N330: exam 3

skin gives clues to

circulation, nutrition, systemic disease

Epidermis

outer layer (protection)

Dermis

largest layer, strength and flexibility

subcutaneous tissue

shock absorption and insulation (fatty layer)

Mucous membranes

barrier for pathogens

Pruiritis

dry, aging, rxn, allergy, mites

inspect the skin for

color, lesions, moisture and integrity

palpate skin for

temperature, texture, turgor, mobility

Pallor

pale skin (white) signs of anemia or shock

if skin is pallor check

nailbeds and lips

Erythema

red, sign of inflammation

erythema in dark skin

purple

Cyanosis

blue skin color low oxygenation of hemoglobin

if cyanotic check

lips, mucosa and nail beds

cyanosis in dark skin

even darker skin w/ dull undertone

jaundice

yellow sign of liver failure; sclera shows 1st

nonblancahble redness

stage 1 pressure injury

skin lesion cancer warning sign

ABCDEF: asymmetry, border irregular, color variation, diameter, elevation, funny looking

what is velvety skin sign of?

thyroid disease

what is vascular lesion?

blood vessel abnormalities; broken capillaries; size < 2mm

what is primary lesion?

changes from previously healthy skin

what is secondary lesion?

evolve from primary lesion over time

Tenting sign of

dehydration

pitting edema for

fluid overload

Pitting Edema Scale

1+ 2mm; 2+ 4mm; 3+ 6mm; 4+ 8mm

how long do you press skin to assess edema

3-4 sec

normal capillary refill

less than 2 seconds for color return

nail beds should be

pink and smooth

Clubbing

hypoxia

Hypoxia

lack of cellular oxygen

skin frailty is common in

aging adults

Wound Types

acute and chronic

acute wound

surgical or traumatic or MASD (moisture-assosciated skin damage)

chronic wound

arterial venous or neuropathic

how should surgical wounds look in 1-4 days

red

how should surgical wounds look in 5-14 days

bright pink

how should surgical wounds look in 15 days - 1y

pale pink

Arterial wounds

poor blood flow to; toes and feet

venous wound

poor blood circulation around; ankles

neuropathic wounds

complication of diabetes

serous fluid

clear, normal

serosanguineous fluid

pale red-pink, plasma RBC; drainage post-op

sanguineous fluid

red bloody drainage; open wound or hemorrhage

purulent fluid

sign of infection; yellow green

which fluid do you report

purulent

what cause pressure injuries?

bony prominences; medical devices

scale for pressure injuries

Braden scale 6-23; lower number = greater risk

stage 1 pressure injury looks like

nonblanchable redness

Stage 2 pressure injury looks like

partial thickness, blister

Stage 3 pressure injury looks like

full thickness w/ fat visible

stage 4 pressure injury looks like

full thickness; muscle or bone visible

Unstageable pressure injury looks like

covered in slough or eschar; can’t see base

deep tissue injury looks like

maroon or purple skin; cause: intense pressure

how do you document pressure injuries

TIME: tissue, inflammation, moisture, edge

what is surgical debridement?

remove dead tissue with scalpel

what is irrigation?

remove surface materials; use NS

what is needed for healing to occur

moist (not wet) wound bed

When to use sterile dressings

24-48 hr post-op

when to use clean dressings

after sterile dressings

3 layers in semi-open dressings

ointment gauze + absorbent + adhesive

factors affect wound healing: DIDN'T HEAL factors

diabetes, infection, drugs, nutrition, tissue necrosis, hypoxia, extensive tension, another wound, low temperature

Penrose drain

open passive drain

JP drain

active portable bulb drain

how long to keep on JP drain?

≤30 ml per drain for 2 consecutive days

Hemovac drain

closed circular portable drain

dehiscense

suture line separation; wound opens

evisceration

tissue under wound separate; organs protrude

what complication is an emergency in wounds

evisceration

what should nurse do with an dehiscence?

cover w/ moist sterile dressing; notify HCP; prep for OR

what should nurse do with an evisceration

cover w/ sterile saline dressing; notify HCP; OR asap!!

nutrition to promote wound healing

protein, high calories, fortified food, zinc

stage 1 of hematoma

reddish

stage 2 of hematoma

purple

stage 3 of hematoma

blueish

stage 4 of hematoma

yellowish

stroke signs and symptoms

facial droop weakness, slurred speech

stroke priority interventions

NPO & notify provider

PERRLA test

Pupils, Equal, Round, Reactive to Light, Accommodation

normal pupil size

3-5mm

abnormal pupil size at rest

pinpoint: < 3mm, dilated: > 7mm

unequal pupils means

CNS issue

what to inspect for reactive to light?

both (direct & indirect) pupils constrict; from side

what to inspect for accommodation?

distant = dilate pupils; nearby 3in = constrict & convergence; from front

adult ear exam

pull up and back

> 3y/o ear exam

pull down and back

clear ear drainage suggest

possible skull fracture

pinpoint pupils suggest

opioid toxicity

what happens in cataract

cloudy lens, blurry vision

what happens in diabetic retinopathy

BV damage to retina; see spots & floaters

what happens in glaucoma

pressure from buildup fluid; peripheral vision loss

what happens in macular degeneration

loss of central vision from aging; #1 blindness/vision loss

seasonal allergy eye signs

redness, lid edema & tearing

bacterial or viral infection eye signs

purulent drainage, redness, discomfort

serious eye signs

sclera redness, throbbing pain, pupil abnormalities

clear/bloody ear drainage indicate

skull fracture

hearing deficit signs

repetition, watch/read lips, turns head

allergy (nose) drainage

clear; pale mucosa

Infection of nose discharge color

yellow or green

unilateral drainage indicate

recent head injury or skull fracture

sinus congestion and pain action

humidify air, warm compress over sinus, wash hands, fluids 2L/day