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NUR 111 Test 4
| Integumentary system includes: | Skin, SubQ layer, Appendages of the skin, Glands, Hair Nails, Blood vessels, Nerves, and Sensory Organs of the skin |
| Function of Integumentary system: | Protection (Primary), Regulation (T, Fluid balance), Sensation (Vit D, Elimination of waste, Nerves (heat/cold)) Psychosocial (Appearance) Absorption (Topical medication) |
| Epidermis | Stratified epithelial cells, Protective, waterproof |
| Dermis | Elastic, connective tissue, Nerves, hair follicles, glands, and blood vessels, Receptors fro pain, pressure and touch |
| Subcutaneous tissue | Adipose tissue and connective tissue, Fat stores , heat insulation, and cushioning, Blood and lymph vessels |
| Mucous Membrane | Lines all body cavities that are open to the exterior, Respiratory, Digestive, Urinary, Reproductive. |
| Function of Mucous membrane | Insensitive to Temperature, except Mouth/Rectum. Sensitive to touch, Receptors that are protective in nature |
| Factors affecting skin integrity | Unbroken & healthy skin & mucous membranes, Resistance to injury, Adequately nourished & hydrated, Adequate circulation, Disease of the skin (Eczema and psoriasis) , Therapeutic measures( Bed rest, cast, heat/cold therapy) |
| Intentional wound | Surgical incision, IV, Lumbar puncture ( Under controlled situation) |
| Unintentional wound | Trauma, accidents, increased risk for infection and bleeding; Uncontrolled situation |
| Open wound | Surface of skin is broken |
| Closed wound | Does not break the skin (Fall or MVA) Soft tissue damage. |
| Acute wound | Progresses through healing process; decrease risk of infection |
| Chronic wound | Does not progress through the healing process; inflammation process continues; increased risk for infection; arterial/venous poor control. Ex: Pressure Ulcer |
| Primary intention | Typical way of healing, SX incision (noncomplicated) heals quickly; small risk |
| Secondary intention | Chronic wound; venostasis ulcer; wound is open, healing occurs through granulation wound heals from inside out. |
| Tertiary intention | Delayed primary closure |
| Local Characteristic of inflammation | Pain, Health, Erythema, and Edema |
| Systematic characteristic of inflammation | Mildly elevated temperature, Leukocytosis, and Generalized malaise |
| Serous drainage | Clear, thin, watery plasma (Normal : small-moderate amounts) |
| Sanguineous exudate | Red, thin, water, fresh bleeding, trauma to blood vessels (Normal: Flank bleeding) |
| Serosanguineous exudate | Thin, watery, pale red to pink (Typically seen) |
| Seropurulent exudate | Thin, water, cloudy, and yellow - tan in color |
| Purulent exudate | Thick, opaque, tan, yellow, green, brown. Indication of infection. |
| Granulation Tissue | Foundation for scar tissue development, Highly vascular, red, bleeds easily, Beefy red in appearance |
| What phase does Granulation tissue form? | Proliferation phase of wound healing |
| Atrophic Scar | Sunken in skin; ache scar |
| Hypertrophic Scar | Build up of tissue but flat |
| Contracture Scar | Burns pull skin tighter making skin pucker |
| Keloid Scar | Raised |
| Striae | Stretch marks; fade over time |
| Local factors affecting wounds | Pressure, Desiccation, Maceration, Trauma, Edema, Infection, excessive bleeding, Necrosis, Bioflim |
| Slough | Moist yellow stringy |
| Escar | Black leathery, burns. |
| Debridement | SX, Chemical or dressing change |
| Biofilm | Biologic microorganism that lay over wound, slimy barrier |
| Systematic factors affecting wounds | Age, circulation, oxygenation, nutrition, wound condition, health status, immunosuppression, medication |
| Wound Complication | Infection, hemorrhage, dehiscence and evisceration, and fistula |
| Dehiscence | Wound no long approximated |
| Evisceration | No long approximated with content coming out |
| Causes of Dehiscence and Evisceration: | Strain (lifting or coughing) anticoagulation, CAM, smoking, obesity, infection and vomiting. |
| Infant/Children | Jaundice and millia (little bumps on nose/checks), Lanugo (hair), smooth/thin, weaker, and Pubic hair at onset of puberty |
| Older adults: | Wrinkles, thin skin, Dryness, scaling, Dark areas, age spots, Fine brittle hair, hair loss, and Gray or white. |
| Cultural consideration: | Skin color, body odor, and hair texture. |
| Psychological effects of wounds: | Pain, anxiety, fear, change in body image |
| Ecchymosis | Bruising |
| Alopecia | Hair loss |
| Hirsutism | Abnormal hair growth, where it does not typically grow |
| Seborrheic keratosis | Patchy over growth of skin |
| Lanugo | Hair covering newborns |
| Erythema | Red |
| Cyanosis | Blue |
| Jaundice | Yellow |
| Pallor | Pale |
| Vitilligo | Pigmentation disorder (Face, hands, arms, and groin) |
| Primary Lesions | Circumscribed, flat: Macule (freckles, petechiae), Patch (vitiligo, birthmark). Palpable, elevated solid masses: Papule (mole) Plaue (psoriasis) Nodule (nervus, wart) Tumor (Lipoma) Wheal (hives, mosquito bites. |
| Primary Lesion | Circumscribed, superficial skin elevation (Free fluid in cavity): Vesicle (herpes simplex) Bulla (blister) Pustule(acne) |
| Secondary Lesions | On skin surface: Crust (impetigo) Scale (dandruff, dry skin) Loss of skin surface: Erosion, Ulcer, and Fissure (athlete's foot). Miscellaneous: Lichenification, atrophy, excoriation, scar, and keloids |
| ABCDE of inspecting lesions | Asymmetrical, Borders, Color, Diameter, Elevation/Evolving |
| Inspection of lesion | Tissue integrity, temperature, texture, thickness, moisture and edema |
| 1 plus edema | 2 mm |
| 2 plus edema | 4 mm |
| 3 plus edema | 6 mm |
| 4 plus edema | 8 mm |
| Turgor | Nonresilant (Hydrated) Resiliency decrease with dehydration causing tenting. |
| Ecchymosis | Bruising |
| Petechiae | Bleeding under the skin; pinpoint |
| Purpura | Large bruising; bleeding under skin |
| Hair inspection | Color, texture (course, fine, brittle) Distribution, scalp lesions? |
| Nail assessment | Shape: convex. Angle: 160 degree, Texture: Smooth (firm & nontender) Color: translucent (pink, even) |
| Capillary refill (blanch test) | Less than 3 seconds (brisk) More than 3 seconds (sluggish) |
| Braden scale: Very high risk | Total score 9 or less |
| Braden scale: High risk | Total score 10-12 |
| Braden scale: Moderate risk | Total score 13-14 |
| Braden scale: Mild risk | Total score 15-18 |
| Braden scale: No risk | Total score 19-23 |
| Factors affecting the response to hot and cold treatments: | Method and duration of application, degree of heat and cold applied, patients age and physical condition, and amount of body surface cover by the application |
| Effects of apply heat: | Peripheral blood vessels dilate ( more o2 , nutrition, and viscosity), muscle tension, and pain |
| Ways to apply heat: | Heat packs, heated blanket, hot compress, sitz bath, and warm soak. |
| Effects of applying cold: | Peripheral blood vessels constrict (viscosity increases) Applying initially (bleeding and ecchymosis decreases) |
| Ways to apply cold: | Ice packs, cooling blanket, cool compress, and ice. |
| Ways to asses with hot/cold treatments: | Asses for local redness, blister, pain, change in LOC, check circulation, asses color. |
| Generalized diagnostic testing: | Skin biopsy, cultures (detect microorganism growth), Immunofluorescent studies, wood's lamp, tzanck test, potassium hydroxide, patch testing ( allergies) |
| Albumin | 19-38 |
| Pre-albumin | 3.4-5.4 |
| WBC | 4.5-10.5 |
| ESR | Men: 0 -15 mm/hr Female: 0-20 mm/hr |
| Culture and Sensitivity | Finds out what antibiotic the bacteria is sensitive to |
| Goals of treatment skin/wounds: | Control severity, prevent infection, and promote healing |
| Localized or short term treatment: | Lice or sunburn |
| Extensive or long term treatment: | Eczema or dermatitis |
| Topical glucocorticoid treatment: | Potency varies |
| Alternative therapies | Aloe vera, chamomile, evening primrose oil |
| Contact dermatitis: | Inflammatory reaction, Physical, chemical, or biological, Response to direct contact with an allergen, |
| Common causes of contact dermatitis: | Soap or detergents |
| Nursing consideration for contact dermatitis: | latex |
| Pressure ulcers | Cause by external pressure that impairs blood flow and caused by forces that tear and injure vessles |
| Fiction | Sliding a Pt up in the bed |
| Shearing forces | Scrapping away a layer of skin |
| Risk factors for pressure ulcers: | Immobility, inadequate nutrition, fecal and urinary incontinence, decreased mental status, diminished sensation, excessive body heat, advanced age, loss of lean body mass, generalized thinning of epidermis, decreased strength, elasticity of skin, |
| Risk factors fro pressure ulcers: | Increased dryness, diminished pain perception, diminished venous, arterial flow, chronic medical condition,. |
| First indication of ulcer development | Blanching ( pallor and whenever pressed does not return to pale/white) Ischemia followed by hyperemia ( when pressure relieved reddened (first stage)) |
| Stage 1 Ulcer: | Skin intact, boney prominence, reddened, darker people may not have blanching |
| Stage 2 Ulcer: | Partial thickness, break in skin; shallow open ulcer; no slough, Red/pink, blister ruptured. |
| Stage 3 Ulcer: | Full thickness, SubQ tissue but no bone tissue, Slough present, Boney prominence has minimal subQ |
| Stage 4 Ulcer: | Full tissue loss; undermining/ tunneling, osteomyelitis, Exposed bone, muscle and ligaments |
| Pressure ulcer assessment | Integrity of surrounding skin, Clinical signs of infection (Inflammation), Client complaints of pain and/or discomfort, signs of infection |
| Preventing pressure ulcers: | Provide nutrients, maintain hygiene, avoid skin trauma, mobility, provide supportive devices, and reducing pressure on body parts |
| Treating Pressure ulcers: | Debridement (Sharp, chemical or mechanical) Autolytic (dressing with moisture with wound care product), and Laval therapy |
| Pressure ulcer education | What pressure ulcers are, common location for pressure ulcers, risk factors for them, skin care, ways to avoid injury, diet and how to care for ulcers ( dressing change and skin barriers) |
| Wound care management | Pain assessment and suture/staples |
| Types of dressing: | Fibrin sealants, Negative pressure wound therapy, and Oxygen therapy. |
| Active ROM | Patient does own range of motion |
| Passive ROM | RN or UAP does range of motion on patient. |
| ROM prevents: | Contractors, foot drop, circulatory problems, blood clots, skin breakdown, fecal impaction and hypostatic pneumonia. |
| Contraindication for ROM: | Acute arthritis, septic joint, bone fracture, head injury (w/o an order), subluxation ( joint out of socket), joint sx (w/o an order), acute cardiovascular pathology, and acute thrombophlebitis. |
| ROM: | Always work from head to toe, perform slow and smooth |
| Flexion | action of bending |
| Extension | act of drawing away |
| Hyperextension | Extension of join beyond normal limits |
| Dorsiflexion | Bending from upper surface to superior surface |
| Plantar flexion | movement of the foot that flexes the foot or toes downward toward the sole |
| Abduction | movement away from the midline |
| Adduction | movement towards the midline |
| Circumduction | movement of a limb or extremity so that the distal end describes a circle while the proximal end remains fixed. |
| Rotation | the action or process of rotating on or as if on an axis or center |
| External rotation | turning outwardly or away from the midline of the body |
| Internal rotation | the turning of a limb about its axis of rotation toward the midline of the body |
| Eversion | A turning outward, as of the eyelid or foot |
| Inversion | A turning inward. |
| Supination | |
| Pronation | |
| Elastic bandage application: | Hold roll in dominant hand, Keep roll uppermost, Unroll 3 inches, Secure with circular turns, Overlap 1/2 to 2/3 width of previous layer, wrap distal to proximal. |
| Rate of muscle strength 5/5: | Full ROM against gravity and full resistance |
| Rate of muscle strength 4/5: | Full ROM against gravity and some resistance |
| Rate of muscle strength 3/5: | Full ROM with gravity ( 50% normal strength) |
| Rate of muscle strength 2/5: | Full ROM with gravity eliminated or support ( 25% of normal strength) |
| Rate of muscle strength 1/5: | No movement; slight contraction of muscle is palpable or visible flicker |
| Rate of muscle strength 0/5: | No contraction; complete paralysis (0% normal strength) |
| Cane | "Hold strong and advance the weak", Two points of support maintained on the ground at all times, Held on stronger side, moves 4-12 inches forward then move weaker leg. |
| Crutches | Non-weight baring or partial weight baring; Height two finger-width below axilla, Weight support by hands and elbows, |
| Non-weight baring crutches | Crutches forward first |
| Partial weight baring crutches: | Crutches and injured extremity forward first |
| Stair climbing with crutches | "The good go up and the bad go down" |
| Walker | Enhances later stability and support the body weight; advance walker, weaker leg, then stronger leg |
| Walker height | Greater trochanter or break of wrist. |
| Hydraulic lift | safest from of transfer for client and caregiver |
| Cerebrum | Reasoning, judgement, concentration, motor, sensory, and speech |
| Cerebellum | Coordination |
| Brainstem | Cranial nerves, respiratory center, and cardiovascular center |
| Factors affecting sensory perception | Congenital and hereditary condition, culture, stress, isolation, medication and illness, lifestyle and personality (quality and quantity of stimuli, personal differences) |
| Neonate | Visual acuity 20/100-20/400, Rectus muscles uncoordinated, transient nystagmus (involuntary movement), esotropia (cross eyed) common , Eustachian tube shorter, wider, and fetus begins hearing at 20 weeks |
| Adults | Changes in accommodation (Greatest decline 45-55 yrs of age), Hearing loss, Hypogeusia (Decreased taste) and Hyposmia (decrease smell) |
| Older adults | Changes in vision, hearing, touch and smell. With one or more impairments at risk for injury, weight loss, falls, malnutrition, and social isolation. |
| Injuries in children | Eye injury due to toys, sports, and activities |
| Injuries in adults | Work related, minor injuries can threaten vision |
| Ear injuries | Children; rupture of tympanic membranes |
| Diabetic Retinopathy | Changes in blood vessels of the retina |
| Cataracts | Clouding (opacification) of lens of eye |
| Glaucoma | Increased fluid pressure inside the eye leads to optic nerve damage |
| Macular degeneration | Damage to the macula, a small spot near the center of the retina and the part of the eye needed for sharp, central vision |
| Common outcomes: | Prevent injury, maintain function, develop effective method of communication, preventing sensory overload, deprivation, reducing social isolation, and performing ADLs independently and safely |
| Nurses | Teaching, promoting healthy sensory function, routine auditory testing of children (before newborns leave hospital) (Chronic ear infection) Avoid noisy environments, |
| Environmental Stimuli | Teach clients how to prevent reduce loss, adjusting environmental stimuli; noise level, lighting, and frequency of entering room. |
| Address sensory overload | Reduce number, type of stimuli, reduce novelty, surprise interruptions, rest periods with no interruptions, and explain sounds in environment. Limit visitors, close blinds, ear plugs, and limit overhead paging |
| Address sensory deprivation | TV, radio, clock, calendar, books, toys, encourage visitors, open blinds, and turn bed in room. |
| Managing acute sensory stimulation | Encourage use of sensory aids and promote use of other senses |
| Impaired Vision safety consideration | Uncluttered environment, clear pathways, organize self-care articles within reach, orient to new location, call light, assistive devices within easy reach, assist with ambulation, and increased risk of depression among adults |
| Impaired hearing safety consideration | Assessed frequently. At home; amplify sounds and flashing lights. |
| Impaired olfactory sense safety consideration | Dangers of cleaning with chemicals and dangers of gas leaks and food poisoning |
| Impaired tactile sense safety consideration | Temperature and pressure. |
| Conductive | Disruption in transmission of sound due to obstruction |
| Sensorineural hearing loss | affects inner ear, auditory nerve pathways due to noise exposure, ototoxic drugs, tumor, vascular disorder, degenerative disease, and trauma |
| Presbycusis | Progressive hearing loss with aging; hair cells of cochlea degenerate with aging, higher pitched tones, conversational speech lost initially |
| Hearing impairment risk factors | 50% of hearing loss in children is genetic(toxoplasmosis, chlamydia) 25% environmental around time of birth, certain infections, craniofacial abnormalities, Very low birth weight, Bilirubin greater then 16 mg/dL, |
| Hearing impairment risk factors | Aminoglycocide medication administered (Mycin drugs), Low apgar score at 1 and 5 minutes, meningitis, mechanical ventilation for over 5 days, and syndromes associated with hearing loss such as downs syndrome |
| Conductive hearing loss | Loss of hearing at all sound frequencies |
| Sensorineural hearing loss | Loss of high frequency tones, speech discrination difficult |
| Presbycusis | Gradual; described as unsociable, paranoid |
| Tinnitus | Perception of sound, noise without stimulus; usually associated with hearing loss, Early identification key element, treat underlying causes |
| Vertigo | Illusion of movement in which client feels that he's revolving in space or that his surrounds are revolving around him. Caused by disturbance in inner ear or adverse reaction to a medication. |
| Adult treatment for Vertigo | Meclizine hydrochloride (Antivert Dramamine) 25-100 mg PO daily in divided doses |
| Meniere's disease | Abnormality in inner ear fluid balance. Manifestations: vertigo, tinnitus, sensorineural hearing loss. May be incapacitating, accompanied by N/V and Diaphoresis |
| Treatment for Meniere's disease | Anxiolytic- diazepam (valium) Antiemetics - promethazine (Phenergan) Diuretics - hydrochlorothiazide (Dyazide) |
| Collaboration in Hearing impairment | Multidisciplinary team if uncorrectable, amplification - does not prevent, minimize or treat loss |
| Hearing aids include | Microphone, amplifier, speaker, earpiece, volume, canal hearing aids, in-ear style, behind-ear hearing aids, and body hearing aid. |
| Assistive listening devices | White noise-masking for client with tinnitus, TTD/TTY telephones, and internet accessibility |
| Stapedectomy | Removal of stapes bone |
| Tympanoplasty | Removal of scar tissue an reconstruct middle ear |
| Cochlear implant | Microphone, speech transmitter, Receiver/stimulator, electrodes, function similar to way ear normally processes and provides sound perception, not normal hearing |
| Possible Nursing Diagnoses | Disturbed Sensory Perception: Auditory, Impaired Verbal Communication, Social isolation |
| Disturbed Sensory Perception | Encourage client to talk about hearing loss, provide info about type of hearing loss, Replace batteries in hearing aids, If hearing aid has toggle switch: be sure it is in appropriate position, talk with family members about communication techniques |
| Hearing Aid Care | Check batteries regularly, clean daily, Turn off and lower volume before removing, remove by rotating slightly forward and pulling it outward, clean with damp cloth, Turn on and adjust volume AFTER inserting. New user may increase wear time gradually |
| Impaired Verbal communication | Wave hand, tap shoulder before speaking. Ensure corrective lenses are clean and client wears, face client, hands away from face. Keep face in full light. Reduce noise in environment before speaking. Use low voice pitch with normal loudness. |
| Impaired Verbal communication | Short sentences, pause at end of sentence. Speak at normal rate Use facial expression, gestures. Provide magic slate for written communication. Do not place IV catheter in dominant hand Rephrase sentences if difficulty understanding Repeat important info |
| Social Isolation | Identify extent and cause of isolation. Encourage client to interact. Treat client with dignity, remind friends/family. Hearing deficit does not indicate cognitive loss. Involve client in activities that do not require hearing. Obtain pocket talker. |
| Cognition | A complicated process by which and individual learns, stores, retrieves, and uses information. Includes: reasoning, problem solving, remembering, interpreting, and communicating. |
| Nervous system | is responsible for control of cognitive function and both voluntary and involuntary activities. |
| Conscious states | Delirium (acute), dementia (chronic), confusion, normal consciousness, somnolence, minimally conscious, and locked -in syndrome |
| Unconscious states | Asleep, Stupor, coma and vegetative state |
| Stupor | around by extreme stimuli |
| Coma | Do not respond to stimuli |
| Vegetative state | Posture or withdraw to stimuli |
| Delirium | Abrupt onset |
| Dementia | Gradual; irreversible onset |
| Risk factors of cognition | Delirium can occur at any stage of developmental process |
| Older adult risk factors of cognition | Chronic medical problem, Polypharmacy, under-treatment of pain, and vision or hearing loss |
| Normal healthy aging risk factors of cognition | Not characterized by cognitive and mental disorders |
| Clinical manifestation of cognition | Range from subtle to acute; Features: fluctuation in alertness, distractibility, disorganized thinking, speech; hallucination=severe |
| Nursing assessment of cognition | Sudden change in mental status needs to be aggressively evaluated, should be screened for depression |
| Possible Nursing Diagnoses | Insomnia, Disturbed sleep patter, Self-Care Deficit, Acute or Chronic confusion, Wandering, Impaired memory, Impaired verbal communication, and Caregiver role strain |
| Possible goals of cognition | Absence of confusion, Cognitive status returns to baseline, discharged to same destination as pre-hospitalization, able to perform ADLs |
| Therapeutic communication | Address person by name, introduce self. Speak clearly. calmly, directly. Provide clear, concise explanation, Allow time for words to be processed, Reinforce reality, Assign same caregiver, verbally reinforces client's strengths |
| Assessment of the HEENT and Neurologic System | 1. Current problems. 2. Past medical history. 3. Family history. 4. Personal and social history |
| HEENT assessment: Current problem | Seizures/convulsions: character, aura (Sense that something changes) LOC, frequency, associated manifestation, timing (duration time of day activities) and medication Pain Gait coordination. Weakness or paresthesia, & changes in mental status or 5 senses |
| HEENT assessment: Past medical history | Trauma, CVA, Meningitis, encephalitis, deformities, HTN, neurologic disorders, and brain SX |
| HEENT assessment: Family HX | Hereditary disorders, Tay-Sachs, Huntington's chorea, Muscular dystrophy, Neurofibromatosis, and alcoholism, MR, Epilepsy, Alzheimer's disease, learning disorders, Weakness or gait disorders, Thyroid disease, DM and HTN |
| HEENT assessment: Personal and Social HX | Enviromental or occupational hazards. Hand, eye, foot dominance, ADL, Sleeping patters, use of alcohol and tobacco, mood-altering drugs, and anxiety |
| Equipment of physical exam | Penlight, Tongue blade, sterile gauze, safety pin or toothpick, Reflex hammer, Aromatic substances, cotton wisps, flavored substances, and familiar objects (coin, key, paper clip) |
| Sex components of Neuro Physical Exam | Muscle tone and strength, Proprioception/Cerebellar function (Assess balance, coordination and fine motor skills), Cerebral function (Pertaining to intellect), Cranial nerves, Sensory Function, and Reflexes |
| Upon entering the room, note the client's | Facial expression, posture, affect, and grooming |
| LOC | Single most valuable indicator of neurological status; awake/alert, lethargic, stuporous, comatose. |
| State of arousal/awareness | AAO x3; AAO to person. States it is 1977 and he is in Vietnam |
| Glasgow coma scale | Highest = 15 ( normal) Comatose =7 or less Lowest = 3 (deep coma) |
| Decorticate | (3 on GCS) Flexion posturing |
| Decerebrate | (2 on GCS) Excretion posturing |
| Immediate Memory | Ask to repeat a series of numbers |
| Recent memory | Name 3 objects and ask client to recall them later in the exam |
| Remote Memory | Ask date of birth or date a major historical event |
| Mathematical ability |
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