Ch 19 Test 1

Question 1

Functions of the skin

Answer 1

Protection
Sensation
Temp regulation
Excretion and secretion

Question 2

What changes occur in skin with aging

Answer 2

1. Lost elastic fibers/adipose tissue sub q, causes to be thinner, wrinkle/sag
2. loss collagen, more fragile slow heal
3. Decreased sebaceous gland dry itchy skin
4. Temp control altered. Cold intolerance
5. Hair thins, grow slowly decrease number follicles,loses color- loss melanocytes
6. Nail growth decreases nails thicken

Question 3

What is reactive hyperemia?

Answer 3

Process by which blood rushes into a place where there was a decrease in cicruclation.

Question 4

Within how many minutes should redness subside from skin before it is working its way to a stage 1 pressure ulcer?

Answer 4

45 minutes

Question 5

Major contributing factors for pressure injury

Answer 5

Immobility 
Inactivity
Moisture
Malnutrition
Advanced age
Altered sensory perception
Lowered mental awareness
Friction and shear

Question 6

Minor contributing factors for pressure injury

Answer 6

Dehydration
obesity
Edema

Question 7

When should you first do a skin exam?

Answer 7

Upon admission( or at least within 8 hours)  perform a detailed skin exam noting appearance.use braden scale . Pay attention to skin over bony prominences.
Reassess every shift.

Question 8

The braden scale for predicting pressure sore risk from 1 bei mb very poor to 4 being no impairment

Answer 8

Asseses point based 9n
 sensory perception
Moisture
Activity
Mobility
Nutrition
Friction and shear

Question 9

An area of skin is red, deep pink, mottled does not BLANCH with fingertip pressure. Darker skin may have a discolorationnof surrounding tissue. Warmth, edema, and induration ( area feels hard)

Answer 9

Stage 1 pressure injury

Question 10

Partial thickness skin loss exposed dermis, wound is pink or red. Looks like a ruptured blister

Answer 10

Stage 2 pressure injury

Question 11

Full thickness skin loss looks like CRATER. extends to fascia. SUBQ skin damaged NECROTIC. fat is visible.UNDERMINING / TUNNELING present. May be damage to surrounding tissue.

Answer 11

Stage 3 C.U.T

Question 12

Full thickness skin loss,extensive NECROSIS DRY BLACK NECROTIC ESCHAR. wet and oozing

Answer 12

Stage 4 pressure injury

Question 13

Loss full thickness . BASE OF INJURY COMPLETELY BLACK OR BROWN. COVERED BY ESCHAR

Answer 13

Unstageable.

Question 14

Purple deep tissue, broken MAROON OR PURPLEblood filled damage to underlying soft tissue from pressure or shearing.

Answer 14

deep tissue pressure injury

AKA DEEP PURPLE

Question 15

How often should ot be repositioned in a wheelchair or chair?

Answer 15

1 hour

Question 16

How often shoukd ot be repisitioned in bed

Answer 16

Every 2 hours

Question 17

Should you massage redened ski

Answer 17

NO! it has already been damaged. Avoid massage over bony prominences.

Question 18

Why isnt a full bath needed wvery day?

Answer 18

Decreased sweat and sebaceous gland activity

Personal preference

Question 19

Thinner skin/decreased sub q fat, pts can have chilling. How can we prevent.

Answer 19

Pre warm bath

Give adequate draping.

Question 20

Type of bath that replaces tub ir shower and can be given in a bath shower or bed

Answer 20

Cleansing bath

Question 21

Type bath that healing or medicinal. Whirlpool, oatmeal

Answer 21

Therapeutic

Question 22

Type moist heat clean anal perineal area. Needs order

Answer 22

Sitz bath

Question 23

Type bath that cleanses ooen wounds aplied medicine solutionsfeet arms soaked

Answer 23

Body soak

Question 24

Tyoe bathneeds order to bring down fever

Answer 24

Sponge bath

Question 25

Do older pts need a full bath every day?

Answer 25

No, pre warm the water, draoe pt, mild soao pat dry, prevent slios falks

Question 26

Benefits of back massage

Answer 26

``` Communicates caring Fosters trust Opportunity to assess skin Stimulates circulation to area Reduces tension promotes relaxation ```

Question 27

Perineal care

Answer 27

Ensure proper draping

Question 28

Mouth care times unconscious

Answer 28

At least ince every 4 hours with moist swabbing every 2 hours Check gag reflex Make sure dont aspirate communicatemcan turn to side

Question 29

Mouth care times concius

Answer 29

Raise bed 45-90 every 4 hours

Question 30

Shaving

Answer 30

No shave before surgery | May not shave beard or mustache withiut order

Question 31

Nail care

Answer 31

Straight across cuts Ve aware of diabetic circukation issues So dont cut on diabetic pts withiut order

Question 32

Ear care

Answer 32

Not with q tios can push wax in | Be careful w hearing aids