chap 14

Question 1

skin is important because

Answer 1

provides a physical barrier that protects underlying tissues & organs

Question 2

3 layers of skin

Answer 2

• epidermis
• dermis
• subcutaneous tissue

Question 3

types of hair

Answer 3

• vellus

- terminal

Question 4

purpose of hair

Answer 4

filters dust and airborne debris

Question 5

lunula (nail)

Answer 5

white portion of nail

Question 6

functions of nails

Answer 6

• protect distal end of fingers/toes
• enhance precise movement
• allow extended precision grip

Question 7

subjective data of health assessment

Answer 7

• history of present health concerns
• personal health history
• family history
• lifestyle/health practices

Question 8

personal health history

Answer 8

• sunburns
• current/previous skin prob
• hospitalizations
• surgery
• allergic reaction
• recent viral/bacterial infection
• pregnancy
• self-injury

Question 9

family history

Answer 9

• recent illness, rash, other skin problems
• skin cancer
• keloids

Question 10

inspection (skin assessment)

Answer 10

• color or color variations
• integrity
• lesions

Question 11

palpation (skin assessment)

Answer 11

• texture
• thickness
• moisture
• temp
• mobility & turgor
• edema

Question 12

Braden scale

Answer 12

• sensory perception
• moisture
• activity
• mobility
• nutrition
• friction & shear

Question 13

perfect braden scale score

Answer 13

23

Question 14

mild risk braden scale score

Answer 14

15-18

Question 15

moderate risk braden scale score

Answer 15

13-14

Question 16

high risk braden scale score

Answer 16

10-12

Question 17

severe risk braden scale score

Answer 17

less than/equal to 9

Question 18

what does the braden scale measure

Answer 18

pressure sore risk

Question 19

hair (objective data)

Answer 19

• color
• condition
• texture
• distribution
• loss
• unusual growth patterns

Question 20

nails (objective data)

Answer 20

• grooming
• color
• markings
• shape
• palpate for texture
• capillary refill

Question 21

common nursing diagnoses

Answer 21

• readiness for enhanced health management
• risk for infection
• risk for imbalanced nutrition
• impaired skin integrity
• ineffective health maintenance
• disturbed body image

Question 22

aging consideration

Answer 22

• decreased perspiration
• sebum decreases
• pale
• skin lesions
• loss of turgor
• sagging/wrinkles
• coarse hair
• nails become thicker, yellow, brittle

Question 23

pressure ulcers

Answer 23

sores on skin @ pressure points

Question 24

contributing factor to pressure ulcers

Answer 24

unrelieved pressure

Question 25

high risk for pressure ulcers

Answer 25

critical care, long-term care facilities, patients on bedrest

Question 26

stage 1 pressure ulcer

Answer 26

intact skin w/ non-blanchable redness - painfull - firm or soft - warm or cooler than adjacent tissue

Question 27

stage 2 pressure ulcer

Answer 27

shallow open ulcer w/ pink wound bed - intact/open blister - shiny/dry shallow ulcer - no slough or bruising

Question 28

stage 3 pressure ulcer

Answer 28

full thickness tissue loss - slough may be present - may have tunneling - bone/tendon NOT visible

Question 29

stage 4 pressure ulcer

Answer 29

full thickness loss w/ bone/tendon/muscle exposed - slough present - tunneliing

Question 30

What is the greatest risk for MRSA

Answer 30

impaired skin integrity

Question 31

most common cancer

Answer 31

skin cancer

Question 32

types of skin cancer

Answer 32

- melanoma - basal cell carcinoma - squamous cell carcinoma

Question 33

ABCDE assessment

Answer 33

``` a- asymmetry b-borders c-color variations d-diameter e-evolution ```

Question 34

risk factors for skin cancer

Answer 34

- sun exposure/tanning - family history - moles - fair skin (burns/freckles easily) - age

Question 35

macule

Answer 35

darkened area that is flat

Question 36

papule

Answer 36

raised area, knotty looking, sometimes pain

Question 37

vesicle

Answer 37

fluid filled, blister

Question 38

wheal

Answer 38

raised, red areas, allergic-type reaction

Question 39

pustule

Answer 39

pus-filled lesions

Question 40

petechia

Answer 40

- type of macule - round red/purple - associated w/ bleeding tendencies - flat

Question 41

ecchymosis

Answer 41

bruising

Question 42

ridging in nail

Answer 42

- can be normal | - can be indicative of nutritional problem

Question 43

koilonychia

Answer 43

- seen in iron-deficiency anemia - endocrine & cardiac disease - "spoon-shaped"