unit four flashcards - N314

macule

flat discoloration <1cm (freckle)

• primary lesion

patch

flat discoloration >1cm (vitiligo)

• primary lesion

papule

raised lesion <1cm (elevated nevi)

• primary lesion

plaque

raised lesion (elevated or depressed related to skin), flat top, >1cm (psoriasis)

• primary lesion

vesicle

small, fluid filled blister <1cm

• primary lesion

bulla

fluid filled blister >1cm (large burn)

• primary lesion

pustule

pus-filled, size varies (acne)

• primary lesion

wheal

smooth papule/plaque, localized edema, irregular irritation (insect bite)

• primary lesion

nodule

solid, elevated lesion that extends into the dermis/sq tissue, <1cm

• primary lesion

tumor

solid, elevated lesion that extends into further tissue, >1cm

• primary lesion

scale

thickened stratum that is flaky (can peel)

• secondary lesion

crust

dried secretions that form a scab (sebum, blood)

• secondary lesion

fissure

linear crack/break in the skin that extends into the dermis (heel crack)

• secondary lesion

ulcer

deep, full-thickness loss of the epidermis and dermis

• secondary lesion

scar

fibrous connective tissue that replaces normal skin. keloid is overgrowth of scar tissue

• secondary lesion

atrophy

reduction or thinning of skin surface causing it to be wrinkled (like cigarette paper)

• secondary lesion

petechiae

pinpoint (<3mm), non-blanching vascular lesion

purpura

larger (>3mm), non-blanching vascular lesion

ecchymosis

large bruise, non-blanching, indicate bleeding

• vascular lesion

cherry angioma

skin growth made of clustered blood vessels

• vascular lesion

acanthosis nigricans

thick, hyperpigmented, velvety patches of skin often in skin fold areas. commonly associated with diabetes or insulin resistance

beau lines

transverse depressions in the nail due to damage of the matrix

spooning

concave nails often due to anemia

anchomycosis

invasion of the nail by fungus

stage one pressure ulcer

intact skin, blanchable redness, skin is not open

• NI: offload pressure, reposition, protect the skin, monitor closely

stage two pressure ulcer

partial thickness skin loss (shallow open ulcer or blister). involves epidermis and/or dermis. wound bed is usually pink/red and moist

• NI: protect wound, moist wound healing, reduce pressure and shear, manage moisture

stage three pressure ulcer

full-thickness loss, subcutaneous fat may be visible, granulation tissue or tunneling may be present. fascia, muscle, tendon, ligament not exposed

• NI: wound care per order, pressure relief, monitor for infection

stage four pressure ulcer

full thickness tissue loss, exposed bone/tendon/muscle. high infection risk

• NI: advanced wound care, possible debridement, infection monitoring

unstageable

full-thickness tissue loss where wound is covered by slough or eschar. cannot stage until enough tissue is removed to see depth

deep tissue injury

persistent, non-blanchable, deep red/maroon/purple, discoloration. may feel boggy, painful, warm or cool

• damage under the skin

friction

superficial rubbing that damages the skin surface (rug burn)

shear

skin stays in place, deeper tissue moves causing damage to underlying blood vessels

supine (position+reason)

laying on back with pillows under head/neck/arms/calves/heels

• avoid prolonged pressure on sacrum, general rest

side laying (position+reason)

pillow between the knees, supporting the back with pressure off the greater trochanter

• useful for sacral pressure relief

semi-fowlers/fowlers (position+reason)

hob is elevated (monitor for sliding/shear)

• helps breathing, eating, aspiration prevention

prone (position+reason)

patient is laying on stomach

• can help improve oxygenation in some respiratory conditions

• risk of pressure injury on toes/knees

sim’s (position+reason)

side laying with the upper leg flexed (rotated)

• pressure relief

contact/transmission

first step of infection process, pathogen reaches the host

colonization

second step of infection process. pathogen begins multiplying in or on the host

invasion/penetration

third step of the infection process. pathogen crosses protective barriers or invades the cells

dissemination

fourth step of the infectious process. pathogen spreads locally or through the blood/lymph

tissue damage

last step of infectious process. tissue damage occurs from cell destruction, toxins, inflammation or necrosis

incubation (stage of infection)

first stage. time between pathogen entry and first symptoms (usually no clinical manifestations)

prodromal (stage of infection)

second stage. early/vague symptoms (malaise, fatigue, low-grade fever)

acute illness (stage of infection)

third stage. symptoms are the strongest and most specific to illness (fever, drainage, elevated wbc, site-specific sx)

convalescence (stage of infection)

fourth stage. recovery stage, symptoms decrease and energy improves slowly

when to use contact precautions?

c.diff, MRSA wound infection, VRE, scabies, draining wounds, some MRDOs

when to use droplet precautions?

influenza, pertussis, meningitis, mumps, rubella, some respiratory

when to use airborne precautions?

TB, measles, varicella/chickenpox, disseminated shingles

when to use enteric precautions?

c.diff, norovirus, infectious diarrhea

when to use neutropenic precautions?

very low WBC/neutrophil counts, chemotherapy patientts, bone marrow transplants

bruxism

grinding/clenching of teeth during sleep

• stress, anxiety, stimulants, sleep disorders, maloccusion

• s/sx: jaw pain, headache, tooth wear, tooth sensitivity, audible grinding

• comp: dental damage, tmj pain, poor sleep

• NI: encourage dental eval, stress reduction, mouth guard

insomnia

difficulty falling asleep, staying asleep, or waking too early

• stress, pain, anxiety/depression, caffiene/alcohol, poor sleep hygiene, medications

• s/sx: difficulty falling asleep, difficulty staying asleep, early morning waking, fatigue, irritability, poor concentration

• comp: falls, depression/anxiety, poor healing, impaired memory, decreased immune function

• NI: sleep hygiene education, cluster care, reduce noise/light, pain control, relaxation

narcolepsy

intense, uncontrollable daytime sleepiness and sudden sleep attacks

• dysfunctional sleep-wake regulation

• s/sx: sudden sleep attacks, excessive daytime sleepiness, cataplexy, sleep paralysis, hallucinations

• comp: injury, safety risks, social impairment

• NI: safety education, scheduled naps, medication adherence

obstructive sleep apnea

airway collapse and breathing pauses during sleep

• upper airway obstruction during sleep

• risk factors: obesity, large neck circumference, male, older age, facial structure

• s/sx: lous snoring, witnessed apnea, gasping/choking, morning headache, daytime sleepiness

• NI: cpap use, weight management, side sleeping, elevate HOB, monitor oxygenation

eustress

positive stress that motivates growth or performance

distress

negative stress that overwhelms coping

allostasis

body process of adapting to stress and maintaining stability to change

allostatic load

wear and tear from repeated or chronic stress

GAS alarm stage

body recognizes stress, activated fight or flight

• s/sx: increased HR, RR, BP, dilated pupils, sweating, anxiety, hypervigilance

GAS resistance stage

body tries to adapt and continue functioning

• s/sx: ongoing fatigue, tension headaches, GI upset, sleep changes, irritability, reduced patience, concentration problems

GAS exhaustion stage

resources are depleted

• s/sx: severe fatigue, illness, poor healing, sleep disruption, HTN, burnout, depression, hopelessness

adaptive defense mechanisms

altruism (help others), sublimation (redirect to healthy), humor, suppression (consciously delay attention)

intermediate defense mechanisms

repression (unconsciously blocking), displacement (redirect toward safe), reaction formation (act opposite of feelings), somatization (distress becomes physical), rationalization (logical explanation to avoid true)

maladaptive defense mechanisms

passive aggression, acting out (impulsive behavior), dissociation (detaching), splitting (all people good/bad), projection (feelings to someone else), denial

actual loss

real, identifiable loss (death of loved one)

perceived loss

loss felt by person but not obvious to others (rejection, loss of confidence)

necessary (maturational) loss

expected developmental loss (child leaving to college)

situational loss

unexpected loss caused by an event (divorce)

grief

internal emotional response to loss

mourning

outward expression of grief, shaped by loss (funerals, religious traditions)

bereavement

state/process of adjusting after loss (period of loss)

normal grief

expected response that gradually becomes more managable

anticipatory grief

grief before the loss occurs (terminal illness)

complicated grief

grief that becomes prolonged, intense, or disabling (stuck in acute grief)

prolonged grief disorder

persistent intense grief lasting beyond expected cultural/social norms and impairing function (failure to adapt to life)

exaggerated grief

intense grief response that may include severe anxiety, depression or self-destructive behaviors (extreme/dangerous manifestations)

delayed grief

grief response occurs later, sometimes triggered by another event

disenfranchised grief

grief that is not socially recognized or supported (loss of an affair)