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Nursing 128 Test 4


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What is alopecia
bald spots
What is hirsutism?
Abnormal hair distribution in females caused by hormonal imbalance/medication.
What is the potassium hydroxide test used for?
To detect fungus problem on skin.
What is a Tzanck's smear?
The most common test of skin cells. Cells taken from lesion & examined under microscope for identification.
What is a Wood's light used for?
To detect skin infections. An ultraviolet black light produces color changes of blue, green, or red on skin in presence of some infections.
What is the patch test for allergies?
Patches are soaked in solution that may be causing allergy and then placed on skin to see reaction.
Name 3 types of skin biopsies.
Punch, Shave, Excision
What is hyperplasia?
Overgrowth of tissue in aging adults.
What is urticaria?
Hives. An allergic reaction.
What is the treatment for pruritis?
Treat the underlying cause. Keep nails short, bath with antibacterial soap, bathe in oily solution to soften skin, soothe irritation. Oatmeal bath helps.
Name the 3 phases of wound healing.
Inflammatory (3-5 days)
Fibroblastic (2-4 weeks)
Maturation (3 weeks - 1 year)
Name the 3 types of wound healing.
First intention - clean laceration
Second intention - deeper injuries
Third intention - open wound, infected or potentially infected.
Mechanisms of healing
Partial thickness/superficial - heal by epithelialization.
Full thickness - heal by contraction (granulation tissue)
Causes of pressure ulcers
Mechanical trauma, pressure, friction, shear.
Risk factors for pressure ulcers.
Mental status, Activity/immobility, nutritional status, incontinence.
Risk factor tool
Braden scale
Pressure ulcer prevention
turning & position
protect bony prominences
teach family about skin care
Stages of pressure ulcers
Two-partial skin loss
Three-subcu & fascia damaged or destroyed
Four-skin loss is full thickness possible damage to muscle & bone
What is debridement?
removal of necrotic tissue. done by physician in client's room or surgery.
What is a pedical graft?
Donor area flap still attached (arm to stomach) graft site immobilized 3-5 days. Surgeon does 1st dressing change. Pressure dressing may be applied to immobilize.
3 types of infectious disorders
Bacterial, Viral, Fungal
Example of a bacterial disorder
Folliculitis or Furuncle (infected hair follicle)Cellulitis. Tx-Heat and antibiotics
Example of a viral infection
Herpes simplex 1 - cold sore. Recurring virus. Virus remains dormant in nervous system. Tx acyclovir.
Example of a fungal infection.
tinea, athletes foot, ringworm, jock itch. Tx-topical antifungal or sever oral antifungal. Caused by a dermatophyte.
2 types of parasitic disorders
Pediculosis (lice infestation), Scabies (mite burrows under skin)
Tx - topical. Change linens, check people who have been in contact
psoriasis cause and S&S
Unknown. Thick papules and plaques w/ silvery scales. No cure. Tx-topical steroids, ultraviolet light therapy, cytotoxic agents to destroy cells.
5 Benign skin conditions
Cysts- tx-antibiotics, heat
Seborrheic keratosis-normal variation of skin w/ aging. no treatment.
Keloids-overgrowth of scar tissue
Warts-small tumors caused by virus. Tx-surgery, topical agents.
Bacitracin, Neomycin used for
skin infections, minor burns, wounds
side effects -rare, rashes, urticaria, scaling, redness.
Acyclovir used for
Herpes simplex, herpes genitalis
Side effects-rash, urticaria, stinging
Antifungals used for?
tinea cruris, tinea pedis, diaper rash. Side effects: burning, stinging, itching, peeling.
Topical corticosteroids are used for?
psoriasis, eczema, pruritus
Side effects: acne, epidermal thinning, purpura, striae.
Proteolytic Enzymes are used for?
chemical debridement
Side effects: transient erythema, dermatitis and fever.
Fibrinolysin and desoxyribonuclease are use for?
debridement of inflamed or infected lesions. Side effects: caution in clients with sensitivity to bovine source materials or mercury compounds.
Sutilains are used for?
open wounds and ulcers resulting from 2nd and 3rd degree burns, decubiti, pvd, wounds from trauma or incisions.
side effects: mild transient pain, local paresthesia, bleeding.
Dextranomer is used for?
cleasing a wet or secreting wound. no side effects listed.
What is the order of examining the abdomen?
Inspection, Auscultation, Palpation, Percussion.
Why is a barium enema done?
To visualize the colon. Detects bowel obstruction or masses in colon.
What medication is given before an EGD?
Conscious sedation (versed).
Nursing considerations post-op for EGD?
V.S. taken until sedation wears off. Client NPO until gag reflex returns. Normal to have sore throat, blood tinged sputum.
Why is a CBC done (related to GI)?
To assess for anemia (RBC's) or infection (WBC's)
What do levels of the enzymes LDH, AST, and ALT tell you?
Info about liver damage.
Why is a stool occult done?
To test for occult blood and parasites.
What are post-op nursing considerations for colonoscopy?
V.S. closely, lots of flatus, cramping, feeling of fullness, may have small amount of blood in first stool fater exam. Report large amounts of blood.
Why is gastric fluid analyzed?
To check for CA cells and other disorders.
Why is urine tested?
To detect bile, provides info re: gall bladder or liver disease and for presence of amylase (indicates pancreatic disorders)
Why are tumor markers assessed in the blood?
To assess the effect of cancer treatment and for the recurrence of cancer.
What is stomatitis?
An inflammation and/or infection of the oral mucosa. May be caused by bacteria, virus, fungus, allergy, vitamin deficiency, esp. B12, iron deficiency, chemo, radiation.
Some nursing diagnosis for mouth cancer and stomatitis.
Ineffective airway, impaired oral mucous membranes, impaired communication, acute pain, risk for infection, disturbed body image.
Non-surgical management for mouth cancer or stomatitis.
radiation or chemotherapy.
Nursing interventions for post-op mouth cancer or stomatitis.
humidified O2, pain meds (morphine), NOP until healing complete, NG tube with tube feedings.
What is achalasia?
The lower esophageal sphincter fails to relax properly with swallowing or abnormal esophageal contractions replace regular peristalsis. Causes progressive dysphagia, regurgitation.
Post-op nursing for esophagus surgery.
monitor for bleeding or signs of perforation. Hematemesis (blood in vomit)
What is the pain like in GERD?
Can radiate to neck, jaw, back. Can resemble cardiac pain.
Causes of hiatal hernia.
Obesity, muscle weakness, trauma, previous surgeries.

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