Term
| what is the body's largest organ? |
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Definition
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Term
| what are the three things that the skin is sensory for? |
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Definition
| pain, temperature, and touch |
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Term
| injury to the skin triggers |
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Definition
| complex healing processes |
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Term
| when assessing the skin of an older patient what would you expect to have a decrease in the skin (7); an increase? |
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Definition
Decrease: thickness, subQ fat, elasticity, vascularity, strength, moisture, functioning of sebaceous glands
Increase: hair density in nose and ears, lentigo, dryness, benign or malignant skin growth |
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Term
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Definition
| small patches of pigmented area |
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Term
| what are the characteristics of nails of pts of older age? |
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Definition
| thicker and slower growing |
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Term
| what are infectious processes due to? |
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Definition
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Term
| infectious processes can be due bacterial, viral, and fungal pathogens. Give examples of bacterial pathogens. |
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Definition
| staph aureus and streptococci |
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Term
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Definition
| a common skin infection that happens mostly in children. caused by staphylococci and streptococci and MRSA |
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Term
| infectious processes can be due bacterial, viral, and fungal pathogens. Give examples of viral pathogens. |
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Definition
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Term
| herpes zoster can lead to |
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Definition
|
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Term
| infectious processes can be due bacterial, viral, and fungal pathogens. Give an example of a fungal pathogen. |
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Definition
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Term
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Definition
| accumulation of lymphatic fluid causing swelling in the extremities |
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Term
| what is the cause of lymphadema? |
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Definition
| when the venous or lymphatic vessels are impaired leading to an abnormal accumulation of fluid that collects |
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Term
| what are 2 results of lymphadema? |
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Definition
| increase in protein fluid and decrease in oxygenation |
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Term
| what is the primary nursing intervention in pts with lymphadema? |
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Definition
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Term
| when assessing redness in the skin what is the cause? |
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Definition
| dilated blood vessels causing increased blood flow to an area |
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Term
|
Definition
| localized injury to the skin or localized tissue |
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Term
| where are pressure ulcers usually found? |
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Definition
|
|
Term
| what do pressure ulcers result from? |
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Definition
| pressure in combination with shearing and friction |
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|
Term
| what is the major contributor to pressure ulcers? |
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Definition
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|
Term
| what is the cause of pressure ulcers in terms of capillary pressure? |
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Definition
| when the pressure on the capillary is greater than the normal capillary pressure the vessels become occluded leading to ischemia which leads to necrosis |
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Term
|
Definition
| skin is intact and redness is nonblancheable |
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Term
|
Definition
| partial thickness of skin loss involving the epidermis and dermis or both |
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Term
|
Definition
| full thickness tissue loss with visible fat being seen |
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Term
|
Definition
| full thickness loss with exposed bone, muscle, or tendon |
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Term
| factors that cause pressure ulcers can be |
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Definition
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Term
| what are 4 other stressors to the integumentary system? |
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Definition
| nutrition, hydration, circulatory and oxygenation changes |
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Term
| appropriate assessment of the skin requires |
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Definition
| proper lighting and proper temperature |
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|
Term
| what type of lighting is best for dark-skinned pts? |
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Definition
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|
Term
| when finding skin that is either cyanotic or flushed what changes are occuring? |
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Definition
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|
Term
| when finding blue or dusky nail beds OR erythema, what changes are occuring in what? |
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Definition
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|
Term
| when finding dull, stringy, thin hair; dry scaly skin with rashes; or dry and brittle nails what changes are occurring in what? |
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Definition
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Term
| local tissue damage results in the need for (2) |
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Definition
| O2 and protein rich diet to promote healing |
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Term
| what does edematous skin look like? |
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Definition
| swollen, shiny, taut, and red |
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|
Term
| If there is a decrease in skin turgor, then |
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Definition
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|
Term
| when assessing temperature be sure to assess |
|
Definition
|
|
Term
| when assessing the texture of the skin assess for any |
|
Definition
| draining lesions or wounds |
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|
Term
|
Definition
| hygiene, illness, and drainage |
|
|
Term
| what is the characteristic of a normal nail angle? |
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Definition
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|
Term
| a sluggish cap refill response takes how long? what does it indicate? |
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Definition
| more than 3 seconds; oxygenation issues |
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|
Term
| clubbing shows presence of |
|
Definition
| chronic O2 deficiency usually in COPD pts |
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|
Term
| used to predict or assess for pressure ulcers? |
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Definition
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|
Term
|
Definition
|
|
Term
| when inspecting the contour and symmetry of the abdomen what are you looking for? |
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Definition
| distention, enlarged organs or masses, movements or pulsations |
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Term
| absent bowel sounds may indicate |
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Definition
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|
Term
| upon palpation of all 4 quads of the abdomen, pain may indicate |
|
Definition
| cholecystitis and pancreatitis |
|
|
Term
| what 3 foods can you encourage your patient to eat in order to obtain fiber in their diet? |
|
Definition
| fruits, green vegetables and garins |
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|
Term
| what are 3 diagnostic tests that can be done for the GI system? |
|
Definition
| stool specimens, ova/parasits, and guaiac testing |
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|
Term
| what are the radiographic tests that can be done for the GI? |
|
Definition
| X-rays, endoscopy, and imaging |
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|
Term
| when is a barium enema performed? |
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Definition
|
|
Term
| when is a contrast given to the patient? |
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Definition
|
|
Term
| what can the contrast for a CT scan cause for the patient? |
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Definition
|
|
Term
| what are the causes of constipation? |
|
Definition
| post op, DM, MS, Parkinsons, and narcotics |
|
|
Term
| what are the S and S for constipation? |
|
Definition
|
|
Term
| what are the S and S for constipation? |
|
Definition
|
|
Term
| what are complications that can arise from constipation? |
|
Definition
| fecal impaction, hemorrhoids, and megacolon |
|
|
Term
| what are the causes of diarrhea? |
|
Definition
| colitis, crohn's disease, and irritable bowel |
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|
Term
| what are medications that can causes diarrhea? |
|
Definition
| stool softeners, laxatives, antiobiotics, chemo, and contrast from CT |
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|
Term
| what are the S and S for diarrhea? |
|
Definition
| abdominal cramping, distension, and dehydration |
|
|
Term
| how do you manage diarrhea? |
|
Definition
| Lomotil, Immodium, IV fluids |
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|
Term
| in severe cases of diarrhea what must occur? |
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Definition
|
|
Term
| what is a complication of diarrhea? |
|
Definition
|
|
Term
| what can dehydration via diarrhea lead to? |
|
Definition
| cardiac dysrhythmias and decreased urine output |
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|
Term
| what does skin turgor assess? |
|
Definition
|
|
Term
| what is a NANDA for constipation? |
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Definition
|
|
Term
| what are 2 NANDA's for diarrhea? |
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Definition
| bowel incontinence and pain |
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|
Term
| what is the main source of energy in the diet? |
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Definition
|
|
Term
| what is required as building blocks for growth, maintenance and repair? |
|
Definition
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|
Term
| what are two essential amino acids in the body? |
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Definition
|
|
Term
| what is the major form of stored energy? |
|
Definition
|
|
Term
| what is accountable for 35-45% of the American diet? |
|
Definition
|
|
Term
| what are the water soluble vitamins? |
|
Definition
|
|
Term
| what are the fat soluble vitamins |
|
Definition
|
|
Term
| what are the macrominerals and how much of them do you need a day? |
|
Definition
| Ca, Mg, and P; more than 100 mg/day |
|
|
Term
| what are the diagnostic tests for malnutrition? |
|
Definition
| total protein and albumin |
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