Integumentary System

Question 1

What is the largest organ?

Answer 1

The skin

Question 2

What are the 4 techniques used by nurses in physical assessment?

Answer 2

Inspection, Percussion, Palpation, and Auscultation.

Question 3

What kind of information can the skin provide us with?

Answer 3

Changes in oxygenation, circulation, tissue damage, hydration, mental issues. Ect

Question 4

What kind of information can the skin provide us with?

Answer 4

Systemic problems, and self-care abilities.

Question 5

What are some examples of systemic skin problems?

Answer 5

Impaired circulation, respiratory disorders, endocrine imbalance, and allergies.

Question 6

What are some examples of self care abilities related to skin?

Answer 6

Hygiene, excercise, and maintenance could be related to mental health.

Question 7

What is the biggest endocrine system in the human body?

Answer 7

The pancreas

Question 8

What can nails help us with?

Answer 8

Assessing a persons mental and physical health.

Question 9

When do we assess the skin?

Answer 9

During comprehensive assessments, when a concern is present, an injury, during hygiene cares, beginning of shift, and when assessing health status.

Question 10

What is cyanosis?

Answer 10

A bluish discoloration of the skin due to poor circulation or inadequate oxygenation of the blood.

Question 11

Which nursing techniques are most important when assessing skin, hair, and nails?

Answer 11

Inspection and pal-station.

Question 12

When do we wear sterile gloves?

Answer 12

Only during important procedures such as surgery or inserting catheters ect

Question 13

What are some examples of subjective data when assessing skin? (6)

Answer 13

Problems/conditions, current symptoms (past family history), lifestyle, practices.

Question 14

What does COLDSPA stand for?

Answer 14

COLDSPA. Definition. Character, Onset, Location, Duration, Severity, Pattern, Associated Factors / How it Affects the client.

Question 15

What is Parkinson’s disease?

Answer 15

Nerve cell damage in the brain causes dopamine levels to drop, leading to the symptoms of Parkinson’s.
Parkinson’s often starts with a tremor in one hand. Other symptoms are slow movement, stiffness and loss of balance.

Question 16

What is subjective data?

Answer 16

Subjective data are information from the client’s point of view (“symptoms”)

Question 17

Define short term memory loss?

Answer 17

Short-term memory loss is when you forget things you heard, saw, or did recently.

Question 18

True or False? Family are apart of the patient

Answer 18

True

Question 19

What’s important when preforming a physical examination?

Answer 19

Preparing the patient - aka getting informed consent, positioning, privacy, protection, and equipment.

Question 20

What’s involved in positioning of a patient?

Answer 20

Ensuring they are in a position that helps for an examination but that is comfortable and warm for the patient.

Question 21

What equipment should you have when preforming a skin assessment?

Answer 21

Gloves, and alcohol based hand rub (or you are frequently washing your hands), an examination light / penlight, a centimetre ruler, and an examination gown and drape.

Question 22

What are the key assessment points of skin assessment?

Answer 22

Skin colour, temp, moisture, and texture. Skin integrity. Skin lesions. Hair condition. And nail condition (capillary refill)

Question 23

What’s involved in a basic skin inspection?

Answer 23

Distinctive odour, colour variations, skin breakdown, primary, secondary or vascular lesions, and level of moisture.

Question 24

What is skin integrity?

Answer 24

Overall skin health

Question 25

What is involved in a colour variation skin inspection?

Answer 25

General colour and pigmentation, general appearance, smooth - moles - acne - hair growth, consistent with genetic backround, lips and conjunctivia- sclera (jaundice), increased areas of pigmentation.

Question 26

What is normal pigmentation?

Answer 26

Light pink to brown or olive

Question 27

What is involved in a lesions skin inspection?

Answer 27

ABCDE. Asymmetry (pattern), Border irregularity, Colour variation, Diameter, Elevation.

Question 28

Why do we use a ruler?

Answer 28

To assess the size of abnormalities on the skin.

Question 29

What do we look at when inspecting for skin integrity?

Answer 29

Nutrition, tissue perfusion, infection, and age.

Question 30

What do we look at when inspecting for skin integrity?

Answer 30

Nutrition, tissue perfusion, infection, and age, signs of pressure injury.

Question 31

What risk assessment scales may we use when inspecting skin integrity?

Answer 31

Braden or water low scale.

Question 32

What are pressure ulcer risk factors?

Answer 32

Perception, Mobility, moisture, nutrition, friction or shear, and decreased tissue tolerance.

Question 33

What are the common pressure injury sites of someone in the posterior position? (10)

Answer 33

Occipital prominence (neck), Spinous process (upper spine), scapula, elbow, iliac crest (lower left back), sacrum (just above anus), lschium (butt) Achilles’ tendon, heel, and sole.

Question 34

What is the posterior position?

Answer 34

Standing

Question 35

What is the lateral position?

Answer 35

Laying on side

Question 36

What is the prone position?

Answer 36

Laying tummy down

Question 37

What are nursing interventions for pressure injury’s?

Answer 37

Ensure dry clear moisturised skin, 2 hourly position changes, 2 hourly skin checkups (at pp), relief aids, avoid friction during transferring, and insure healthy diet/fluid intake.

Question 38

What do we look at in terms of texture and thickness of the skin?

Answer 38

Whether the ski is rough/smooth, thin/thick/fragile, or scaliness.

Question 39

How do you determine skin texture?

Answer 39

Stroke the skin lightly with fingertips.

Question 40

What should normal skin texture feel like?

Answer 40

Smooth, soft, and flexible.

Question 41

True or false, texture is different in parts of the body.

Answer 41

True it can be for example comparing thickness of feet to hands.

Question 42

How should you assess temperature differences?

Answer 42

Using the back of your hand assessing changes of upper / lower limbs and opposing limbs.

Question 43

What may localised heat indicate?

Answer 43

Inflamination or infection

Question 44

What may coldness indicate?

Answer 44

Decreased blood flow

Question 45

How do you palpate for turgor/elasticity?

Answer 45

You gently pinch the skin under the clavicle or sternum and then release. (In elderly use skin on back near clavicle)

Question 46

What is a normal result when palpating for turgor/elasticity?

Answer 46

You will see the skin easily move back to its place

Question 47

If the skin is dehydrating what will happen during a turgor/elasticity palpate?

Answer 47

It will not return so easily and it will usually tent

Question 48

How do you palpate for oedema?

Answer 48

Press firmly for 5 seconds with the thumb and release?

Question 49

What is pitting oedema?

Answer 49

Pitting edema is when a swollen part of your body has a dimple (or pit) after you press it for a few seconds. It can be a sign of a serious health issue.

Question 50

What is non pitting oedema?

Answer 50

accumulation of excess fluid in soft tissues, causing swelling

Question 51

How do you palpate for tenderness?

Answer 51

Palpate lightly and watch for facial expressions.

Question 52

The accumulation of fluid in intercellular space is what?

Answer 52

Not normal.

Question 53

What is oedema?

Answer 53

a condition characterized by an excess of watery fluid collecting in the cavities or tissues of the body.

Question 54

What does the palpating of capillary refill test for?

Answer 54

The circulation of the periphery

Question 55

When palpating capillary refill what are you looking for?

Answer 55

Colour returning in the nail bed

Question 56

How quick should your nail return to pink in a good capillary refill?

Answer 56

1-2 seconds