Skin Assessment and Wound Care in Older Adults, Exams of Nursing

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ADPIE - Nursing Process - correct answer>> Assessment, Diagnosis, Plan, Intervention, Evaluation World Health Organization definition of health - correct answer>> Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. Framework of Healthy People 2030 - correct answer>> Principles Overarching Goals Plan of Action History & Context Level of Prevention - correct answer>> Primary- Prevention Secondary- Screening Tertiary-Rehab Risk Factors - correct answer>> Modifiable Non-modifiable Prevent Constipation in Older Adults - correct answer>> Increase Fiber (35 to 50g) & Fluid Intake (2L), Exercise Regularly Common Adverse Drug Events in older Adults - correct answer>> Edema, N/V, Anorexia, constipation, dehydration, dizziness, syncope, acute confusion, dysrhythmias, urinary retention, and hypotension Major predictor of morbidity & morality - correct answer>> Delirium Confusion Assessment Method (CAM) - correct answer>> Acute onset and fluctuating course

Inattention Disorganized thinking Altered level of consciousness Monitor Older Adults receiving Antipsychotics ADEs - correct answer>> Anticholingeric Effects ORTHOSTATIC Hypotension Parkinsonism Restlessness Hyperglycemia & DM When do you assess skin on pt that is reddened? - correct answer>> Every 8 hours Immobility - correct answer>> Long periods of immobility Musculoskeletal Immobility - correct answer>> Wasting, Osteoporosis Integumentary Immobility - correct answer>> Pressure Injuries GI Immonility - correct answer>> Constipation Cardiovascular Immobility - correct answer>> orthostatic hypotension, thrombus formation (DVT) Neurological Immobility - correct answer>> depression, forgetfulness, anxiety, confusion -pressure on skin will cause nerve pain/damage Renal/Urinary Immobility - correct answer>> Stones Incontinence Respiratory Immobility - correct answer>> atelectasis -> pneumonia

Metabolic Fluid & Electrolyte Imbalance-Immobility - correct answer>> Dehydration or Fluid Overload Orthostatic Hypotension - correct answer>> A drop of more than 10 mmHg in systolic or 10 mmHg in diastolic pressure between positions Walker Procedure - correct answer>> Lift Walker Move walker about 2 feet forward Small Steps Check Balance Repeat Proper body Mechanics - correct answer>> Maintain a wide, stable base with your feet Place the bed at the correct height----waist level while providing direct care and hip level when moving patients Keep the patient or work directly in front of you to prevent your spine from rotating Keep the patient as close to your body as possible to prevent reaching Use appropriate safe patient -handling equipment Cane Procedure - correct answer>> Cane in strong hand- use unaffected side Well Balanced Cane, Weak Leg, then strong leg Physiological Effects Immobility - correct answer>> Changes in Sleep/Wake Cycle Impaired Coping Changes in Body Image Anxiety Depression Behavioral Changes

Assessment of skin - correct answer>> Once per shift, upon admission, or nursing instinct Access individuals with any devices assess skin every 2 hours for skin breakdown Inspect skin - correct answer>> -Beneath and around compression stockings •Bony prominences •Skin to skin areas •Any areas where the client lacks sensation •Special attention if the client is getting pain epidural /spinal pain medications

• epidural or spinal caths (monitor and ensure infection free, access toe sensation)
• assess perinuem Functions of Skin - correct answer>> Protection, Homeostatis (Water Balance), Temperature Regulation, Sensory, Vitamin Synthesis, Psychosocial Skin Cultural Assessment - correct answer>> Detective subtle color changes Assess: Mucous Membranes, Nail Beds & Skin tones Skin Assessment Process - correct answer>> Skin temperature, tugor (back of hand, head, clavicle), color (blanchable to nonblanchable), texture, moisture (incontinence, wounds, ostomy, ilesotosmy), integrity, capillary relief (hypoperfusion), edema Skin Alterations - correct answer>> White- decreased Hgb & blood flow Yellow-orange- Jaundice, Cartoenemia, Urochrome level Red- Vasodilation Blue- Cyanosis Reddish Blue- decreased peripheral circulation Brown- Melanin Production Assessing skin changes on darker skin tones - correct answer>> Cyanosis- lips or tongue are gray, nail beds are blue, conjunctiva is white

Inflammation- increased warmth, shiny or pitting, assessment of both extremities Jaundice- yellow oral mucous membrane or sclera Bleeding- swelling, petechiae Dryness - correct answer>> -scaling -flaking -lanolin, antipruritic agents, topical/ oral antihistamines Pruritus - correct answer>> - Itching -scabies, lice -iodine medications -antipruritic agents

• topical corticosteroids
• antihistamines -ultraviolet white Serosanguineous exudate - correct answer>> Blood-tinged amber fluid consisting of serum and red blood cells Normal for first 48 hours Urticaria - correct answer>> - Hives -edematous wheals with intense itching -pallor halo -blanch with pressure -vary in size -antihistamine -steroids -epinephrine

Physical assessment and health history - correct answer>> •Inspect and palpate all skin surfaces •Determine current changes in medications, lotions, soaps •Fluid status •Exposure to environmental irritants Patient Teaching for Skin Care - correct answer>> •Explain medication regimen if needed •Explain all procedures and care in terms that the patient and family will understand •Teaching needed for those with •Dryness •Pruritus •Urticaria •Keeping follow up appointments •Notifying healthcare provide Psoriasis - correct answer>> chronic scaling disorder, skins changes in 5 days •Autoimmune reaction •Severe psoriasis patients may have psoriatic arthritis (30%) Types of Psoriasis - correct answer>> •Psoriasis vulgaris Most common type -Plaque Psoriais •Exfoliative psoriasis •Palmoplantar psoriasis Guttate Inverse Pustular Erythrodermic •No known cure

Clinical Manifestations of Psoriasis - correct answer>> -Pruritus •Shedding (4 to 5 days) •Silvery white scales •Raised areas •Redness •Papules •Round plaques •Scalp, elbows, knees, lower back, buttocks, sacrum •Yellow discolored pitted nails •Joint inflammation and deformity when severe Treatments psoriasis - correct answer>> -Steroids •Tar preparations •Anthralin preparations •Ultraviolet light treatments •Retinoid derivatives •Keratolytic agents Biological agents - correct answer>> - Inifiximab, significant side effects, big thing is infection -MAB- IMMUNE MODULATOR Risk for infection, & Malignancy Given IV on Weeks 0,2, Shingrix, Zostavax - correct answer>> zoster (shingles) virus vaccine Shingrix- not to be given if receive previous dose of Zostavax Burns - correct answer>> Monitor for pulmonary edema Genetic Mutations - correct answer>> CDKN2A & CDK4-6 familial melanoma

Etanercept (enbrel) - correct answer>> Given twice weekly for 3 months

• biological agent TNF inhibitor Serious infection risk Risk for malignancy
  • report cough, fever, s/s of illness -avoid large crowds, washing hands, avoid people who are sick Patient Teaching Psoriasis - correct answer>> Psoriasis can occur at any age, but median onset 28 years of age •More prevalent in obese white female Caucasians •Skin pigmentation affects appearance of lesions. Patient Teaching •Encourage patients to verbalize concerns •Apply topical steroids •Instruct not to scratch •Monitor skin, stress reduction •Warm water bath not hot •Use of emollients •Instruct patient to keep all follow up appointments •Use sunscreen •Notify healthcare provider Skin Cancer - correct answer>> •Abnormal growth of skin cells Types •Basal Cell (waxy, rolled edge)

-Exposed to the sun, long term UV radiation •Squamous (rough, central ulceration) -Prolonged exposure to UV light -Sunbathing, tanning beds or lamps •Melanoma- worst one -ABCDE (Asymmetry,Border, Color, Diameter, Evolving) Prevention of Skin Cancer - correct answer>> Sun Prevention (Sunscreen) Protective Clothing Avoid sun at peak hours Meds that increase photosensitivity Skin Mole Map (Monthly) Cellulitis - correct answer>> - An infection in an opening in the dermis or subcutaneous tissue Causes & Risk Factors •Most common organisms •Staphylococcus •Group B streptococci -Any opening in the skin •Intravenous infusion therapy •Venous insufficiency (diabetes) Types of Celluitis - correct answer>> Localized- one area, redness, warmth, pain Systemic- fever, chills, malaise Regional- lymph nodes Lymphadenopathy- painful, enlarged, redness Labs for cellulitis - correct answer>> •Wound culture and sensitivity •Serum white blood cell count

Treatment of cellulitis - correct answer>> •Physical assessment and health history •Most cellulitis treated outpatient •Treatment depends on location and severity •Antibiotics •Topical, oral, IV •Warm moist compresses •Elevation of extremity Patient Education of cellulitis - correct answer>> -Ensure that patient and family understand •Teach patient to apply warm moist compressed •elevate part at least 6 inches above heart •Wash hands prior to performing wound care •Teach patient preventive infection measures •Teach patient to inspect skin daily •Instruct to keep follow up appointments •Notify healthcare provider Tarzarotene - correct answer>> Can cause birth defects Topical Retinoid combined with topical corticosteroid therapy helps with psoriasis flare ups Varicella-zoster virus (shingles) - correct answer>> •Primary prevention - Zostavax, Shincrits (older than

50. 2 doses •Weakened immune system-previous eruption of chicken pox HSV2- inguinal nerves HSV1- trigmental nerve Purulent Exudate - correct answer>> creamy yellow pus- staph greenish blue pus/fruity odor- pseudomonas

beige pus/fishy odor- proteus brownish pus/fecal odor- usually occurs after intestinal surgery Shingles causes - correct answer>> Reactivation of Varicella zoster (chicken pox virus) •Usually occurs with weakened immune system •Stress •Illness Shingles Clinical Manifestations - correct answer>> Painful vesicular eruption •clustered vesicles •tingling •pruritis •burning •pain at site •fatigue •malaise •fever •headache Shingles - correct answer>> - red painful vesicles Therapeutic Management of Shingles - correct answer>> Vaccination •After 50 •Two doses 2-6 months apart Antivirals- less course of sickness, need to be given between 24 to 72 hours •Acyclovir •Valaciclovir •Famciclovir Topical creams

•Analgesics to relieve pain •Systemic corticosteroids •Non-steroidal anti-inflammatory agents Triamcinlone injected SQ Physical assessment and health history - correct answer>> •Administer medications as prescribed and monitor effectiveness •Talk with and listen to patient concerns •Explain all procedures and care in terms that the patient and family will understand •Standard precautions unless disseminated or immunosuppressed patient, then requires contact and airborne precautions •Do not care for patient if you have not been vaccinated or have not had chicken pox •Promote comfort •Monitor for complications Herpes Zosters - correct answer>> usually occurs after age of 50 years •Affects Caucasian men and women more frequently than others Importance of vaccination - correct answer>> •Adherence to medication regimen •Dressings and care of lesions •Proper hand washing •Alternative pain reduction •Diversional activities •Relaxation techniques •Instruct to get plenty of rest •Avoid scratching or rubbing area •Avoid others that have not had chicken pox or vaccine •Notify the healthcare provider as needed

Nail Disorders - correct answer>> Alterations in Nail Colors -White -Yellow/Brown (Jaundice) -Red -Blue Paronychia - correct answer>> - infection of the nail cuticle Clubbing - correct answer>> - long term hypoxia Onycholysis - correct answer>> - Separation of the distal end of the nail from the underlying nail bed Onychomycosis - correct answer>> - Fungal infection of the nail Terry's Nails - correct answer>> - Nail turns white Leukonychia (white spots) - correct answer>> White spots that vary in size and shape on nail surface Beau's lines - correct answer>> - transverse linear depressions (reduced blood flow to nails) Pitting - correct answer>> - depressions in nail plate Trauma to nail - correct answer>> - Tearing, blunt force, "stubbing" Hematomas under nail are not treated unless 50% of nail is bruised Foot Care - correct answer>> Podiatrist- best care for diabetics Dry foot throughly, never wear the same pair of shoes two das in a row Clean feet and nails thoroughly with soap and water after showering in public facilities, like fitness centers, public pools

Phases of wound healing - correct answer>> •Inflammatory phase- vasodilation, start repair process, warmth, swelling, WBC enter, fibroblast •Proliferative phase- couple weeks, collagen, angiogenesis (creation of new blood vessels) •(Remodeling) Maturation phase- Tough (Scar) tissue First Intention - correct answer>> post surgical, sutures/ staples, clean incision Second intention - correct answer>> healing inside out, longer to heal Third intention - correct answer>> high risk infection, debridement, can suture when healing Causes & Risk Factors Wounds - correct answer>> Malnutrition •Impaired blood flow and oxygen delivery •Impaired immune response/Impaired inflammatory process •Infection •Wound separation •Presence of foreign body •Age •Medications- steroids impair wound healing •Smoking Lab & Diagnosis Wounds - correct answer>> Wound culture and sensitivity- what bacteria, what medications work •Serum white blood cell counts Draw C&S and then start antibiotics due not wait Management of Wounds - correct answer>> Wound assessment- PRIORITY -Neurovascular assessment

-CMS check (Color, Movement, Sensation) •Cleaning the wound •Closure of the wound •Dressing application •Topical/oral/IV antibiotics •Avoidance of corticosteroids •Regular wound care & dressing changes •Promote nutrition, rest, smoking cessation Suture - correct answer>> remove every other suture, remove closest to suture line as possible Pressure Injuries - correct answer>> Develop over areas of bony prominence when tissue is compressed for extended periods, which results in oxygen depletions and cell death. •Most common sites for pressure ulcers •The goal is to prevent pressure ulcers Causes of Pressure Injuries - correct answer>> •Pressure •Friction •Shearing forces Risk factors Pressure Injuries - correct answer>> -impaired mobility, thin fragile skin with aging, decreased sensory perception, impaired level of consciousness, moisture, incontinence, wound drainage and excessive perspiration, shearing, poor nutrition and infection Pressure Injuries Stages - correct answer>> Stage 1: Intact skin, non blanchable with localized redness Stage 2: Shallow, open ulcer, pink- red wound Stage 3: Full thick skin loss with visible SQ fat Stage 4: Full thick, exposed bone, tendon, muscle Unstageable: Full thick skin loss, slough, eschar

wound debridement methods - correct answer>> Wet to dry, continuous wet gauze, topical enzyme preparations, moisture retentive dressings Lab & Diagnosis Wound Healing - correct answer>> •Wound culture and sensitivity, ONLY DO IF LOOKS INFECTED •Wound biopsy •White blood cell count •Noninvasive and invasive arterial blood flow studies •Nutritional status evaluation, ALBUMIN & PREALBUMIN Wound Dressings - correct answer>> Alginate Anti microbial Collagens Foams Gauze (moist) Hydrocolloid Hydrogel Superabsorbent Transparent Films Continuous Negative Pressure Wound therapy - correct answer>> Use caution in patients on anticoagulant therapy Monitor Wound - correct answer>> Size, Base, Margins, Response Therapeutic Management Wound Healing - correct answer>> -Wound assessment and care •Antibiotics •Nutrition Assessment •Vitamin C supplement •Zinc supplement

•Debridement •Enzymatic •Surgical •Mechanical •Adjunctive wound healing treatments •Technologies in wound healing •Enlistment of interdisciplinary team WOUND VAC - correct answer>> CONTRAINDICATION (ANTICOAGULANTS) Patient Teaching for Wounds - correct answer>> •Care of the wound •Bathing •Nutrition •Rest •Smoking cessation •Home health care •Keeping follow up appointments •Notifying the healthcare provider WHEELCHAIR PUSH UP - correct answer>> 5 TIMES EVERY HOUR Q Complications Of Wound Healing - correct answer>> -Hemorrhage •Infection •Dehiscence •Evisceration Perioperative Assessment - correct answer>> A- Allergies B-Bleeding C- Cortisone (Impair Wound Healing)

D- Diabetes E-Emboli Health Hx, Physical Assessment, Anxiety, Venous Thromboembolic Risk (based on Immobility) Pre-operative Risk Factors - correct answer>> Infection/Sepsis Anemia (H&H) Hypovolemia Diabetes (Blood Sugar, possibly hold insulin) HTN Electrolyte Imbalance (Potassium, Magnesium, Sodium) Pregnancy ALWAYS REPORT ELECTROLYTES, H&H, PTT, INR Surgical Complications - correct answer>> NSAIDS Anticoagulants Antihypertensives Antidepressants- INCREASE RISK OF SEROTONIN SYNDROME Perioperative Diagnostics - correct answer>> CBC Urinalysis Pregnancy Tets Clotting studies- PTT & INR ELECTROLYTE LEVELS (K 3.5 TO 5.5, Na 135 to 145) Creatine/BUN ABG's ECG CXR Pulmonary Function

Perioperative Nursing Care - correct answer>> Witness Informed Consent Administer enemas and or laxatives • Administer scheduled medications • Monitor for NPO • Perform Skin preps • Ensure jewelry, dentures, prosthetics, make up, nail polish and glasses are removed • Advanced directives • Establish IV site • Preop check list / time out • Confirm and verify correct surgical site. • Psychosocial preparation • Nursing implementation to reduce client and family anxiety • Preoperative teaching Informed Consent - correct answer>> Surgeons responsibility to get consent Nurses witness Need 2 witness if signed with X In coma- call POA or court signed If emergency, independent physicians sign consent Surgery Complications - correct answer>> -Severe anxiety and panic

• DVT
• Allergic reactions (MH, ask about family hx of high fever during sx)
• Respiratory depression from Medication sedatives
• Opioids
• Fluid overload
• Gastrointestinal issues- Needs to pass gas or stool Time Outs - correct answer>> Verify the Client- right person?
• Check History, documents, Client ID, Implants, prothesis etc..
• Mark the procedure site with the surgeon's initials
• Time out for the team, Correct patient, Procedure side

and site. Malignant Hyperthermia - correct answer>> Unknown, Genetics Muscle Rigidity, Tachycardia, increase end tidal CO2, increase body temperature, decreased O2 salts MH Cart Call Anesthesia, Anesthesia stopes meds Dantrolene is given, Cool IV fluids, O2, Cooling Blankets Muscles Relax Beta Blockers ICU, Monitor 24 hours postoperative MH reaction Regional Anesthesia - correct answer>> Between L4 & L5, pt is awake, should be able to feel toes, check for reduced CMS (Color, Motor, Sensation), monitor for hypotension, headache, respiratory paralysis Prioritize safety - correct answer>> CALL BELL SIDE RAILS BED ALARM LOWEST POSITION ASSESSMENT Nursing Assessment Sx - correct answer>> ABCs Respiratory-Efforts, O2, breathing patterns, snoring, RR, strider

• Cardiac-BP- 15 to 20 points drop or increase call MD
• Vital signs
• Positioning
• Neurologic- postoperative delirium
• Dressing and drains- document output
• Nutritional needs
• Renal Function

• Bowel function
• VTE Post Op Dressing Change - correct answer>> Surgeon does 1st dressing change If you notice blood or drainage mark it Monitor suture site( redness, warmth, drainage) Post op blood transfusion - correct answer>> MONITOR POST OP TRANSFUSION REACTION FOR 7 DAYS Dehiscence - correct answer>> separation of wound bed, feels like splitting open, can happen a couple days post-op Evisceration - correct answer>> insides coming out, EMERGENCY, sterile. Sterile gauze & water, abd pads, stay with patient Hemorrhage - correct answer>> COLINS- FRONT OF ABDOMEN TURNERS- BACK, FLANK BRUISING BP & HR DROP Thromboembolic event - correct answer>> DVT- SWELLING, REDNESS, ABSENT PULSES TED HOSES ANTICOAGULANTS HEEL EXERCISES- 5 TO 10 Q2 Urinary Retention postoperative - correct answer>> 8 hours post-op need to urinate Bladder scan

Paralytic Ileus - correct answer>> a neurogenic or muscular impairment of peristalsis that can cause functional intestinal obstruction Post-op respiratory interventions - correct answer>> assess respiratory status every 4 hours, PRN turn patient every 2 hours ambulate patient 3 times daily elevate head of bed patient cough and deep breathe every 2 hours monitor sputum amount, odor, consistency Incentive spirometry Pain - correct answer>> an unpleasant sensory and emotional experience associated with actual or potential tissue damage Acute pain - correct answer>> Less than 3 months Chronic Pain - correct answer>> More than 3 months Referred Pain - correct answer>> pain that is felt in a location other than where the pain originates Radiating Pain - correct answer>> pain felt at the site of tissue damage and in nearby areas Nociceptive Pain - correct answer>> Normal Pain Neuropathic Pain - correct answer>> pain from damage to neurons of either the peripheral or central nervous system Pain Assessment - correct answer>> An evaluation of the factors that alleviate or exacerbate patient's pain

Nonpharmacological Measures Pain - correct answer>> Distraction Cutaneous Stimulation- pain relief in the moment Pharmacological Methods Pain - correct answer>> NSAIDs Opioids PCA- ONLY PT CAN PRESS BUTTON TO RECEIVE MEDS Pain Complications - correct answer>> Undertreatment Sedation, Respiratory Depression Anemia - correct answer>> Reduction in RBCS, Hgb, Hct Related to oxygenation Varies from mild to life threatening Normal RBC live for 120 days Iron Deficiency Anemia - correct answer>> Low H&H, Hemi- Red meat, liver. Nonhemi- plant sources Causes-Diet, Losing Blood, Pregnancy B12 Anemia - correct answer>> Not enough B12 B12- Perneous anemia Causes- Gastric Sx, vegan diets Bariatric- pt stay on IM B12 for life Sickle Cell Deficiency - correct answer>> Genetic Folic Acid (B9) deficiency - correct answer>> Not Common, diet CHRONS, Ulcerative Colits, ETOH Abuse Methotrexate- folic acid antagonist

Iron Deficiency S/s - correct answer>> Fatigue, Tachycardia, Pale, Cold, Tachypnea, Tired, Chest Pain, Angina, Heart Attack, Blood vessels are vasoconstricting and oxygen is not reaching vessels heart muscles start to die and cause pain. Fissures on side of mouth B12 Deficiency S/s - correct answer>> Cognitive Decline, behavioral changes, altered feel in extremities, BEEFY RED TONGUE-Glossitis, Fall risk, Fissures on side of mouth Sickle Cell s/s - correct answer>> PAIN, Hypoxic event, Make small clots in small or large vessels blocking distal perfusion, Cold extremities, weak pulses, Tachycardia, Tachypnea, RBC Cells die between 10 to 20 days, Enlarged Spleen, Jaundice, Joint Pain, Joint deformities, Arthritis, Amputations, Kidney Failure, CVA, Heart Attack, Folic acid s/s - correct answer>> SOB, Pain, CP, Heart attack, Fatigue, Skin yellowing Risk factors iron deficiency anemia - correct answer>> Loss of blood Lack of iron in diet Alcoholism B12 Deficiency anemia risks - correct answer>> Crohns Bariatric sx Chronic diarrhea Diverticula Tapeworm Overgrowth intestinal bacteria Chronic use of PPI or metformin Sickle Cell Risks - correct answer>> Pregnancy

Hereditary Dehydration Hypoxia Viral or bacteria infections Alcohol High Altitudes High or low body temperature Strenuous exercise Anesthesia Folic Acid Anemia Risks - correct answer>> Malnutrition Malabsorption Seizure meds Methotrexate Pregnancy Labs Iron Deficiency Anemia - correct answer>> H&H, MCV (Mean Corpuscular Volume) Size of RBC, MCHC (Mean Corpuscular Hemoglobin Concentration - Color of RBC LOW H&H, small & pale RBC TIBC- total iron binding capacity- is Higher B12 Anemia Labs - correct answer>> MCV higher Folic Acid Anemia Labs - correct answer>> Folic acid, H&H, B9 & B12 Sickle Cell Anemia Labs - correct answer>> decreased RBC and Hgb elevated bilirubin exposing RBC to deoxygenation causes sickling