Skin/Burns Flashcards Preview

NCLEX-RN (5) Adult Health > Skin/Burns > Flashcards

Flashcards in Skin/Burns Deck (63)
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1

What is petechiae and purpura?

Petechiae and purpura are purple or red colored spots on the skin that occur when a small blood vessel bursts.

 

2

What is ecchymosis?

Ecchymosis is bruising of the skin.

3

What is a spider angioma?

A spider angioma are small broken blood vessels on the surface of the skin.

They occur in the elderly and are not a concern. It also occurs with clients who have liver disease.

 

4

What are Steven's Johnson syndrome and Toxic epidermal necrolysis?

Immediate complication

Steven's Johnson syndrome and toxic epidermal necrolysis are really bad adverse reactions of many meds that cause a severe rash all over the body.

Always let the HCP know if you notice a rash, especially after the client starts a new med.

5

What is the general teaching to prevent a skin disorder from getting worse?

To prevent a skin disorder from getting worse, always teach the client to:

  • not scratch the rash or damaged skin
  • keep nails short
  • not pick sores or lesions
  • wear loose clothing

6

What is the client at risk for when there is an open wound or rash?

Infection, due to a break in the skin.

7

How often are clients turned to prevent pressure ulcers?

Turn clients at least every 2 hours.

8

What is pruritus?

Pruritus is itchy skin.

It is common for clients to receive diphenhydramine to decrease itching.

9

What is serous wound drainage?

Serous wound drainage is clear or straw-colored.

It is a normal finding.

10

What is purulent wound drainage?

Purulent wound drainage is thick, yellow, green, brown or tan.

It indicates an infection.

11

What is serosanguinous wound drainage?

Serosanguinous wound drainage is pale red and watery.

It is a normal finding.

12

What is sanguineous wound drainage?

Sanguineous wound drainage is bright red.

It indicates active bleeding.

13

What are the 3 main layers of the skin?

  1. epidermis: top layer
  2. dermis: includes blood vessels, nerves, sweat glands
  3. hypodermis: subcutaneous fat

14

What are the steps to getting a skin or wound culture?

  1. clean area first with normal saline going from close to the wound to away from the wound
  2. debride if needed
  3. use a sterile applicator or nasal swab to get a sample
  4. put in container
  5. send to lab

 

15

When are antibiotics started: before or after collecting the culture?

Start the antibiotics AFTER the culture is collected.

16
Describe:

Candida albicans

Candida albicans is an infectious fungal disease of the skin.

It is also called a yeast infection, thrush, or oral candidiasis.

17
Risk factors:

Candida albicans

Risk factors to candida albicans are frequently due to a decreased immune system from:

  • chemotherapy
  • steroids
  • immunosuppressed
  • long term antibiotics

18

On what areas of the body is candida albicans frequently found?

Candida albicans is found in warm, moist places where fungus likes to grow such as:

  • skin folds
  • mouth
  • vagina
  • under breasts

19
Interventions:

Candida albicans

  • keep skin folds dry
  • antifungal such as fluconazole or nystatin powder or suspension

20
Describe:

Cellulitis

Cellulitis is an infection of the skin caused by Streptococcus or Staphylococcus. It frequently causes one leg to be red and edematous.

The client is treated with antibiotics.

 

21
Describe:

Acne vulgaris

Acne vulgaris is a chronic skin disorder that occurs more often in teenagers due to hormone changes.

22

What are acne lesions called?

  • "zits"
  • blackheads (closed comedones)
  • whiteheads (open comedones)

23
Prevention and treatment:

Acne vulgaris

  • don't pick at face
  • gently wash the face using prescribed topical agents
  • benzoyl peroxide or antibiotics may be prescribed

24
Describe:

Psoriasis

Psoriasis is a chronic non-infectious inflammatory skin disorder.

The cause is not known.

25

What do psoriasis lesions look like?

Psoriasis looks like silvery-white scales on a raised, reddened, round plaque.

It normally affects the scalp, knees, elbows.

26
Medications:

Psoriasis

Psoriasis meds focus on decreasing the inflammation. The most common meds are:

  • steroids
  • salicylic acid to soften the plaque

27
Describe:

Eczema (atopic dermatitis)

Eczema is an allergic skin reaction that is itchy. There are small blisters and redness.

The cause is unknown but there is a higher risk if other allergies are present.

28
Teaching:

Eczema

  • use warm water to bathe, not hot water
  • don't bathe every day
  • use mild soap
  • apply non-scented lotions

29
Medications:

Eczema

Topical steroids are applied to the rash.

30

Who is most at risk for skin cancer?

  • older clients
  • light-skinned clients

31

How often should clients do a thorough skin cancer check?

once a month

32

What is a skin cancer assessment?

  • A: asymmetry
  • B: border irregularity
  • C: color that is not uniform
  • D: diameter > 1/4 inch (6mm)
  • E: evolving (changing) size, shape or color

Notify HCP of these changes.

33

At what times during the day should a client stay out of the sun?

Between 10 a.m. and 4 p.m.

34

What SPF factor of sunscreen should be used?

At least 15 SPF or higher.

Apply 30 minutes before going outside.

35
Describe:

Melanoma

Melanoma is a highly metastatic skin cancer.

It is typically a red, dark blue, black or even a white color.

 

36
Describe:

Basal cell carcinoma

Basal cell carcinoma is a type of skin cancer that rarely metastasizes. 

It is described as having a "waxy nodule with pearly borders".

37
Describe:

Squamous cell carcinoma

Squamous cell carcinoma is a type of skin cancer that looks like an oozing, bleeding and crusting lesion

Larger tumors are associated with higher risk of metastasis.

38

How are skin cancers diagnosed and treated?

A biopsy is performed and then surgery to remove the tumor.

39

What is a stage 1 pressure ulcer?

Stage 1 pressure ulcer: skin is intact, red, non-blanching, warm and painful. 

Non-blanching means that when you press your finger on it, it stays red.

40

What is a stage 2 pressure ulcer?

Stage 2 pressure ulcer: the first layer of skin has come off and it looks like a shallow, pink wound or blister.

41

What is a stage 3 pressure ulcer?

Stage 3 pressure ulcer: there is full-thickness skin loss into the dermis and subcutaneous tissue.

42

What is a stage 4 pressure ulcer?

Stage 4 pressure ulcer: there is exposed bone, tendon or muscle.

43

What is an unstageable pressure ulcer?

Unstageable pressure ulcer: when the ulcer is covered with slough or eschar.

  • Slough is dead white blood cells and skin debris.
  • Eschar is dead tissue and is black in color.

44

On what areas are pressure ulcers more common?

Pressure ulcers are more common on bony and thin skin areas such as:

  • back of head and ears
  • shoulder
  • elbows
  • hips
  • coccyx
  • heels

45
Risk factors:

Pressure ulcers

  • moist skin
  • immobility
  • poor nutrition
  • skin being pulled on when moving up or down in bed
    • called "friction and shear"

46

How are pressure ulcers prevented?

  • keep skin dry
  • don't massage bony areas
    • can cause capillary damage and necrosis
  • ​turn every 2 hours
  • apply skin lotion or cream

47

Why do burns have a high risk of airway problems?

Immediate complication

Smoke inhalation

Always assess airway first and give oxygen.

48

What is the best indicator of fluid intake and output in a burn client?

Urine output

It needs to be at least >30 mL/hour for an adult.

49

What is the Parkland formula?

The parkland formula is used to calculate how much fluids a burn client needs in 24 hours.

Give Lactated Ringer's = 4 mLkg % of body burned

Example: 4 mL X 75 kg X 40% = 6000 mL

50

How are the fluids divided up when calculating the 24-hour amount of fluids needed (using the Parkland formula)?

Divide fluids up:

  • give 1/2 of the amount in the first 8 hours
  • give the remaining amount in the next 16 hours

Example: If 6000 mL is to be given total

  • give 3000 mL (375 mL/hr) for the first 8 hours
  • give 3000 mL more (or 187.5 mL/hr) for the next 16 hours

51

Why is there ↑ potassium in a burn client?

The burn destroys the cells and the potassium is released into the vascular space increasing the amount in the blood.

52

Why is the hematocrit ↑​ in a burn client?

There is fluid loss, causing the hematocrit to become concentrated.

53

What type of room does a burn client need to be placed in?

Burn clients are placed in a private room and placed on protective isolation (neutropenic precautions) to prevent them from getting an infection:

  • wear gown and gloves
  • sterile procedures

54

What type of injections should a burn client NOT get?

Do not give IM or subcutaneous injections in a burned client since the client will be unable to absorb the medicine.

55

How will the burn client receive pain meds?

Pain meds will be given through IV in a burn client.

56

What is the room temperature kept at for a burn client?

Keep the room warm since the client has heat loss due to skin loss.

57

What is the "Rule of 9's"?

The Rule of 9's assesses the percentage of the burned area on a client.

 

58

What is a stage 1 burn?

It is also called a superficial burn.

A stage 1 burn is when the epidermis (first layer) is damaged.

It is red without blisters.

59

What is a stage 2 burn?

It is also called a superficial partial-thickness burn.

A stage 2 burn is when the epidermis and dermis are damaged.

There is edema with blisters that are yellow. 

60

What is a stage 3 burn?

It is also called a deep partial-thickness burn.

A stage 3 burn is when all the layers of the skin are damaged.

The area is stiff, red or white and dry. 

61

What is a stage 4 burn?

It is also called a full-thickness burn.

A stage 4 burn is when the burn has gone through all the layers of the skin and reached the muscle, tendon or bone.

It is a black color. 

62

What surgery will be needed if the burn is not healing on its own?

Skin grafts

63

How should the burned area be positioned in order for skin grafts to heal?

Immobilize the area to promote the adhering of the graft to the skin.