NURS 2001 Health/Fundamentals Final

fluid intake and output measurements

are totaled at the end of the shift and totals transferred to a graphic record

shift totals

are calculated at the end of a 24 hr period

the nurse compares the 24 hr fluid measurements and also compares them to previous measurements

How does a nurse determine whether the output is proportional to the intake?

• oral fluids (water, juice, soft drinks, coffee, tea, etc. water taken w/ meds), ice chips (recorded as ½ the original amount), foods that becomes liquid at room temp (ice cream, sherbert, popsicle, gelatin), tube feedings/water used to flush the tube, parenteral fluids (iv’s, piggybacks, and blood transfusions, GU irrigant (irrigation fluids amounts)

What substances count as fluid for intake vs output?

60-100 bpm

What is the normal HR range?

12-20 breaths per minute

what is the normal RR range?

90/60 - 120/80 mmHg

What is the normal range for BP?

95-100 % O2

What is the normal range for O2 saturation?

98.7 - 100.4 F

What is the normal temp range?

immature skin, prolonged duration of pressure, maceration, dermatitis, poor perfusion

• diaper rash, skin tears, pressure injuries

What are the risk factors for impaired skin integrity for neonates and children?

skin thinning, decreased elasticity, less SubQ tissue, decreased blood supply, dehydration, wrinkles, decrease cell rate replacement l/t thermoregulation issues

Risk factors for impaired skin integrity of older adults?

• reduced blood circulation, alterations in thermoregulation, incontinence, loss of collagen, muscle atrophy, impaired sensation

  • skin tears, pressure injuires, skin infection, incontinenece-associated dermatitis

What are the risk factors for impaired skin integrity of individuals with decreased mobility?

• decreased moisture, dry skin, maceration, elevated body temp, decreased blood and lymph flow

  • skin tears, pressure injuries, diabetic ulcers, moisture lesions, skin-fold rashes

What are the risk factors for impaired skin integrity of those with obesity?

• radiation resulting in inflammation, skin surface damage, decreased blood supply

  • pressure injuries, delayed wound healing, skin infections, radiation induced dermatitis

What are the risk factors fro impaired skin integrity of those with cancer?

• skin changes due to hepatic disx, renal disx, malnutrition, stomas, psycosocial issues

  • skin tears, pressure injuries, infections, moisture associated lesions, jaundice

What are the risk factors for impaired skin integrity of chronic illness?

most likely related to sun exposure, evolving changes in moles warrant further evaluation are alterations in size, color, texture, or shape, onset of itching or bleeding, and nonhealing wounds. Melanoma on trunk, arms, or legs is associated with severe sunburn during childhood or adolescence

What are the s/s of melanoma?

pallor, erythema, cyanosis, jaundice, mottled

What are the abnormal color changes?

pallor

• loss of color

  • location: face, conjunctivae, nail beds, palms, lips, buccal mucosa

  • indication: anemia, shock, lack of blood flow

cyanosis

• blueish for fair skin, grayish for dark skin

  • location: nail beds, lips, oral mucosa, palms

  • indication: hypoxia, impaired venous return

Jaundice

• yellow-orange

  • location: skin, sclera (best for fair skin), mucous membranes (best for dark skin)

  • indication: liver dysfunction, red blood cell destruction

Erythema

• dyschromia —> irregular skin discoloration generally caused by vascualr changes in the blood vessels

• location: face, skin, trauma, pressure areas

• indications: inflammation, local vasodilation, substance use, sun exposure, rash fever

mottling

reddish purple, marbling pattern that indicates poor pefusion

Annular, confluent, discrete, group, gyrated, target, serpiginous, verruciform, umbilicated, fuliform, linear, polycyclic, diffuse, generalized, satellite, symmetrical, zosteriform

lesion shapes and configurations

annular

ring shaped lesion

confluent

joining or running together

discrete

distinctly separate

group

clusters

gyrated

wood-grain apperance

target

red rings around red center

serpiginous

curvy and snake like

verruciform

circumscribed, papular with rough surface

umbilicated

central depression

fuliform

finger-like projections

linear

in a line

polycyclic

coalescing circles

diffuse

distributed widely across affected area without pattern

generalized

distributed over large body area

satellite

lesions in close proximity to larger lesions as if orbiting

symmetrical

distributed equally on both sides

zosteriform

follows 1-2 dermatome lines

• spread from nerve

• does not cross midline

Primary lesions

• initial reaction to internal or external environment (macule, papule, plaque, vesicle, pustule)

Macule

nonpalpable, skin color change, <1cm (ex. freckles)

papule

palpable, circumscribed (elevated), solid elevation of skin, <1cm (ex. mole)

patch

nonpalpable, skin color change, >1cm

plaque

palpable, raised, >1cm

nodule

palpable, circumscribed, deep, firm, 1-2 cm

wheal

palpable, irregular borders, edematous

vesicle

serous fluid filled, <1cm

cyst

sac-like pocket of membranous tissue, >1cm

bulla

serous fluid filled, >1cm

pustule

puss filled, varies in size

secondary lesions

result from a change in a primary lesion (crust, scale, fissure, erosion, ulcer, excoriation, lichenification)

crust

dried blood, serum, gas; dried secretions from primary lesion

scale

flakes of skin that exoliate; rapid turnover of epidermal layer, resulting in accumulation of and delayed shedding of epidermis

fissure

linear crack

erosion

lost epidermis, no bleeding, moist surface

ulcer

loss of epidermis and dermis with possible bleeding and scaring

excoriation

skin picking

lichenification

hyperpigmentation, thickening of the skin

petechiae, purpa, ecchymosis

What are the vascular lesions?

petechiae

pinpoint, flat, deep reddish purple, 1-3mm; do not blanch

purpa

deep reddish purple, flat, >3mm

ecchymosis

purple, fading to green or yellow over time, variable in size, flat

• Coagulation/Hemostasis

• inflammatory

• cell proliferation

• remodeling/maturation

What are the phases of wound healing?

Hemostasis/coagulation

• occurs immediately after initial injury

• involved blood vessels constrict and blood clotting begins

• exudate is formed causing swelling and pain

• increased perfusion results in heat and redness

• platelets simulate other cells to migrate to the injury to participate in other phases of healing

inflammatory

• follows hemostasis and lasts about 4 to 6 days

• WBCs move to the wound

• macrophages enter wound area and remain for extended period

• they ingest debris and release growth factors that attract fibroblasts to fill in wound

• patient has generalized body response

cell proliferation

• phase begins within 2 to 3 days of injury and may last up to 2 to 3 weeks

• new tissue is built to fill wound space through action of fibroblasts

• capillaries grow across wound

• a thin layer of epithelial cells forms across wound

• granulation tissue forms a foundation for scar tissue development

remodeling/maturation

• final stage of healing begins about 3 weeks to 6 months after injury

• collagen is remodeled

• new collagen tissue is deposited

• scar becomes a flat, thin, white line

infection, hemorrhage, dehiscence and evisceration, and fistula formation

What are the wound complications?

swelling/edema, erythema, temp changes-warm/hot, increased drainage, odor, separation of wound edges

What are the signs of skin infection?

• braden scale: used to assess a person’s risk of developing pressure injuries

• location, identify stage of injury if applicable, measurements (length, width, depth), any tunneling/undermining, color, temperature, surrounding/periwound tissue, drainage/odor, appearance (granulation, slough, eschar).

What are the types of skin integrity assessment?

undermining

open area extending under intact skin along the edge of the wound

tunneling

a narrow channel or passage-way extending in any direction from the based of the wound. this results in dead space with potential risk for abcess formation

shearing

gravity pushing patient down on bed/chair, skin moved against a fixed surface

friction

2 forces rubbing against each other (skin against skin)

• Asymmetry

• Border irredularity

• Color Variation

• Diameter > 6 mm

• Elevation and Enlargement

What is the meaning of ABCDE of melanoma?

urticaria

a skin reaction that causes itchy welts

exanthem

medical term for a widespread rash

stage 1 of pressure ulcers

non-blanchable erythema of intact skin, no opening, pain may be present

stage 2 of pressure ulcers

• partial thickness skin loss, exposed dermis, wound bed is viable, pink/red/moist, intact or ruptured serum

stage 3 of pressure ulcers

• full thickness skin loss; not involving underlying fascia, adipose tissue is visible, undermining may be present, potential for slough and eschar

stage 4 of pressure ulcers

•  full thickness skin loss with extensive destruction, ecposed/palpable muscle, tendon, ligament, cartilage, bone, undermining and tunneling may be present

unstageable pressure ulcer

• Base of ulcer covered by slough and or eschar in wound bed, extent of tissue loss/damage obscured byslough/eschar, unable to view wound base 

dehiscence

• separation or splitting open layers of a surgical wound

eschar

• black in appearance

  • dry, dead tissue, necrotic

  • needs to be removed for wound to heal

slough

• yellow/white in appearance

  • part of inflammatory process

  • fibrin, WBCs, bacteria and debris are present

  • accumulation of dead cells, needs to be removed for wound to heal

serous drainage

yellow fluid that leaks out of wound

sanguineous drainange

contains fresh, bright red blood and a clear, yellow fluid

serosanguineous drainage

thin and watery fluid that is pink in color

purulent drainage

thick/milky and can vary in color, from grayish or yellow to green and even brown.

primary intention, secondary intention, and tertiary (delayed) intention

What are the phases of wound healing?

primary intention

• clean laceration and surgical incision

• closed w/ sutures/adhesives

• fast healing

secondary intention

• wound left open to heal

• granulation tissue forms from bottom

• wound needs to be moist

• prolonged healing

tertiary (delayed) intention

• combines primary and secondary healing

• wound left open 5-10 days then closed

• decreases infection in wounds that were originally dirty

if patient is unable to stand

When do you use the romberg scale?

• have patient stand with their feet together, arms at their sides, and eyes open; he should be able to stand upright with no swaying.

  • If they can do that, have them close eyes and stand the same way

  • if they fall or breaks stance after closing eyes, the romberg test is positive.

What is done during romberg assessment?

• HTN, obesity, diabetes mellitus, smoking, family Hx stroke

• Most affected: african americans, hispanics, and native americans

RF for stroke?

ischemic stroke

obstruction within a blood vessel supplying blood to the brain

hemorrhagic stroke

when weakened blood vessel ruptures