Fundamentals Exam 2

Question 1

Name the six types of skin dicoloration

Answer 1

Cyanosis
Pallor
Jaundice
Erythema
Ecchymosis
Petechiae

Question 2

bluish discoloration typically assessed in nail beds, lips, mouth, conjunctiva

Answer 2

Cyanosis

Question 3

decrease in tissue oxygenation

absence of underlying red tones in the skin

in brown skinned clients, skin may appear as a yellowish brown tinge

in black skinned clients, skin may appear ashen gray

usually assessed in areas with the least pigmentation:

	- conjunctiva
	- oral mucous membranes
	- nail beds
	- palms of hands or soles of feet

Answer 3

Pallor

Question 4

yellowish orange discoloration typically assessed in sclera, mucous membranes and skin

Answer 4

Jaundice

Question 5

reddened areas of the skin

Answer 5

Erythema

Question 6

areas of bruising on the skin

Answer 6

Ecchymosis

Question 7

pinpoint sized, red or purple spots caused by small hemorrhages in the skin layers

Answer 7

Petechiae

Question 8

From the RYB color code of tissue.. what does a red, moist tissue mean?

Answer 8

PROTECT/COVER THE TISSUE
Granulation tissue which is progressing toward healing
Skin needs to be protected to avoid disturbing regenerating tissue

Question 9

In what ways do you protect the skin to help avoid disturbing the regenerating or healing tissue?

Answer 9

Gentle cleansing
Protect skin around wound
Fill space in wound
Cover with appropriate dressing
Change as infrequently as possible

Question 10

From the RYB color code of tissue.. what does yellow tissue mean?

Answer 10

CLEANSE THE TISSUE
There is slough present (stringy substance attached to wound bed – may be accompanied by purulent drainage)

Must be removed before the wound can heal

- Irrigate wound
- Apply wet to damp normal saline dressings

Question 11

From the RYB color code of tissue.. what does black or brown tissue mean?

Answer 11

DEBRIDE THE TISSUE
There is eschar present (Necrotic tissue)

Must be removed before healing can occur – called “Debridement”.

Question 12

Name the beginning components of a skin assessment

Answer 12

Examine the upper extremities while the client sitting
Remove stockings/stocks to expose the lower extremities
Compare Bilaterally
Examine lesions individually
Use an assessment tool to predict pressure-ulcer risk
Inspect and Palpate Simultaneously
Have Proper Equipment

Question 13

What are some more specific things to look for when performing a skin assessment?

Answer 13

Temperature (should be warm to touch)

Texture/feel of the skin

Turgor (the skins elasticity.. skin should snap back when pinched and if not then the turgor is poor)

Edema (swelling from excessive fluid in the tissue)
-palpate area – if fingers leave an indentation, it is called pitting edema

Lesions

Question 14

What are the 4 types of wound drainage?

Answer 14

Serous- clear and watery
Sanguineous- bright red
Serosanguineous- pale, red, and watery
Purulent- thick, yellow, green, tan, or brown

Question 15

Localized areas of tissue necrosis that develop when soft tissue is compressed between a bony prominence and an external surface for a prolonged period of time

Answer 15

Pressure ulcer

Question 16

The decrease in blood supply of a pressure ulcer is called..

Answer 16

Ischemia

Question 17

What is reactive hyperemia?

Answer 17

When pressure on the skin is relieved and turns red from vasodilation because extra blood flow is getting to the area. If redness does not dissappear then there is most likely tissue damage

Question 18

Describe a stage 1 pressure ulcer

Answer 18

An observable change
Redness
No open skin areas

Question 19

Describe a stage 2 pressure ulcer

Answer 19

Partial thickness skin loss involving epidermis/dermis
There is now a superficial break in the skin
Abrasion, blister, or a shallow red/pink crater
No slough (which is white and yellow drainage)

Question 20

Describe a stage 3 pressure ulcer

Answer 20

Full thickness skin loss involving damage or necrosis (death) of subQ tissue
Deep crater
There is no visible bone/tendon/muscle but slough may be present

Question 21

Describe a stage 4 pressure ulcer

Answer 21

Full thickness skin loss with extensive destruction
Tissue necrosis (death of tissue)
Damage to muscle, bone, or tendon
Slough or eschar (necrotic tissue) may be present

Question 22

What is an unstageable ulcer?

Answer 22

A suspected deep tissue injury that will look like a bruise but underneath is developing a stage 3 or 4 pressure ulcer
Documented as unstageable, NOT stage 1

Question 23

What makes an ulcer unstageable?

Answer 23

Full thickness tissue loss where the base is covered by slough (yellow/tan/gray/green/brown) or eschar (tan/brown/black) to the point where the depth nor stage of the wound can be determined until the slough and eschar is removed

Question 24

Wounds often misclassified as pressure ulcers

Answer 24

Skin Tears
Arterial Ulcers
Venous Ulcers
Diabetic Ulcers
Perineal Dermatitis

Question 25

What are the 3 phases of wound healing?

Answer 25

Inflammatory Proliferative Maturation

Question 26

Assessing pulse

Answer 26

Most commonly assessed peripherally (radial pulse) and centrally (apical pulse) Normal pulse is 60-100 beats/min - above 100: tachycardia - below 60: bradycardia Assess normal, bounding, or weak pulse Regular or irregular rhythm Normal arteries will feel straight, soft, and smooth Abnormal arteries will feel twisted and hard 2 nurses should take radial and apical pulse at the same time and radial will never be greater than apical

Question 27

Assessing blood pressure

Answer 27

Measured in mmHg Systole is peak force Diastole is minimum force The difference between the two is called pulse pressure and its normally 40mmHg Normal is around 120/80 Hypotension is a BP below 100/60 consistently Hypertension is a BP above 140/90 mmHg consistently Pre-hypertension is a BP between 120/80 and 139/89

Question 28

Assessing respirations

Answer 28

Normal adult respiration is 12-20 times/min Inspiration lasts 1-1.5 seconds Expiration lasts 2-3 seconds Looks for depth: shallow or deep breaths? Look at rhythm: regular or irregular breaths? Normally silent Symmetric lung expansion Lung ascultation

Question 29

Assessing pulse oximetry

Answer 29

Taken at the same time as regular vital signs Measures arterial blood oxygen saturation Sensor usually placed on finger, possibly toe nose or earlobe Normal is 95-100% Below 70% is life threatening

Question 30

Assessing temperature

Answer 30

Normal is 98.6 but anywhere from 97-99 Adults over 70 can range from 95-99 ``` Assessment Sites: Mouth (PO): 3-8 minutes Rectal: 2-4 minutes Axillary (Ax): 10 minutes Tympanic (seconds) Forehead / Temporal Artery (seconds) ```

Question 31

Complication with oxygen therapy

Answer 31

O2 ehances combustion and a fire will burn more readily Prohibit smoking All electrical equipment must be grounded Repair frayed cords that can spark and ignite a flame Prohibit any flammable solution containing alcohol or oil. Oxygen toxicity Damage to lungs can occur. Initial symptoms include: nonproductive cough, substernal chest pain, GI upset, and dyspnea. With continued exposure to high concentrations of O2, symptoms become more severe. Structural damage to lungs can occur Drying of the mucous membranes When O2 flow rate is higher than 4 L/min, humidification is usually added to the delivery system. Monitor water level and change humidifier as needed. The humidification system may be a source of bacteria as well as the delivery equipment. Change equipment per agency policy can range from 1-7 days.

Question 32

Nursing care for a patient using oxygen therapy

Answer 32

Cleanse the cannula or mask by rinsing with clear, warm water every 4-8 hours as needed Check the skin around the ears, back of neck and face for pressure points and signs of irritation. Provide mouth care prn Assess nasal and oral mucous membranes for signs of dryness. Pad tubing in areas that put pressure on the skin. Lubricate nostrils, face, and lips to relieve drying effects of oxygen –Do not use Petroleum Jelly – it is combustible! Position tubing so it does not pull on face or nose. Ensure that there is no smoking in the area. Assess and document response to therapy. Make sure equipment is operating properly

Question 33

Increases workload of heart This increases oxygen demand and blood flow Also causes damage to blood vessels and increases development of atherosclerosis Diet can play a role in treatment

Answer 33

Hypertension

Question 34

High blood sugars are linked with increased development of atherosclerosis, increased lipids and triglycerides

Answer 34

Diabetes

Question 35

Elevates serum lipids Increases blood coagulation Increases blood pressure

Answer 35

Stress

Question 36

Edema characteristics

Answer 36

-collection of fluid in the interstitial compartment -be sure to note amount, extent, and type -edema can be generalized or confined to a body part -always compare extremities -Independent edema has swelling all the time -Dependent edema swelling goes away after awhile -Pitting edema: feels soft and leaves an imprint when finger pressed against skin -Brawny: feels hard or gelatinous skin looks shiny, moist, no pitting

Question 37

Describe the process of defecation

Answer 37

The expulsion of feces from the anus & rectum called a Bowel Movement (BM) Frequency and amount varies from individual to individual Peristaltic waves move feces into rectum where client becomes aware of need to defecate When client is on toilet or bedpan the external sphincter relaxes and feces is ex-pulsed If defecation re-flux is ignored or external sphincter muscle is contracted consciously, the urge to defecate will disappear for a few hours before occurring again

Question 38

What are the 10 factors affecting defecation?

Answer 38

1. Age: defecation lessens with age 2. Diet: bulk foods are necessary to provide volume 3. Fluids: soften stool and increase peristalsis 4. Activity: stimulates peristalsis, also if you have weak muscles you are less likely to control your bowels 5. Psychological factors: anxiety and anger can increase peristaltic activity, depression can slow it resulting in constipation 6. Defecation habits: don't ignore the urge because the longer you wait the harder it will be to expel 7. Medications: check to see if side effects affect elimination 8. Diagnostic procedures: barium can cause constipation and diarrhea 9. Anesthesia and surgery: may cause slow or ceasing movements 10. Pain: may suppress the urge to defecate if pain is experienced resulting in constipation

Question 39

Describe the normal assessment of feces

Answer 39

Color: normally brown Consistency: normally formed, soft, semi-solid, moist Shape: clyndrical, shape of rectum Amount: varies with diet Odor: affected by ingested foods or medications Constituents: undigested food, etc.

Question 40

Abnormal findings on feces color

Answer 40

If its clay or white: absence of bile pigment Black or tarry: Iron, upper GI bleed or diet high in red meat & dark green veggies Red: lower GI bleed, some foods (beets) Pale: diet high in milk & milk products and low in meats, malabsorption of fats Orange or green: intestinal infection

Question 41

Abnormal findings on feces odor

Answer 41

Pungent: infection or blood

Question 42

Abnormal findings on feces consistency

Answer 42

If its hard, dry stool: dehydration or decreased intestinal motility Diarrhea: increased intestinal motility

Question 43

Abnormal findings on feces shape

Answer 43

Narrow, pencil shaped, or string like: indicates obstructive condition of rectum

Question 44

Abnormal findings on feces constituents

Answer 44

``` Pus – bacterial infection Mucus – inflammatory condition Parasites Blood – GI bleed Fat - malabsorption ```

Question 45

What is an Occult Blood test and how does it work?

Answer 45

It detects GI bleeding 1. Use a tongue blade to place a small amount of stool on a slide 2. Place a few drops of reagent onto smear 3. Observe for color changes 4. Blue - a guaiac positive any other color is negative

Question 46

List the steps in collecting a specimen of feces

Answer 46

1. Have pt defecate into clean bedpan or commode 2. Try to avoid contact with urine & tissue 3. Use tongue blade to transfer specimen to container 4. Usually need 1 inch or 15-30 ml of liquid stool 5. May need all of stool for a timed test

Question 47

A mass or collection of hardened feces

Answer 47

Fecal Impaction

Question 48

Dilated veins in anorectal area

Answer 48

Hemorrhoids

Question 49

Temporary or permanent artificial opening in the abdominal wall

Answer 49

Stoma

Question 50

Solution introduced into the rectum and large intestine. Promotes defecation by distending the intestine, irritating intestinal mucosa, or softening the feces (lubricating rectum) to increase peristalsis

Answer 50

Enemas

Question 51

Which enema is the safest?

Answer 51

Isotonic, because there is no movement of fluid between the colon and interstitial fluid

Question 52

Normal assessment of urine

Answer 52

I & O: 60 ml/hour (1500 ml/day) is normal for the kidneys Color: pale straw or amber colored Clarity: transparent, no sediment Odor: ammonia in nature, concentration urine (not a lot of water) is very strong smelling Amount: each void should be every 24 hours/every day

Question 53

Describe the clinical significance of the urine pH

Answer 53

Acidic pH: starvation, diarrhea, diet high in protein | Alkaline pH: UTI, diet high in fruits & vegetables

Question 54

Describe the clinical significance of specific urine gravities

Answer 54

Elevated (concentrated urine) means dehydration | Decreased (diluted urine) means over-hydration

Question 55

List 4 things that should NOT be present in urine

Answer 55

Glucose: could be indicative of Diabetes Ketone bodies: could be indicative of Diabetes or starvation Blood: could be indicative of UTI, kidney disease, renal calculi Protein: could be severe stress or renal disease

Question 56

Ways to prevent a UTI

Answer 56

Avoid tight fitting pants (irritation to urethra and prevents ventilation of perineal area) Wear cotton underwear Women need to wipe and clean from front to back Shower rather than bathe (bacteria present in bathwater) Encourage to void at least every 4 hours Cranberry juice (acidifies pH of urine) Urinating after sexual intercourse

Question 57

Improves blood flow to body part Promotes delivery of nutrients and removal of wastes Lessons venous congestion in injured tissues

Answer 57

Vasodilation

Question 58

Effects of local heat

Answer 58

Assist in wound healing Promote drainage (drawing out infected material out of wounds) Reduces inflammation and infection Relieves local pain, stiffness, or aching, particularly of muscles and joints

Question 59

Reduces blood flow to the area Promotes blood coagulation at the site of an injury Reduces oxygen needs of tissues

Answer 59

Vasoconstriction

Question 60

Effects of local cold

Answer 60

Vasoconstriction Decreased tissue sensitivity Local anesthesia/relieves pain Shivering Slows or stops bleeding/fluid loss Slows bacterial activity in clients with an infection Reduces swelling in injured tissues, including sprains and fractures

Question 61

Heat produces maximum vasodilation in 20-30 minutes. After that, reflex vasoconstriction occurs This is called ______ meaning its not helping Heat should not be applied for longer than the 30 minutes – allow 30-60 minutes for the tissue to recover before applying heat again to the same area

Answer 61

Rebound effect

Question 62

Cold produces maximum vasoconstriction in 10-30 minutes. ______ occurs after this. Apply cold for no longer than the 30 minutes and allow tissue to recover for 30-60 minutes before applying cold again to the same area.

Answer 62

Rebound vasodilation