Nursing 128 Test 4
Terms
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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.
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Inflammatory (3-5 days)
Fibroblastic (2-4 weeks)
Maturation (3 weeks - 1 year) - Name the 3 types of wound healing.
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First intention - clean laceration
Second intention - deeper injuries
Third intention - open wound, infected or potentially infected. - Mechanisms of healing
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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
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turning & position
protect bony prominences
teach family about skin care - Stages of pressure ulcers
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One-redness
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
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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
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Cysts- tx-antibiotics, heat
Seborrheic keratosis-normal variation of skin w/ aging. no treatment.
Keloids-overgrowth of scar tissue
Nevi-mole
Warts-small tumors caused by virus. Tx-surgery, topical agents. - Bacitracin, Neomycin used for
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skin infections, minor burns, wounds
side effects -rare, rashes, urticaria, scaling, redness. - Acyclovir used for
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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?
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psoriasis, eczema, pruritus
Side effects: acne, epidermal thinning, purpura, striae. - Proteolytic Enzymes are used for?
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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?
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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.