Adult Skin

Question 1

Stage I pressure ulcers

Answer 1

• no loss of tissue
• epidermis remains intact
• reddened but does not blanch (turn white)

Question 2

Stage II pressure ulcers

Answer 2

• epidermis and a part of the dermis are lost

Question 3

Stage III pressure ulcers

Answer 3

• expose subcutaneous fat
• not deep enough to expose bone and muscle

Question 4

Stage IV pressure ulcers

Answer 4

expose bone and muscle

Question 5

Unstageable pressure ulcer

Answer 5

• wound is covered by slough or eschar
• can not assess how deep the pressure injury goes

Question 6

Superficial first-degree burns

Answer 6

• pink to red
• have no blisters
• dry
• moderately painful

1st degree

Question 7

Superficial partial-thickness burns

Answer 7

• appear red
• wet blisters
• erythema that blanches with pressure
• severe pain

superficial second-degree

Question 8

Deep partial-thickness burns

Answer 8

• appear yellow, white, or dry
• minimal to no blanching with pressure
• minimal pain due to a decreased sensation
• sluggish cap refill

2nd degree

Question 9

Full-thickness burns

Answer 9

• involve the full thickness of skin
• white, black, brown, or red
• leathery and dry

3rd degree

Question 10

Severe burn care

Answer 10

• NPO
• EKG
  
  • esp with electrical burns
  • potassiums shifts = HYPERKALEMKA
• ABG
• TPN
• isotonic fluids
  
  • LR
• Tdap prophylaxis

Question 11

Severe burn care order

Answer 11

• assess airway/breathing,circulation (vital signs)
• adminster oxygen and cover burns with sterile guaze
• establish PVAD and give isotonic fluids
• insert catheter
• adminster tDAP

Question 12

Emergent- Resuscitative

burn stage

Answer 12

• first 24-48 hrs
• airway
• fluid management
  
  • HYPOVOLEMIC
    
    • hyponatremia
    • low albumin
    • low pH (acidosis)
    • HYPERkalemia
    • high hematocrit (dehydration)
• wound care

Question 13

Acute

burn stage

Answer 13

• Fluid mobilization
  
  • diuresis (increased urine) ends when burn is covered and completely healed
  • HYPERVOLEMIA
  • hyponatremia
  • hypokalemia (d/t diueresis)
  • low albumin
  • low pH (acidosis)
  • hematocrit low/normal
• wound care
  
  • prevent infection
  • promote healing
• acid/ base balance

Question 14

Rehabilitation

Answer 14

• begins when burn wounds are covered or healed
  
  • can start self-care activity
• resume functional role in society
• functional & cosmetic reconstruction

Question 15

Rule of 9’s

Answer 15

Question 16

Escharotomy

Answer 16

• removes eschar, slough, and dead tissueto relieve compartment syndrome
• considered successful when pulses return

Question 17

Venous stasis ulcer

Answer 17

• granulation tissue
• edema
• intact peripheral pulses
• no pain with walking
• usually around ankle
• skin dry and flaky

Question 18

Treatment for venous stasis ulcers

Answer 18

• compression hose
• vasodilation medication
• pentoxifylline
• leg elevation
• surgical debridement in extreme cases

Question 19

Arterial ulcers

Answer 19

• found in between toes
• painful
• peripheral pulses are diminished
• Intermittent claudication

Question 20

Diabetic ulcers

Answer 20

• usually found on the plantar area of the foot
• peripheral pulses are present
• variable pain due to neuropathy

Question 21

Arterial and diabetic foot ulcer

Answer 21

• little granulation tissue
• wound bed is deep
• risk factors such as hypertension and diabetes mellitus
• Compression hose is not recommended

Question 22

venous and diabetic ulcer

Answer 22

• intact peripheral pulses
• no leg pain

Question 23

Parkland formula

Answer 23

• used to calculate fluid requirements following a major burn
• 4 mL x client’s weight(kg) x surface area burned
• determines 24-hour fluid requirement
• 8 hours initially and then the remaining 16 hours

Question 24

Intrinsic factor

Answer 24

refers to anything essential or belonging naturally

Question 25

Decubitus

Answer 25

pressure ulcer

Question 26

Onychia

Answer 26

inflammation of the nail bed and matrix resulting from either injury or infection

Question 27

Onychomycosis

Answer 27

- fungal infection of the nail plate/bed - appear deformed - white or yellow discoloration

Question 28

Onychomadesis

Answer 28

- separation of the nail plate from the matrix - chemotherapeutic agents, antibiotics, anti-epileptic agents, etc., may cause this condition - in kawasaki disease

Question 29

Onychorrhexis

Answer 29

- brittle nails that break easily - no appearance

Question 30

Punch biopsy

Answer 30

- circular blade 1mm-10mm - priority is monitor for bleeding

Question 31

Scleroderma

Answer 31

- causes fibrosis to connective tissue - skin thickening/hardening - taunt and shiny - finger spasms - arthritis - muscle stiffness - significant fatigue - dysphageia - esophageal reflux - renal failure

Question 32

Gout

Answer 32

- tophi

Question 33

Psoriasis

Answer 33

- T cells become overactive - target healthy skin cells - inflammation - increased production of skin cells - formation of plaques/scaly patches - red/itchy - monitor self-esteem

Question 34

Melanoma identification

Answer 34

- ABCD - Asymmetry - Border uneven/irregular - Color more than 1 - Diameter 6mm - Evolution

Question 35

Skin changes with age

Answer 35

- cant retain moisture - drier skin - low production of skin oils (sebum) - itchy - decreased nail growth - thicker nails = risk for fungal infection - decrease pigmentation - melanocytes decrease