Exam #2 Flashcards
(81 cards)
How are skin lesions primarily assessed?
Color.
How else are they assessed?
Irregular border, shape, diameter > 5-6mm.
What signs do you look for when inspecting the skin?
Edema, moisture, petechiae, ecchymoses.
What signs do you look for when inspecting the skin in a darker skinned patient?
Pallor (ask grey of mucous membranes), Cyanosis (lips, tongue, nail beds, palms, soles), Inflammation (warmth and redness), Jaundice (hard palate), Skin bleed (darker).
Where do you look for skin tears, especially on the elderly patients?
Where their clothing rubs, upper extremities where the skin is grasped, under tapes and dressings.
What is the difference between a macular rash and a papular rash?
Macular rashes are flat and papular rashes are raised.
Where is it best to assess skin temperature?
On the forearm with the back of you hand.
Describe the differences between 1st, 2nd, and 3rd intention healing.
1st = clean cut, sewed shut, thin scar. 2nd = deep, wide, granulated, not swen. 3rd = delayed closure, granulation, risk for infection, scar.
When skin and underlying tissue are pressed against a bony prominence or external surface for a period of time it can cause a _____, or tissue _____.
Pressure ulcer. Anoxia.
Name all 9 risk factors for pressure ulcers.
Impaired mental status, sensory deficits, immobility, elderly, very thin or obese, mechanical, shearing or friction, moisture or secretions, impaired nutritional status.
What is the best way to prevent pressure ulcers?
Shift your weight (even the slightess mvmt) q15mins.
Should you massage reddened areas or the legs of those at risk for DVT?
No!
In the clinical setting, how often should you turn a patient?
Every 2 hours minimum.
What are the scoring ranges on the Braden scale?
11 or under = severe, 12-14 = moderate, 15-16 = mild.
What does black, yellow, and red tissue indicate?
Black = necrosis, yellow = infection, red = healing.
What are the 4 stages of pressure ulcers? Describe them.
Stage 1 = red, unblanchable, skin intact. Stage 2 = Partial thickness skin loss. Stage 3 = Full thickness skin loss, may have some eschar. Stage 4 = Damage to muscle, bone, and/or support.
Which method of debridement is NON-selective?
Mechanical.
Which type of debridement is selective? What are its advantages and disadvantages?
Some enzymatic debriders are selective, but not all. Advantages - it is fast acting with minimal damage to healthy tissue. Disadvantages - expensive, need prescription, must be carefully applied, may have discomfort.
How does the autolytic method of debridement work and when is it used?
It uses the body’s own enzymes. Best used in stage 3 or 4 with light to moderate exudate.
What method of debridement is fastest?
Surgical
What does negative pressure wound therapy provide and what DON’T you use on it?
It provides drainage and vascularization, and you should NEVER put it over healthy tissue. Usually used on ST3 or ST4.
What changes to an ulcer should you inform the provider of?
Sudden deterioration or increase in size or depth. Changes in color or texture of granulated tissue.
What albumin level is considered a sign of impaired nutritional status? Lymphocytes?
Albumin < 3.5mg/dL. Lymphocytes < 1800mm3.
What % weight loss is considered INS?
Greater than 15% of body weight.
