing changes?
Mechanical Debridement
What kind of debridement is when ointments are applied directly onto the necrotic material and then covered by dressing. These ointments can be Accuzyme, Panafil, Ziox, Liberase, and Elastase. These materials then "eat into" the necrotic tissue and dissolve it away over time. Must be very careful not to allow meds to contact intact skin.
Enzymatic Debridement
Autolytic Debridement---The body has the capacity to remove necrotic tissue through ______. This capacity can be supported through application of occlusive dressings- Hydrocolloid or Hydrogels- or materials that hold body fluids close to the wound bed and keep it moist; such as calcium alginates. This approach should not be used dif the wound is infected.
autolysis
What are materials such as Duoderm or Tegasorb that are placed over the wound and then allowed to remain in place for a period of time. The idea is to keep the wound bed moist and the oxygen level low. Problems include rollingup of edges of dressing, causing additional pressure areas.
hydrocolloids
What are made from seaweed and may have a "fishy" odor when dressing is removed. They dissolve and "fill in" the area under an occlusive dressing and help to keep the good body fluids close to the bed of the wound. Turns into a jelly that may be yellowish in color. They include Algiderm, AlgiSite, and Sorban
Calcium Alginates
Some pressure ulcers need surgical reconstruction for covering such as skin grafting, skin flaps, musculocutaneous flaps, and _____ flaps. Post-operative management includes ensuring pressure relief to the operative site for a minimum of 2 weeks.
free
All stage II through stage IV pressure ulcers are assumed to be colonized with what? Expect that you patient will be treated with an antibiotic, generally administered IV if the patient is hospitalized, but po if the patient is in home care.
Bacteria
Fluid balance and adequate _____ are essential in promoting healing.
nutrition
During the evaluation of an ulcer you should monitor ___ and fever.
WBC