Skin and Wound Care: Understanding the Largest Organ and Pressure Ulcer Management, Exams of Nursing

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NUR 205 EXAM 2 Questions with Verified Answers.

Largest Organ of the body - ANS the Skin Two layers of the skin - ANS Epidermis and Dermis Epidermis - ANS top layer of skin Stratum Cornea - ANS Outermost layer of the epidermis, which consists of flattened, keratinized cells Define Pressure Ulcers - ANS Described as impaired skin integrity related to unrelieved, prolonged pressure, usually over a boney prominence Pressure Ulcer Risk Factors - ANS -decreased mobility -decreased sensory perception -fecal or urinary incontinence -poor nutrition Individuals at risk for pressure ulcers - ANS -older adults that have experienced a trauma -those with spinal cord injuries -those who have sustained a fractured hip -those in long-term homes or community care, the acutely ill -individuals with diabetes -patients in critical care settings (ICU) Dermis - ANS inner layer of skin, provides tensile strength, mechanical support, and protection for the underlying muscles, bones, and organs Tissue Ischemia - ANS Pressure applied over a capillary exceeds the normal capillary pressure, and the vessel is occluded for a prolonged period of time. Dermal-epidermal junction - ANS separates dermis and epidermis 3 pressure related factors that contribute to pressure ulcer development - ANS - pressure intensity -pressure duration -tissue tolerance Non-blanch able hyperemia - ANS redness that persists after palpation and indicates tissue damage Stage 1 Pressure Ulcer - ANS -intact skin with nonblanchable redness -warm to touch, edema, can be a hardened area

Stage 2 Pressure Ulcer - ANS -partial thickness skin loss -shallow but open -no slough or drainage -red/pink wound bed Stage 3 Pressure ulcer - ANS -full thickness tissue loss with visible underlying fat -NO bone, muscle or tendon is visible -can have slough -undermining/tunneling Stage 4 Pressure ulcer - ANS -full thickness tissue loss WITH visible muscle, bone or tendon -tunneling/undermining Unsaleable Pressure Ulcer - ANS -Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or Escher (tan, brown or black) in the wound bed. -cannot be measured/depth unknown Suspected Deep Tissue Injury - ANS -Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. -depth unknown Primary Wound Healing - ANS -wound that is closed -surgical incision -wound that is sutured or stapled -heals quickly with minimal scar formation Secondary Wound Healing - ANS -wound edges not approximated -pressure ulcers, surgical wounds that have tissue loss or contamination -wounds heal by granulation tissue formation Tertiary Wound Healing - ANS -wound that is left open to air for several days, then wound edges are approximated -wounds that are contaminated and require observation for signs of infection -closure of wound is delayed until risk of infection is resolved Acute Wound - ANS -wound that proceeds through an orderly and timely reparative process -ex: trauma, surgical incision -wound edges are clean and intact Chronic Wound - ANS -wound that fails to proceed through an orderly and timely process -ex: vascular compromise, chronic inflammation, or repetitive insults to tissue

-continued exposure to insult impedes wound healing (diabetes) 4 phases of wound healing - ANS 1. Hemostasis

2. Inflammation
3. Proliferation
4. Maturation Dehiscence - ANS wound pulls apart at the suture line Evisceration - ANS Protrusion of the internal organ through an incision Hemorrhage - ANS Excessive or profuse bleeding Hematoma - ANS a solid swelling of clotted blood within the tissues. Wound Infection is.... - ANS the second most common health care associated infection Purulent Drainage - ANS thick yellow, green, tan or brown drainage. Usually indicative of an infection Serous Drainage - ANS clear, watery plasma Serousanguinous Drainage - ANS pale, pink, watery, mixture of clear and red fluid Sanguineous - ANS bloody drainage Braden Scale for Predicting Pressure Sore Risk - ANS -sensory perception, moisture, activity, mobility, nutrition, friction and shear -19-23 not at risk 15-18 low risk 13-14 moderate risk 10-12 high risk *** 18 or lower needs interventions Less than or equal to 9 very high risk Factors that influence wound formation and healing - ANS -nutrition -tissue perfusion -infection -Age -psychosocial impact of wounds Protein - ANS Fibroplasias, angiogenesis, collagen formation and wound remodeling, immune function Fluid - ANS -Essential fluid environment for all cell function

• At least 2000-3000ml per day

Calories - ANS Fuel for cell energy "protein protection" Skin integrity assessment - ANS -identify the patient's risk for developing impaired skin integrity or poor wound healing -identify signs and symptoms associated with impaired skin integrity or poor wound healing -examine patient’s skin for actual impairment in skin integrity Interventions for pressure management - ANS -turns or reposition every 2 hours in bed or 1 hour in a chair -keep skin clean dry and intact -use moisture barrier -keep hydrated and adequate diet Wound care interventions - ANS -irrigate wound with saline -apply appropriate dressings -evaluate patient’s pain and medicate accordingly Evaluate Wound/nursing actions - ANS -perform daily total body skin and wound assessments and document -palpate reddened area around sacrum Debridement - ANS removal of contaminated or dead tissue and foreign matter from an open wound Complete Assessment - ANS initial exam, base line data General survey, vital signs, all body systems Focused Assessment - ANS assessment conducted to assess a specific problem; focuses on pertinent history and body regions Episodic Assessment - ANS focuses on evaluating a client’s progress Emergency Assessment - ANS rapid focused assessment conducted to determine potentially fatal situations SOAP - ANS subjective, objective, assessment, plan (S)OAP Subjective - ANS -client info -problems, allergies, home medications -chief complaint -family history -past medical history -personal and social history

S (O) AP

Objective - ANS -General status -mental status -skin -HEETNT -vital signs, weight -heart, chest, lung -neuron, abdomen, genitalia SO (A) P Assessment - ANS -rationale derived from subjective and objective data -list of different diagnoses -may include anticipated problems such as progression of disease process SOA (P) Plan - ANS -diagnostic tests -client education -referrals -follow ups Cyanosis - ANS bluish discoloration of the skin Erythema - ANS redness of the skin Pallor - ANS paleness Jaundice - ANS A yellowing of the skin and eyes Fine Crackles - ANS -short high pitched sounds during inspiration -found in pneumonia, heart failure, asthma, COPD Coarse Crackles - ANS loud, bubbly noise heard during inspiration; not cleared by a cough -usually with diminished gag reflex pulmonary fibrosis and pulmonary edema Wheeze - ANS high-pitched, musical, squeaking adventitious lung sound heard on expiration -occurs in small airways -asthma * Rhonchi - ANS loud rumbling sounds heard on auscultation of bronchi obstructed by sputum -sounds like snoring -only sounds that clears by coughing -heard on expiration

-usually COPD or chronic bronchitis Pleural friction rub - ANS localized grating or creaking sound caused by the rubbing together of inflamed pleurae -heard on inspiration and expiration -heard in patients with pleurisy S1 and S2 - ANS the Lob Dub sounds when assessing the heart Lordships - ANS increased curvature of the lumbar spine (sway-back condition) Kyphosis - ANS hunchback, exaggerated thoracic curvature Scoliosis - ANS lateral curvature of the spine Cranial Nerve 1 - ANS Olfactory (smell) Cranial Nerve II - ANS Optic - vision Brzezinski’s sign - ANS pain with resistance and involuntary flex of hip/knee when neck is flexed to chest when lying supine Kerning’s sign - ANS a diagnostic sign for meningitis marked by the person's inability to extend the leg completely when the thigh is flexed upon the abdomen and the person is sitting or lying down Schema - ANS individual’s cognitive structure or framework of thought Schemata - ANS Mental models of the world that we use to guide and interpret our experiences Assimilation - ANS the ability to incorporate new ideas, objects, and experiences into the framework of ones thoughts Accommodation - ANS adapting our current understandings (schemas) to incorporate new information Sensorimotor (birth-2 years) PiagetTheory - ANS -Infants learn through concrete motor actions; by touching, tasting and smelling -Accomplish object permanence (6 months) -Develop capacity for mental imagery -Organize information into categories -Increasingly able to use purposeful activity Pre operational stage (2 to 7 years)

Piaget Theory - ANS -words and symbols represent objects -thinking is one dimensional -lacks concept of conservation of mass -very egocentric -Theory of Mind developing -false belief test -empathy Concrete operational stage (7 to 11 years) Piaget Theory - ANS Children become able to use concepts of time, space, volume, and number but in ways that remain simplified and concrete, not abstract Formal operational stage (11 years to adulthood) Piaget Theory - ANS person is able to think abstractly and logically Solving concrete problems Trust vs. Mistrust Infant (birth to 18 months) Erikson - ANS infants learn to trust when they are cared for in a consistent warm manner Autonomy vs. Shame and Doubt Toddler (3 to 6 years) Erikson - ANS toddler learns to exercise will and to do things independently; failure to do so causes shame and doubt Initiative vs. Guilt School age (6-12 years) Erikson - ANS the child finds independence in planning, playing and other activities Identity vs. role confusion Adolescence (12 to 20 years) Erikson’s - ANS teenagers and young adults search for and become their true selves Intimacy vs. Isolation Early adulthood (20-35 years) Erikson - ANS individuals form deeply personal relationships, marry, begin families Generativist vs. Stagnation Middle adulthood (35-65 years) Erikson - ANS in which middle-aged people begin to devote themselves more to fulfilling one's potential and doing public service Integrity vs. despair Late adulthood (65 years to death) Erikson - ANS in which those near the end of life look back and evaluate their lives

Kohlberg’s theory of moral development - ANS pre-conventional, conventional, post- conventional Freud’s Psychosexual Stages - ANS oral stage, anal stage, phallic stage, latency stage, genital stage Immunizations are... - ANS an important aspect of health promotion during childhood Children gender dysphonia - ANS an incongruence between ones experienced and expressed gender and assigned gender of a duration of at least 6 months End of life care legal and ethical issues - ANS outcomes related to care during illness and the dying experience should be based on the client’s wishes Delirium - ANS an acutely disturbed state of mind that occurs in fever, intoxication, and other disorders and is characterized by restlessness, illusions, and incoherence of thought and speech. Dementia - ANS a slowly progressive decline in mental abilities, including memory, thinking, and judgment, that is often accompanied by personality changes Depression - ANS A prolonged feeling of helplessness, hopelessness, and sadness Polypharmacy - ANS The use of many different drugs concurrently in treating a patient, who often has several health problems. Most common adverse sign to a medication in the elder adult - ANS Mental status change Enteric-coated and extended release tablets or capsules - ANS should never be crushed or opened Macronutrients - ANS Carbs, Proteins and fats Micronutrients - ANS vitamins and minerals needed for health Birth weight.... - ANS doubles by 6 month and triple by 1 year of age. Malnutrition - ANS lack of proper nutrition, caused by not having enough to eat, not eating enough of the right things, or being unable to use the food that one does eat. -insufficient (anorexia nervosa) -excessive (bingeing/inadequate) Vegans need? - ANS vitamin B12, zinc, calcium and iron

Risk factors for malnutrion - ANS pregnancy Very young (premise) Very old Celiac disease - ANS autoimmune disease caused by sensitivity to gluten TPN - ANS total parenteral nutrition -if it runs dry there is a high risk of BS dropping rapidly -needs dextrose fast -do not let it go empty -Q6 BS checks Cellulitis - ANS Infection/inflammation of skin cells Athletes foot - ANS Fungus infection usually in the skin of the toes and soles Sun burns - ANS mild redness to deep tissue injury depending on degree Photosensitivity - ANS increased reaction of the skin to exposure to sunlight; side effect to some drugs