Foundations Exam 2 Study Guide

What are the things that affect skin integrity?

1-Motion
2-Tactile perception
3-Perfusion
4-Oxygenation
5-Nutrition
6-Tissue Integrity
7-Elimination
8-Pain

What causes decreased tactile perception?

Decreased profusion

How does perfusion impact skin integrity?

You need a good blood supply in order to provide adequate oxygen to tissues

What is needed for proper skin nutrition?

Hydration and protein

What is cyanosis?

Blue discoloration of the skin due to lack of oxygen

What can cyanosis be caused by?

COPD, respiratory disease, or hypothermia

What is ecchymosis?

Bruising

What is erythema?

Redness of the skin

What can erythema be caused by?

Inflammation, hyperthermia, infection, heat exposure

What is jaundice?

-Yellow discoloration of the skin
-Found in mucous membranes due to excess bilirubin

What is pallor?

Paleness seen in the lips, conjuntiva, palms, and coles

What can pallor be caused by?

Cold or anemia

What are petechiae?

Broken capillaries due to a change in pressure, coughing, or injury

What are examples of intentional skin variations?

-Tattoos
-Coining
-Cupping

What are examples of benign skin conditions?

-Moles
-Freckles
-Age spots
-Angiomas
-Warts

What are nursing interventions for wounds, pressure ulcer prevention, and treatment?

-Nutrition therapy
-Turning and positioning
-Skin hygiene
-Wound cleaning and irrigation
-Heat and cold application

What are examples of primary skin lesions?

-Macule
-Nodule
-Pustule
-Plaque
-Vesicle
-Bulla
-Papule

What is a macule?

A change in color only (Ex. Freckle)

What is a nodule?

Change in elevation

What is a pustule?

Filled with pus (Ex. Pimple)

What is a vesicle?

Fluid filled, clear, not pus

What are examples of secondary skin lesions?

-Scale
-Scar, atrophy, atrophic scar
-Crust oozing
-Fizzure, erosion, ulcer

What are examples of vascular skin lesions?

-Petechiae
-Purpura
-Ecchymosis
-Angioma
-Capillary hemangioma
-Telangiectasia
-Vascular spider
-Vascular star

You are suspicious that this lesion could be skin cancer. What are some risk factors for skin cancer?

-Age
-Immune suppression
-Family/personal history
-Chemical and UV exposure
-Skin tone and moles

What does ABCDE stand for?

A: Asymmetry
B: Border
C: Color
D: Diameter
E: Evolution

What is asymmetry in ABCDE?

One half of lesion does not match other half

What is border in ABCDE?

Irregular, uneven, or notched borders
*Cancer likes to web out, so it's hard to tell where it starts and stops*

What is color in ABCDE?

-Variable in color
-Ranges from tan, brown, or back to white, red, or blue

What is diameter in ABCDE?

Typically exceeds size of a pencil eraser

What is evolution in ABCDE?

Looks different from other moles; changes in size, shape, or color

What is a stage 1 pressure ulcer?

Intact, non blistered skin with nonblanchable erythema, or persistent redness

What is a stage 2 pressure ulcer?

-A partial thickness wound that involves the epidermis and/or dermis but does not extend below the level of the dermis
-Ex. Blister

What is a stage 3 pressure ulcer?

Full-thickness wounds that extend into the subcutaneous tissue but do not extend through the fascia to muscle, bone, or connective tissue

What is a stage 4 pressure ulcer?

Full thickness wound, that is deeper than stage 3 and involves exposure of muscle, bone, or connective tissue

Purulent exudate

-Yellow/green
-Risk for infection is present

Sanguineous exudate

Blood drainage

Puro-sanguineous exudate

Puss and blood drainage

Sero-sanguineous exudate

Clear and blood tinged exudate

What is a clean wound?

One in which there is no infection and infection risk is low

What is a clean-contaminated wound?

No infection is present, but the risk for infection is greater
-Ex. Surgical incision

What is a contaminated wound?

Results from a break in sterile technique likely from perforation
-Ex. Internal ruptures (bowel perforation)

What is an infected wound?

Clinical signs of infection: Redness, warmth, increased drainage
-Ex. Localized, pustulent

What is a colonized wound?

One or more organisms present on surface of wound when a swab culture is obtained

Dehiscence

Partial or complete separation of tissue layers during the healing process
-Ex. 1-2 sutures, one layer "pops"

Evisceration

Total separation of the tissue layers, allowing the protrusion of visceral organs through the incision

What is maceration?

A condition in which moisture causes a softening of the skin
-Can be from sweat, urine, or feces
-Breaks down skin and an ulcer can occur

What is a nursing intervention for an infected wound?

Wound cleansing and irrigation

What is a nursing intervention for a colonized wound?

Debridement

What is a nursing intervention for a clean-contaminated wound?

Suture care

What is a nursing intervention for a contaminated wound?

Bandaging and binders

What is a nursing intervention for a clean wound?

Hot and cold compress application

What are 3 different risk factors for pressure ulcers?

-Decreased sensory perception, activity, or mobility
-Increased moisture
-Decreased nutrition

What are 3 nursing interventions for pressure ulcers?

-Turning and positioning patient every 2 hours
-Provide skin hygiene
-Use pillows and support surfaces to decrease pressure on bony prominences

What is bursistis?

-Inflammation of bursae (cartilage between bones)
-Edema, point tenderness, and erythema of affected joint

What is gout?

-Sudden and progressively severe onset of pain and edema in affected joint
-Triggered by trauma, surgery, alcohol, or systemic infection
-High in uric acid, found in red meat
-Elbows, wrists, and feet

What is rheumatoid arthritis?

-Autoimmune disease
-Happens at any age
-Whole body symptoms: most present in the mornings
-Pain, edema, and stiffness of fingers, wrists, ankles, feet, and knees

What is osteoarthritis?

-Edema and aching with diffuse pain during movement
-Bone ends rub together, which results from a decrease in cartilage
-Pain later in the day, one side of the body

What is a herniated/slipped disc?

Shooting pain down one side of the body, not bilateral

What type of approach do you use for a musculoskeletal examination?

Cephalocaudal organization with side-to-side comparisions for examining bone, muscles, and joints

What do you use a lateral view for?

To assess cervical concave, thoracic convex, and lumbar concave for kyphosis and lordosis

What do you use a posterior view for?

To ensure that scapula, shoulders, and iliac crest are not higher than the other (symmetry)

What does a rigid and woody palpation assessment indicate?

Dystrophy

What is crepitus?

Clicking or popping with movement that can indicate a lack of cartilage

What is the difference between active and passive ROM?

Active ROM is when the patient goes through the movements themselves while passive ROM requires the nurse to hold and guide the joint through movement

What is abduction?

Movement away from the midline of the body

What is adduction?

Moving a body part toward the midline

What is pronation?

Rotation of the hand so that the palm faces downwards or backwards

What is supination?

Rotation of the hand so that the palm faces upwards

What is plantar flexion?

Movement where the top of the foot points away from your leg

What is dorsiflexion

Movement where the top of your foot comes closer to your body

What is rotation?

Process of moving the joint around the axis (circular motion)

What is lateral flexion?

Movement of the body part to the side (Ex. Bending sideways)

What is flexion?

Bending at a joint (Ex. Bending your elbow)

What is extension?

Increasing the angle between bones of the limb at the joint

What are the muscle strength definitions and how would a nurse document muscle strength?

Indicate whether it was active or passive ROM and scale resistance on the 1-5 scale

What are some safety precautions for a patient with a musculoskeletal problem?

-Place them in a room close to the nurses station to prevent falls
-Always keep the bed in the lowest position with 2 side rails up to facilitate movement
-Make sure that the call light is in reach along with frequently used materials
-Monitor vital signs during ambulation to ensure that they do not experience orthostatic hypotension
-Stop ROM activities as soon as patient complains of pain
-When transferring a patient, ensure that the movements are synchronized and smooth

What are the proper steps for medication administration?

1. Check order
2. Gather supplies and equipment
3. Perform hand hygiene
4. Identify patient using 2 identifiers
5. Prepare medications according to dose, route,etc.
*Verify medication to MAR when accessed, after preparation, and before administration*
6. Document and dispose of materials
7. Perform hand hygiene

What are the steps involved in withdrawing medication from a vial/administration of medication from a vial?

1. Perform hand hygiene
2. Clean top of vial with alcohol swab
3. Unwrap syringe
4. Remove cap of needle and place it on medication cart
5. Draw air into syringe to equal ordered dose
6. Insert needle into vial
7. Invert bottle, keeping needle in liquid
8. Withdraw ordered dose
9. Remove syringe from vial
10. Check dose and remove any excess air
11. Re-cover needle and place in sharps container

What are the sites for an IM injection?

-Deltoid
-Vastus lateralis
-Ventrogluteal

What are the sites for a SQ injection?

-Abdomen
-Lateral areas of upper arm and thigh
-Upper ventrodorsal gluteal area

What are required to be in each medication order from a provider?

-Patient name
-Date and time the order is written
-Name of drug to be administered
-Dosage of drug
-Route of drug administration
-Frequency of drug administration
-Signature of person writing order

What are the steps when completing a wound dressing change?

1. Gather supplies and equipment
2. Hand hygiene
3. Identify patient using 2 identifiers
4. Position and drape the patient properly and expose wound
5. Place a bag on the bed
6. Remove tape and gauze one later at a time
7. Dispose of old dressing and remove excess adhesive on patient skin
8. Measure wound, observe drainage characteristics, and assess wound for infection
9. Clean the wound with normal saline
10. Dry the wound using sterile gauze and patting motion
11. Apply dressing and secure dressing with tape
12. Dispose of materials and perform hand hygiene

What is supine position?

Patient lies flat on back

What is prone position?

Patient lies face down

What is semi-fowler position?

The head of the bed is at 30 degrees and knees are flat

What is fowler's position?

Patient in sitting position with pillow supporting thigh and legs

What is Sim's position?

Patient in semi-prone position lying on the left side

What is side-lying position?

Patient lying on side

What is dorsal recumbent position?

Patient lying supine with legs bent

What is the lithotomy position?

Patient lying supine with feet in stirrups

What is the knee-chest position?

Patient lying in prone position with buttocks and knees drawn to chest

How many patient identifiers are used for medication administration?

2

How many times is medication verified for accuracy in medication administration?

3 times:
1. Confirmation that label matches MAR
2. Preparing medication and checking label against MAR
-Recheck of medication label before opening package at bedside

How does continence impact skin integrity?

If the patient is incontinent, it increases the risk for infection and impaired skin integrity

What gauge needle is used for an IM injection?

18-22

What length needle is used for an IM injection?

1-1.5 inch

What gauge needle is used for a SubQ injection?

25-27

What length needle is used for a SubQ injection?

3/8-5/8 inch

What gauge needle is used for an ID injection?

26-27

What length of needle is used for ID injections?

1/4 to 1/2 inch