Module 4, Module 3 exam 2

What is important to know about consuming adequate protein and vegans?

A person following a vegan or vegetarian diet should eat a varied diet of plant-based foods to get the required range of amino acids. This includes high-protein foods, such as tofu, tempeh, lentils, nuts, seeds, and quinoa.

melain

A pigment that gives the skin its color

Indispensable amino acids

Histidine, lysine, and phenylalanine

What is the most common cause of burn related death in the first 72 hours?

If patients survive the initial 72 hours after a burn injury, infections are the most common cause of death.

Where are the blisters located on a patient w/ genital herpes?

In girls and women, blisters may appear around the vagina, the urethra, the cervix, or between the vagina and the anus, or around the anus. In boys and men, blisters may appear on the penis and foreskin, and sometimes inside the urethra, on the scrotum or in the area between the penis and the anus, or around the anus.

ostomy

Opening made to allow the passage of drainage (e.g. ileostomy)

Serosanguineous

Pale, red, watery: mixture of clear and red fluid

Peristalisis

Periodic muscle contraction and relaxation, or rhythmic waves, which mix food mass and move it forward

What is the treatment for a patient w/ head lice?

Permethrin lotion 1% is approved by the FDA for the treatment of head lice. Permethrin is safe and effective when used as directed. Permethrin kills live lice but not unhatched eggs.

What is the cause of psoriasis?

Psoriasis is caused, at least in part, by the immune system mistakenly attacking healthy skin cells. If you're sick or battling an infection, your immune system will go into overdrive to fight the infection. This might start another psoriasis flare-up. Strep throat is a common trigger.

Main intervention for hypovalemia

Push iv fluids

Body Mass Index (BMI)

a measure of body weight relative to height

vegan

a person who does not eat food from any animal source

verruca

an epidermal tumor caused by a papilloma virus, also called a wart

Vitamin E (Tocopherol):

antioxidant, Food Source: vegetable oils, green leafy vegetables, cereals, apricots, apples, peaches Toxicity: interfere vitamin K

tinea pedis

athlete's foot keep the feet dry

nonthermal burns

burns resulting from electricity, chemicals, and radiation.

What would you note on the sputum where you would suspect inhalation injury?

carbonaceous sputum (burned saliva)

Thermal burns

caused by contact with open flames, hot liquids or surfaces, or other sources of high heat Treat by removing victim from source, cool burn with water, check for bleeding and shock, seek medical attention

Serous

clear, watery plasma

Vitamin C (Ascorbic Acid):

connective tissue, antioxidant protects from free radicals Food Source: strawberries, citrus, tomatoes, broccoli, cabbage, helps with the formation of collagen Deficiency: Scurvy (easy bruising, pinpoint skin hemorrhages, poor wound healing, bleeding gums), depleted by smoking ( vasoconstrictors the blood vessels which slows down healing) Toxicity: GI disturbances

Purulent

containing pus

eschar

dead matter that is sloughed off from the surface of the skin, especially after a burn

Vitamin A (Retinol):

enable eye to adjust to the light, tissue growth, reproduction, immune function Food Source: carrots, sweet potato, liver, egg yolk, whole milk, green or orange vegetables, fruits Deficiency: night blindness, xerosis (dry skin) Toxicity: birth defect, hair loss, bone, liver damage

burn shock

hypotension, decreased urinary output, tachycardia, tachypnea & restlessness.

tinea corporis

ringworm of the body

Dehydration

• >2% total body weight loss results in symptoms • Monitor infants & older adults for fluid imbalance

Renin-Angiotensin-Aldosterone System (RASS)

• Aldosterone regulate the amount of sodium reabsorbed by the kidney

Maintaining Fluid & Electrolyte Balance

• Fluid & electrolyte must be kept in balance • When solutions on both sides of a permeable membrane are equal in concentration then they are isotonic

Plasma proteins

• Mainly albumin and globulin • Organic compounds of large molecular size • Retained in blood vessels • Control water movement • Colloids guard blood volume (colloidal osmotic pressure)

Wet to Dry Dressing

• May help to debride the wound, Ex: necrotic tissue in the wound sticks to the dry gauze • However it is easy to damage granulation tissue w/ this method Changeless frequently because you want some of the debris, slough will stick to the dressing

Chemical buffer system

• Mixture of acid and base that protects a solution from wide variations in pH • Main buffer system: carbonic acid(H2CO3)/base bicarbonate(NaHCO3)

Nursing Process for the Patient with an Integumentary Disorder 2

• Outcome and goals • Implementation • Prevent skin problems • Provide education • Provide safety tips • Evaluation • Determine if outcomes were met

Body Water Functions

• Particles and electrolytes in water determine all internal shifts & balances between compartments • Extracellular vs intracellular • Sodium, Chloride, Potassium, Bicarbonate & protein

Electrolyte

• Play a major role in osmolality, Water regulation, acid-base balance, enzyme reactions & neuromuscular activity • All must be consumed from diet

Signs of Wound Infection

• Redness • Warmth • Swelling • Purulent drainage • Unpleasant smell • Pain around wound • Fever above 100°F

Physiologic buffer systems

• Respiratory control: carbon dioxide leaves the body • Acidosis/alkalosis

Rehabilitation Phase Burns

• Starts on admission • "Officially" begins when 20% or less of the TBSA remains burned • Rehabilitation • Promote independence and function • Promote mobility • Prevent contractures

eczema manifestations

•Papularlesions •Vesicular lesions •Erythema

Scabies

•Wavy, brown threadlike lines •Hands, arms, body folds & genitalia •Burrow eggs under skin S/E: itching

Cellulitis Manifestation

•infection involving underlying tissues of the skin. •Streptococcus pyogenes •May spread and become life-threatening as the infection invades the deeper tissues, lymph nodes & bloodstreams.

What are the fungal infections?

Ringworm of the body (tinea corporis) Contrary to its name, ringworm is caused by a fungus and not a worm. Athlete's foot (tinea pedis) Jock itch (tinea cruris) Ringworm of the scalp (tinea capitis) Tinea versicolor. Cutaneous candidiasis. Onychomycosis (tinea unguium)

Debriding agents (Santyl)

SANTYL® Ointment is a biologic treatment that is appropriate for both initial debridement, as well as maintenance debridement of necrotic tissue.

excoriation

Skin sore or abrasion produced by scratching or scraping

Which factor aggravates psoriasis? Select all that apply. One, some, or all responses may be correct. Stress Overuse of alcohol Streptococcal infections Beta blockers Angiotensin-converting enzyme (ACE) inhibitors

Stress Overuse of alcohol Streptococcal infections Beta blockers Angiotensin-converting enzyme (ACE) inhibitors Psoriasis is an autoimmune disorder that has genetic implications. Factors that aggravate the condition include stress, overuse of alcohol, streptococcal infections, and medications such as beta blockers, ACE inhibitors, lithium, and antimalarials.

Which food would a nurse mention when reinforcing teaching about foods to avoid in the dietary control of gout? 1 Eggs 2 Shellfish 3 Fried poultry 4 Cottage cheese

2 Shellfish Shellfish contains more than 100 mg of purine per 100 grams. Increased dietary red meat and seafood can increase the risk of gout. Eggs, fried poultry, and cottage cheese are low in purine.

Hydrogel

A hydrogel is a network of crosslinked polymer chains that are hydrophilic, sometimes found as a colloidal gel in which water is the dispersion medium. A three-dimensional solid results from the hydrophilic polymer chains being held together by cross-links.

how can you tell if a mole is cancerous ?

Biopsy

Folic Acid:

DNA & hemoglobin synthesis, cell division Also given to alcoholics, helps with hemoglobin synthesis Food Source: green, leafy vegetables, liver, beef, fish, legumes Deficiency: neural tube defects for pregnant women, (spinal Bifida & anencephaly)

What are the foods that are high in folic acid?

Leafy Greens Vegtables liver beef fish legumes

Infract

Localized area of necrosis

Debridement

Mechanical • Wet to dry Enzymatic • Topical enzymes (Santyl) • Digest necrotic tissue Surgical- doctor goes and removes dead tissue Must clear so granulation can happen. The new skin that is forming.

What are the nutrients that support the body's natural immune defense mechanism?

Micronutrients with the strongest evidence for immune support are vitamins C and D and zinc.

malignant melanoma

Most serious form of skin cancer; often characterized by black or dark brown patches on the skin that may appear uneven in texture, jagged, or raised.

keloids

Nodules formed in wound healing due to excessive collagen, increased TGF-Beta activity

Tinea cruris (jock itch)

Rash, scaling small papules in groin and medial thigh area

Dispensable amino acids

The amino acids the body can make for itself, also called nonessential amino acids

amino acids

The building block for proteins containing carbon, hydrogen, oxygen, and nitrogen

basal metabolic rate (BMR)

The metabolic rate of a nongrowing, resting, fasting, nonstressed endotherm.

digestive enzymes

-Amylase (saliva): starch -Protease/hydrochloric acid (gastric): proteins -Protease/lipase/amylase (pancreas): sugar -Bile salts (liver): fats

A client receives an autograft for a severe burn and is taught how to change the dressing. A week after receiving the graft the client identifies that the edges of the graft are curling up and asks the nurse about it. Which response by the nurse is appropriate? 1 "May I take a look at it?" 2 "It's time for another graft." 3 "Is there any sign of redness?" 4 "Let me see whether it is infected."

1 "May I take a look at it?" An autograft is a permanent graft that should not be rejected, and the nurse should assess the site immediately. An autograft is a permanent graft that should not need to be replaced, so another graft would not be planned. The nurse needs to assess the site because the responsibility of assessment should not be left to the client. The response "Let me see whether it is infected" may increase the client's anxiety and draws a conclusion before assessment of the site. Additionally, infection usually is associated with purulent drainage, which was not described.

Which drug can cause chemical burns? 1 Anthralin 2 Prednisone 3 Tazarotene 4 Calcipotriene

1 Anthralin Anthralin is a strong irritant that has an action similar to tar and can cause chemical burns with topical use. Prednisone is a corticosteroid applied topically to treat psoriasis. Tazarotene and calcipotriene are teratogenic (cause birth defects).

Which food would a nurse recommend for a client taking prednisone for systemic lupus erythematosus, because it contains the most potassium per serving to correct possible hypokalemia? 1 Broccoli 2 Oatmeal 3 Fried rice 4 Canned carrots

1 Broccoli Potassium is plentiful in green leafy vegetables. Broccoli provides 207 mg of potassium per half cup. Oatmeal provides 73 mg of potassium per half cup. Rice provides 29 mg of potassium per half cup. Cooked fresh carrots provide 172 mg of potassium per half cup, but canned carrots provide only 93 mg of potassium per half cup.

Which symptom would the nurse observe in a client with seborrheic dermatitis? 1 Dandruff 2 Red, oozing, crusty rash 3 Dry, silvery patches on elbows and knees 4 Red, weeping areas with clear margins surrounded by vesicles and pustules

1 Dandruff Seborrheic dermatitis of the scalp is known as dandruff. It is a chronic inflammatory skin disease that results in fine, powdery scales, thick crusts, or oily patches. A red, oozing, crusty rash is a sign of atopic dermatitis (eczema). Dry, silvery patches (often on elbows and knees) is a sign of psoriasis, an autoimmune disease characterized by an abnormal proliferation of skin cells. Red, weeping areas with clear margins surrounded by vesicles and pustules are a sign of intertrigo, an inflammation of the skin where two skin surfaces touch.

Which treatment measure applies to pruritus? Select all that apply. One, some, or all responses may be correct. 1 Lubricant 2 Emollients 3 Corticosteroids 4 Antihistamines 5 Stress management 6 Avoidance of known irritants

1 Lubricant 2 Emollients 3 Corticosteroids 4 Antihistamines 5 Stress management 6 Avoidance of known irritants Medical treatment measures for pruritus (itching) include lubricants in the bath water and emollients applied to the skin after a bath, medications such as corticosteroids and antihistamines, stress management, and avoidance of known irritants.

Which is the most important topic to include in teaching to promote the comfort of a client with a pruritic skin disease? 1 Sleep 2 Exercise 3 Elimination 4 Hand hygiene

1 Sleep Pruritic skin diseases often interfere with sleep. Adequate rest increases the client's ability to tolerate the itching, thereby decreasing the damage to the skin. Exercise and elimination are not specifically associated with the discomfort of a client with a pruritic skin disease. Hand hygiene is an infection control measure.

Factors Determining a Major, Moderate or Minor burns

1. % of TBSA burned 2. Victims age 3. Specific location 4. Cause of the burn 5. Other disease present 6. Depth of burn 7. Injuries sustained during burn Medical Management • Evolves through three phases • Emergent phase • Acute phase • Rehabilitation phase

the nurse is preparing to administer a continuous tube feeding to a client with a nasogastric tube. The primary health care provider has prescribed an amount of 100 mL/hr. The tube feeding setup is an open system, a bag that has formula added at intervals. How much formula should the nurse plan to add to fill the feeding bag 1. 400 mL of formula 2. 600 mL of formula 3. 800 mL of formula 4. Enough formula to last for 8 hours

1. 400 mL of formula Rationale: Feeding can be hung at room temperature for a period of 4 hours. If 100 mL/hr is prescribed, the nurse should fill the feeding bag with a maximum amount of 400 mL. Feeding hung longer than 4 hours at room temperature creates the risk of bacterial invasion in the formula.

A postoperative client has been placed on a clear liquid diet. Which items is the client allowed to consume? Select all that apply. 1. Broth 2. Coffee 3. Gelatin 4. Pudding 5. Ice cream 6. Vegetable juice

1. Broth 2. Coffee 3. Gelatin

The nurse is asked to assist with preparing a client who will be receiving a continuous total parenteral nutrition (TPN) solution via a central line. Does the nurse plan to institute which interventions for this client related to the TPN? Select all that apply. 1. Central line dressing changes per protocol 2. Blood glucose monitoring around the clock 3. Monitoring central venous pressure every shift 4. Using an electronic infusion pump with the infusion 5. Applying sequential compression devices (SCD) to the legs 6. Reviewing prescribed blood laboratory values including electrolytes

1. Central line dressing changes per protocol 2. Blood glucose monitoring around the clock 4. Using an electronic infusion pump with the infusion 6. Reviewing prescribed blood laboratory values including electrolytes

Wound Treatment

1. Closure - sutures, staples, surgical adhesive and steristrips 2. Drains and Drainage - at first drainage looks like blood (sanguineous), then it looks pink (serosanguineous) and finally, as the wound heals the drainage becomes clearer to slightly yellow fluid (serous) 3. Measurement of Wounds and Observation of Drainage - size, type, closure, size, condition of wound bed, condition of the skin surrounding the wound, pain, drainage. 4. Cleaning wounds 5. Dressings 6. Documenting wound care Give analgesics 30 minutes prior

Definition of Vitamins

1. be a vital, organic substance that is not a carbohydrate, fat, or protein and 2. be necessary to perform a specific metabolic function or to prevent a deficiency disease 3. It cannot be manufactured by the body in sufficient quantities to sustain life, so it must be supplied by diet.

Sodium:

135-145 normal range water balance, muscle action Food Source: cured meat, canned or processed food Deficiency: poor skin turgor, rapid, thready pulse Toxicity: dry mucous membrane, thirst, flushed, >temp,

Which intervention for itching would the nurse determine puts the client at risk for injury? 1 Use of lotion after bathing 2 Addition of oils to the bath water 3 Application of topical anesthetics 4 Administration of corticosteroids

2 Addition of oils to the bathwater The addition of oils to the bathwater will moisturize the skin and soothe itching but may create an unsafe situation as it will make the bathtub slippery. Using lotion after bathing, applying topical anesthetics, and administering corticosteroids will not put the client at risk for injury.

Which action would be taken immediately by a nurse caring for a client who arrives at the emergency department after a dog bite with tearing of skin and deep soft-tissue injury. 1 Inform the owner of the dog about the client's injury. 2 Assess the client's injury, vital signs, and past history. 3 Notify the appropriate community agency to capture the dog. 4 Obtain a prescription for human rabies immune globulin.

2 Assess the client's injury, vital signs, and past history. To make effective decisions, baseline information about the client's condition, extent of injury, and significant past health history is needed. Informing the dog's owner is not the first priority, and the owner may be unknown because the dog may be a stray animal. Notification of authorities is done after the injured person has received basic care. Inoculation for establishment of short-term passive immunity to rabies is done after the initial assessment and treatment of the wound.

Which action would a nurse explain as the next step to take after the flames are extinguished when a person's clothes catch on fire? 1 Give the person sips of water. 2 Assess the person's breathing. 3 Cover the person with a warm blanket. 4 Calculate the extent of the person's burns.

2 Assess the person's breathing. A patent airway is most vital, so the nurse should assess the person's breathing. If the person is not breathing, cardiopulmonary resuscitation should be initiated. The person should be given nothing by mouth because large burns decrease intestinal peristalsis and the person may vomit and aspirate. Covering the person with a warm blanket is not done until assessment for breathing is completed. Calculating the extent of the person's burns is not the priority. This assessment is done after transfer to a medical facility.

Which alteration in skin color would be observed in a client diagnosed with methemoglobinemia? 1 Red 2 Blue 3 White 4 Yellow-orange

2 Blue Blue discoloration of the skin may indicate an increase in deoxygenated blood associated with methemoglobinemia. Red (erythema) may be associated with generalized inflammation. White (pallor) may indicate a decreased level of hemoglobin. It may signify a risk of anemia and shock. A yellow-orange skin discoloration may indicate jaundice and is associated with liver disorders.

Which intervention will decrease the occurrence of pressure ulcers when caring for a client with quadriplegia? 1 Avoiding leg massages 2 Frequent repositioning of client 3 The increasing fiber content in food 4 Encouraging weight-bearing exercises

2 Frequent repositioning of client

Which type of diet would the nurse expect to be prescribed for a client with pulmonary tuberculosis? 1 Liquid protein supplements 2 Small, frequent, high-calorie meals 3 Foods high in calories and low in protein 4 Meals low in calories but high in carbohydrates

2 Small, frequent, high-calorie meals Clients with tuberculosis tend to have anorexia and lose weight. Small, frequent, high-calorie meals encourage food intake and provide calories for weight gain. Liquid protein supplements are not necessary. Protein and other nutrients can be obtained through natural foods. Low proteins are contraindicated as an increased protein intake is necessary for tissue building. Meals low in calories but high in carbohydrates are impossible as carbohydrates contain calories.

The nurse prepares to give a bath and change the bed linens for a client with cutaneous Kaposi's sarcoma lesions. The lesions are open and draining a scant amount of serous fluid. Which should the nurse use during the bathing of this client? 1. Gloves 2. Gown and gloves 3. Gown, gloves, and mask 4. Gown and gloves to change the bed linens and gloves only for the bath

2. Gown and gloves Rationale: Gowns and gloves are required if the nurse anticipates contact with soiled items, such as wound drainage on bed linens. Masks are not required unless droplet or airborne precautions are necessary.

Which event occurs soon after the time of injury in a client who sustained minor skin injuries from an accident? 1 Thinning of the scar tissue 2 Formation of granulation tissue 3 Migration of leukocytes to the site of injury 4 Arrival of fibroblasts to the site of infection

3 Migration of leukocytes to the site of injury Migration of leukocytes takes place in the inflammatory phase, which begins at the time of injury and lasts 3 to 5 days. Scar tissue is formed in the maturation phase, which occurs after the inflammatory and proliferative phases. Formation of granulation tissue and migration of fibroblasts occur in the proliferative phase, which occurs after the inflammatory phase but before the maturation phase.

The nurse who is assisting in a weight loss program prepares to monitor a client's weight. The client receives education about caloric intake and weight reduction. In order to lose 2 pounds per week, the caloric intake should be decreased by how many calories per day? 1. 100 calories 2. 500 calories 3. 1000 calories 4. 1500 calories

3. 1000 calories

the nurse receives a telephone call from the admissions office and is told that a child with acute bacterial meningitis will be admitted to the pediatric unit. The nurse prepares for the child's arrival and plans to implement which type of precautions? 1. Contact 2. Enteric 3. Droplet 4. Neutropenic

3. Droplet

A newly pregnant client is asking how to prevent neural tube birth defects. Does the nurse reinforce which food choices to include in the diet? Select all that apply. 1. Milk 2. Peanuts 3. Oranges 4. Broccoli 5. Egg yolks 6. Grapefruit

3. Oranges 4. Broccoli 6. Grapefruit Rationale: Folic acid (folate) helps prevent neural tube birth defects; it is found in green, leafy vegetables; liver, beef, and fish; legumes; and grapefruit and oranges. Peanuts are high in protein and niacin. Milk is high in calcium and vitamin D. Egg yolks are high in vitamin A, iron, and cholesterol.

Which response would the nurse give to a client who asks, "What is causing my acne?" 1 "Eating chocolate" 2 "Eating fatty foods" 3 "Poor hygiene" 4 "Increased androgenic hormones"

4 "Increased androgenic hormones" Acne is a skin condition characterized by comedones, pustules, and cysts; it is caused by increased androgenic hormones. It is not caused by chocolate, fatty foods, or poor hygiene.

Which response would the nurse give to a client who asks, "What is the cause of my psoriasis?" 1 "The cause of psoriasis is unknown." 2 "Psoriasis is caused by a fungal infection." 3 "Coming in contact with a substance you are allergic to will cause psoriasis." 4 "Psoriasis is an autoimmune disease where your skin cells divide more rapidly than normal."

4 "Psoriasis is an autoimmune disease where your skin cells divide more rapidly than normal." "Psoriasis is an autoimmune disease where your skin cells divide more rapidly than normal." Psoriasis is an autoimmune disease characterized by the abnormal proliferation of skin cells. The cause is not unknown. It is not a fungal infection. Psoriasis is not an allergic reaction; atopic dermatitis may be caused by contact with an allergen.

Which function would the nurse associate with the epidermis? Select all that apply. One, some, or all responses may be correct. 1 Serves as an energy reserve 2 Provides cells for wound healing 3 Serves as a mechanical shock absorber 4 Inhibits proliferation of microorganisms 5 Allows the photoconversion of 7-dehydrocholesterol to vitamin D

4 Inhibits proliferation of microorganisms 5 Allows the photoconversion of 7-dehydrocholesterol to vitamin D The epidermis inhibits the proliferation of microorganisms because of its dry external surface. It also allows the photoconversion of 7-dehydrocholesterol to vitamin D. The subcutaneous tissue serves as an energy reserve. The dermis helps provide cells for wound healing. Subcutaneous tissue acts as a mechanical shock absorber.

Which goal is a nurse trying to achieve when placing a client with severe burns on a circulating air bed? 1 Increasing mobility 2 Preventing contractures 3 Limiting orthostatic hypotension 4 Preventing pressure on peripheral blood vessels

4 Preventing pressure on peripheral blood vessels Preventing pressure on peripheral blood vessels The circulating air bed disperses body weight over a larger surface, reducing pressure against the capillary beds and allowing for tissue perfusion. These beds are used for clients who are immobile. They do not increase mobility. Range-of-motion exercises will help prevent contracture. Limiting orthostatic hypotension is achieved by dangling the legs over the side of the bed, not by using a particular type of bed.

the abdominal postoperative client has been tolerating a full liquid diet, and the nurse plans to advance the diet to solid food as prescribed. Does the nurse collect data regarding which important item before advancing the diet to solids? 1. Food preferences 2. Cultural preferences 3. Presence of bowel sounds 4. Dentition and ability to chew

4. Dentition and ability to chew

Which instructions should be included in the teaching plan for a mother whose newborn is human immunodeficiency virus (HIV) positive? 1 Instruct the mother to check the anterior fontanel for bulging and sutures for widening each day. 2. Instruct the mother to feed the newborn in an upright position with the head and chest tilted slightly back to avoid aspiration. 3. Instruct the mother to feed the newborn with a special nipple and burp the newborn frequently to decrease the tendency to swallow air. 4. Instruct the mother and family to provide meticulous skincare to the newborn and to change the newborn's diaper after each voiding or stool.

4. Instruct the mother and family to provide meticulous skincare to the newborn and to change the newborn's diaper after each voiding or stool. Rationale: Meticulous skin care helps protect HIV-infected newborn from developing secondary infections. Feeding the newborn in an upright position, using a special nipple, and bulging fontanels are unrelated to the pathology associated with HIV

A client has been diagnosed with pernicious anemia. In planning care for the client, the nurse anticipates that the client will be treated with which vitamin or mineral? 1. Iron 2. Folic acid 3. Thiamine 4. Vitamin B12

4. Vitamin B12

Calcium:

9.5- 10.5 normal range bone formation, muscle & nerve action • Food Sources: dairy, collard greens, kale, tofu, rhubarb, sardines, yogurt, fortified food • Deficiency: osteoporosis, cramps, tetany, +Chvostek's (tap the cheek) or Trousseau's sign (blood pressure on the arm and contracts/spasm) Vitamin D aids with absorption of vitamin C • Toxicity: muscle weakness, constipation, bone pain, much calcium will result in stones in the urine

What is the purpose of wet to dry dressing change?

A "wet to dry" dressing is used to remove dead tissue from a wound. A piece of gauze is moistened with a cleansing solution. Then it's put on the wound and allowed to dry. After the dressing dries, the dead skin tissue sticks to the gauze and comes off the wound when the bandage is removed

hypovolemic shock

A condition in which low blood volume, due to massive internal or external bleeding or extensive loss of body water, results in inadequate perfusion. symptoms: urination less than 30 ml, tachycardia, low blood pressure, respiratory rate high

Kwashiorkor

A disease of chronic malnutrition during childhood, in which a protein deficiency makes the child more vulnerable to other diseases, such as measles, diarrhea, and influenza.

Type 2 (HSV-2)

A type of HSV that is associated with genital herpes. Various types of vesicles •Flulike symptoms occur 3-4 days after vesicles erupt •Pain, redness, pruritis •May experience difficulty voiding w/ severe outbreak.

Foams (Allevy)

ALLEVYN* Adhesive Dressing is water/bacteria-proof. Indicated for moderate to high exudating wounds. Hydrocellular structure allows for a moist wound environment.

The nurse is caring for a patient recently diagnosed with shingles. The nurse anticipates administering which medication? O Penicillin O Acyclovir O Oseltamivir O Griseofulvin

Acyclovir Rationale Acyclovir is an antiviral used to treat shingles. Penicillin is an antibiotic, and griseofulvin is an antifungal, so both are inappropriate. Oseltamivir is a medication to treat influenza

Hydrofiber (Aquacel)

Alginate and hydrofiber dressings may help with infection control by holding bacteria in absorbed wound fluid, thereby reducing overall bacterial load within the wound and minimizing airborne bacteria during dressing changes.

What is required when applying topical cream?

Apply a small amount of cream gently in the direction of hair growth using a gloved hand — do not rub vigorously. When applying a medicated cream (such as a steroid cream or ointment) apply sparingly and only to affected areas. Emollients can usually be used more plentifully

Burns Assessment

Assessment • Depth of the burn • Causative agent • Temperature • Duration of contact • Burn thickness • Age & comorbidities • Rule of nines (TBSA) • Pain scale • Respiratory difficulties • Inhalation burn *Rule of nines does not take into account the difference levels of growth & is not accurate for children.

Abnormal mole

Asymmetric borders are uneven multiple colors larger than 1/4 inch ' change shape size and color

What is the teaching for a patient taking B12 injections?

B-12 deficiency risk factorsalcohol abuse. smoking. certain prescription medications, including antacids and some type 2 diabetes drugs. having an endocrine-related autoimmune disorder, such as diabetes or a thyroid disorder

What are the complications that you should prevent in the first 48% for a patient with severe burn?

Bacterial infection, which may lead to a bloodstream infection (sepsis) Fluid loss, including low blood volume (hypovolemia) Dangerously low body temperature (hypothermia) Breathing problems from the intake of hot air or smoke. Scars or ridged areas caused by an overgrowth of scar tissue (keloids)

Transparent film (Tagaderm)

Breathable, Mepore® Pro is a self-adherent dressing that absorbs blood and exudate. The backing film allows showering and protects the wound from water and contamination. Mepore Pro is a skin friendly adhesive that provides secure and gentle fixation.

What is the purpose of high protein diet?

Build. Protein is an important building block of bones, muscles, cartilage, and skin. Repair. Your body uses it to build and repair tissue. Oxygenate. Red blood cells contain a protein compound that carries oxygen throughout the body. Digest. Regulate.

What type of diet are patient with extensive burn injury?

Carbohydrates are the favored energy source for burn patients as high-carbohydrate diets promote wound healing and impart a protein-sparing effect. High-protein foods include meat, fish, eggs, legumes, milk, yogurt, cheese, and nuts. You should eat high-protein foods at every meal and as snacks. If needed, vitamins may be recommended by the health care team. The health care team also monitors the level of salt in your blood.

What would exacerbate eczema?

Certain foods can worsen your eczema. You might experience a flare-up after you consume foods and ingredients that are inflammatory. Examples include sugar, refined carbohydrates, gluten, red meats, and dairy.

Psoriasis Clinical Manifestations/Assessment

Clinical Manifestations/Assessment •Appear raised, erythematous, circumscribed, •White scales/patches •Primary lesion is popular becomes plaques •Located in scalp, elbows, chin & trunk. •Mild, moderate or severe •Mild pruritus, the feeling of depression, frustration & loneliness (self-conscious)

What are the triggers for a patient w/ psoriasis?

Common triggers for psoriasis include stress, illness (particularly strep infections), injury to the skin and certain medications

What is the purpose of debridement?

Debridement is a procedure for treating a wound in the skin. It involves thoroughly cleaning the wound and removing all hyperkeratotic (thickened skin or callus), infected, and nonviable (necrotic or dead) tissue, foreign debris, and residual material from dressings.

What should be included in the assessment for a patient w/ T-tube

Drainage bag positioned correctly Record and empty drainage per facility's protocol Assess color and consistency of drainage Inspect skin and abdomen frequently Need physician's order to clamp or flush the t-tube

What is priority for a patient during the first 24 hours with a severe burn injury?

Due to the capillary leak, most burn centres advise not to use colloids and other blood products within the first 24 hours [17]. If used in the early phase (up to 12 h), it can lead to a prolonged tissue oedema and consecutive lung complications

Hydrocolloid (DuoDERM)

DuoDERM Extra Thin dressing is designed to reduce the risk of further skin breakdown & can be used as a primary hydrocolloid dressing for dry to lightly

papules

Firm, raised areas such as pimples and the eruptions seen in some stages of chickenpox and syphilis.

The nurse in the clinic is examining the skin of a patient with plaque psoriasis. The nurse would expect to see which type of lesion? O Flat, nonpalpable macule O Deep, firm, well-defined lesion O Irregularly shaped cutaneous edema O Elevated lesion with a rough, flat top that is greater than O 1 cm in diameter

Flat, nonpalpable macule Rationale Plaque psoriasis is characterized by rough, flat-topped, elevated lesions. Flat, nonpalpable macules are patches. A nodule is a deep, firm, well-defined lesion. A wheal is an irregularly shaped area of cutaneous edema.

What are interventions to prevent infection with patient who has severe burn injury?

For serious burns, after appropriate first aid and wound assessment, your treatment may involve medications, wound dressings, therapy and surgery. The goals of treatment are to control pain, remove dead tissue, prevent infection, reduce scarring risk and regain function

Which foods are rich in Vitamin C? What is the purpose of Vitamin C

Good sources include citrus fruit, such as oranges and orange juice. peppers. strawberries. blackcurrants. broccoli. brussels sprouts. potatoes.

What are foods high in Vitamin K?

Green leafy vegetables, such as kale, spinach, turnip greens, collards, Swiss chard, mustard greens, parsley, romaine, and green leaf lettuce. Vegetables such as Brussels sprouts, broccoli, cauliflower, and cabbage. Fish, liver, meat, eggs, and cereals

Is genital herpes contagious when the blister aren't present?

Herpes infections are most contagious when symptoms are present but can still be transmitted to others in the absence of symptoms.

What are the signs/symptoms and priority interventions for a patient wtih hypovolemic shock?

Hypotension. Hypovolemic shock produces hypotension with narrowed pulse pressure. Cognitive. The patient experiences decreased sensorium. Tachycardia. Rapid, shallow respirations. Oliguria. ... Clammy skin. Three goals exist in the emergency department treatment of the patient with hypovolemic shock as follows: (1) maximize oxygen delivery - completed by ensuring adequacy of ventilation, increasing oxygen saturation of the blood, and restoring blood flow, (2) control further blood loss, and (3) fluid resuscitation.f

What is the most common cause of death for patient with burn injury in the emergent phase?

Hypovolemic shock is a common cause of death in the emergent phase in patients with serious injuries. Monitor vital signs. Monitor cardiac status, especially in cases of electrical burn injuries.

The nurse is performing the admission assessment of an elderly patient. On the assessment of the skin, the nurse notes full-thickness tissue loss over the right heel; however, bone is not exposed. The nurse would anticipate the diagnosis of which stage of a pressure ulcer? O I O II O III O IV

III Rationale An area of full-thickness tissue loss that does not expose bone is most likely a stage III pressure ulcer. If bone is exposed, it is a stage IV pressure ulcer. A stage pressure ulcer is characterized by an area of nonblanchable erythema. Partial-thickness loss characterizes a stage Il pressure ulcer

What should a patient w/ genital herpes inform their partner?

If you have herpes, you should talk to your sex partner(s) and let him or her know that you do and the risk involved. Using condoms may help lower this risk but it will not get rid of the risk completely. Having sores or other symptoms of herpes can increase your risk of spreading the disease.

What is the nursing diagnosis for a patient with an open wound?

Impaired Skin Integrity

How is a fungal infection spread?

Infections are spread by direct skin contact (with humans or animals), or indirectly from contaminated articles on floors or in the soil. Shared changing rooms and showers are often a source of tinea, while some infections are spread by sharing of items such as towels.

What signs/symptoms are indication of inhalation injury?

Inhalation Injuries Coughing and phlegm. A scratchy throat. Irritated sinuses. Shortness of breath. Chest pain or tightness. Headaches. Stinging eyes. A runny nose.

Which condition would a nurse explain is caused by the virus that causes chickenpox? 1 Athlete's foot 2 Herpes zoster 3 German measles 4 Infectious hepatitis

Invasion of the posterior (dorsal) root ganglia by the same virus that causes chickenpox can result in herpes zoster or shingles. This may be caused by reactivation of a previous chickenpox virus that has remained dormant in the body or by recent contact with an individual who has chickenpox. Athlete's foot is caused by a fungus. German measles and Hepatitis type A are caused by other viruses.

What is the most important to teach a mother of a patient w/ eczema?

Moisturize your skin at least twice a day. Find a product or combination of products that works for you. You might try bath oils, creams, ointments or sprays. For a child, the twice-a-day regimen might be an ointment before bedtime and a cream before school. Ointments are greasier and sting less when applied. Apply an anti-itch cream to the affected area. A nonprescription hydrocortisone cream, containing at least 1 percent hydrocortisone, can temporarily relieve the itch. Apply it no more than twice a day to the affected area, after moisturizing. Using the moisturizer first helps the medicated cream penetrate the skin better. Once your reaction has improved, you may use this type of cream less often to prevent flare-ups. Take an oral allergy or anti-itch medication. Options include nonprescription allergy medicines (antihistamines) — such as cetirizine (Zyrtec) or fexofenadine (Allegra). Also, diphenhydramine (Benadryl, others) may be helpful if itching is severe. But it causes drowsiness, so it's better for bedtime. Don't scratch. Rather than scratching when you itch, try pressing on the skin. Cover the itchy area if you can't keep from scratching it. For children, it might help to trim their nails and have them wear gloves at night. Apply bandages. Covering the affected area with bandages helps protect the skin and prevent scratching. Take a warm bath. Sprinkle the bath water with baking soda, uncooked oatmeal or colloidal oatmeal — a finely ground oatmeal that is made for the bathtub (Aveeno, others). Soak for 10 to 15 minutes, then pat dry. Apply moisturizer while the skin is still damp. Choose mild soaps without dyes or perfumes. Use soap that's superfatted and nonalkaline. Be sure to rinse off the soap completely. Use a humidifier. Hot, dry indoor air can parch sensitive skin and worsen itching and flaking. A portable home humidifier or one attached to your furnace adds moisture to the air inside your home. Wear cool, smooth-textured clothing. Reduce irritation by avoiding clothing that's rough, tight or scratchy. Also, wear appropriate clothing in hot weather or during exercise to prevent excessive sweating. Treat stress and anxiety. Stress and other emotional disorders can worsen atopic dermatitis. Acknowledging those and trying to improve your emotional health can help.

What are the interventions for a patient with dry skin?

Moisturize. Moisturizers provide a seal over your skin to keep water from escaping. ... Use warm water and limit bath time. ... Avoid harsh, drying soaps. ... Apply moisturizers immediately after bathing. ... Use a humidifier. ... Choose fabrics that are kind to your skin.

What are the interventions for a patient with respiratory distress?

My approach to respiratory distress Airway management. Oxygen (including high flow humidified nasal oxygen) Positive end expiratory pressure. Positive pressure ventilation. Chest decompression. Bronchodilators (and steroids eventually) Epinephrine. Nitroglycerin.

Herpes Simplex Medical management

No cure •Infection control & handwashing •Keep it clean and dry •Loose absorbent clothing •acyclovir (Zovirax), valacyclovir (Valtrex), acetaminophen, lidocaine, codeine and aspirin, NSAIDS (ibuprofen) •Assess for HIV •Comfort & vasodilation •10 to 15 minutes •Be cautious for Orthostatic hypotension

The nurse explains to the parents of a child who has impetigo how to manage the disease at home. Which instructions would be included for the parents? O "Research safety information on the Internet." O "Wash your hands every time you touch your child O "Immediately report if there is honey-colored crust. O "Do not use chemical soaps because they may burn the child's skin

O "Wash your hands every time you touch your child Rationale Impetigo is a highly contagious streptococcal infection, and it could spread if the caregiver or anyone touches the patient. Therefore, the nurse instructs the parents to wash their hands every time they touch the child. Chemical or antiseptic soaps are used to clean the infected area because they prevent the growth of microorganisms. The nurse does not instruct the parents to look for safety information on the Internet because some of the information found there may be inaccurate. The dried exudate from ruptured vesicles is honey colored and can be easily removed. Therefore, it is not important to report it to the health care provider.

The nurse is providing education to a patient with new-onset type 2 herpes simplex genital lesions. Which statement regarding type 2 herpes simplex, if made by the patient, indicates a need for further education? O "I will also be tested for human immunodeficiency virus." O "With medication, I will be able to cure my herpesvirus infection O "I can expect to experience flulike symptoms for several days after the vesicles erupt." O "IF I become pregnant and have active lesions at delivery, I will have to deliver via cesarean section."

O "With medication, I will be able to cure my herpesvirus infection!! Rationale There is no cure for herpesvirus infection. Medical treatment focuses on treating symptoms. It is important to test individuals with herpesvirus for human immunodeficiency virus (HIV) Flulike symptoms often occur with herpes vesicle eruption. Transmission of herpesvirus during childbirth can be fatal to the baby, so cesarean section delivery is vital when active lesions are present.

The nurse notices that a patient with fever has erythema, pain, and tenderness over an area of the skin. Which infection does the nurse suspect in the patient? O Cellulitis O Impetigo O Herpes simplex O Pityriasis rosea

O Cellulitis Rationale The nurse would suspect cellulitis, an infection of the skin and underlying subcutaneous tissues. The affected areas become erythematous, edematous, tender, and warm to the touch. In impetigo, the lesions are small, flat blemishes that are flush with the skin surface and develop into pustulant vesicles, which rupture and form a dried exudate. Herpes simplex is identified when the patient develops cold sores. Pityriasis rosea is a single lesion, referred to as a scaly patch. It is a scaly area that is 1 to 3 inches in diameter with a raised border and a pink center that resembles ringworm (a fungal infection).

Which terminology would be documented in the medical record for an infection of a hair follicle? O felon O Folliculitis O A furuncle O A carbuncle

O Folliculitis Rationale Folliculitis is an infection of a hair follicle, usually caused by Staphylococcus aureus. The infection may involve one or several follicles. It often occurs after shaving. A furuncle, also known as a boil, is an inflammation that begins deep in the hair follicles and spreads to the surrounding skin; it is often located in the posterior area of the neck, the forearm, the buttocks, or the axillae. A carbuncle is a duster of furuncles. It is an infection of several hair follicles that spreads to surrounding tissue. A felon occurs when the soft tissue under and around an area, such as the fingernail, becomes infected.

Tinea capitis, Microsporum audouinii infection, tinea corporis, and tinea pedis are examples of which type of infection? O Viral skin infections O Fungal skin infections O Bacterial skin infections O Infections commonly acquired in health clubs

O Fungal skin infections Rationale Tinea capitis, M. audouinii infection, tinea corporis, and tinea pedis are all examples of fungal skin infections. These dermatophytoses are superficial infections. These are not bacterial in origin. (An example of a bacterial skin infection is cellulitis.) These are not viral in nature. (An example of a viral skin infection is herpes zoster.) Not all of these fungal infections are commonly acquired at health clubs. Tinea pedis, or athlete's foot, can be found between the toes of a person whose feet perspire heavily, it also can be spread from contaminated public bathroom facilities and swimming pools.

A patient comes to the clinic with a cluster of vesicles at the corner of the mouth. The nurse anticipates the patient will be diagnosed with an infection caused by which organism? O Neisseria gonorrhoeae O Chlamydia trachomatis O Herpes simplex virus type 1 O Herpes simplex virus type 2

O Herpes simplex virus type 1 Rationale The patient demonstrates signs of a herpes simplex virus infection. Type 1 herpesvirus is more common than type 2, which generally affects the genitals. Neisseria gonorrhoeae and Chlamydia trachomatis do not cause vesicles at the corner of the mouth.

The nurse is performing the admission assessment of a patient at the nursing home. The nurse notes the patient has widespread nevi across the body. Which characteristic, if demonstrated by one of the nevi, would cause the nurse to be concerned about malignancy? O Flat surface O Regular color O A Circular shape O Irregular border

O Irregular border Rationale Moles with an irregular border should be further assessed for malignancy. Other indicators of malignancy include raised surface, variations in color in the mole, and an irregular shape.

A patient with urticaria is prescribed diphenhydramine therapy. Which medication effect best explains the purpose of prescribing this medication? O It prevents severe dryness of the skin. O It treats eczema and psoriasis. O It manages inflammation and pain. O It blocks histamine at the H1, receptor site.

O It blocks histamine at the H1, receptor site. Rationale Urticaria occurs as a result of the release of histamine in an antigen antibody reaction. Therefore, diphenhydramine, an antihistamine, is prescribed because it blocks histamine at the H receptor site. Urticaria does not cause dryness of skin, however, wheals or hives are caused by an allergic reaction. Estar Gel and PsoriGel are applied once a day at bedtime, along with a moisturizer, to treat eczema and psoriasis. Topical steroids are applied to manage inflammation and pain in the patient.

Which physical attribute would be associated with darker skin tones or freckles in patients? O Melanin O The dermis O Sudoriferous glands O Stratum germinativum

O Melanin Rationale Highly specialized cells called melanocytes in the epidermis give rise to the pigment melanin that is responsible for the skin color. Higher concentrations of melanin result in darker skin tones. The dermis is the true skin and varies in thickness throughout the body. The sudoriferous glands are sweat glands, which excrete sweat and cool the body's surface. The stratum germinativum is the inner layer of the epidermis that provides a constant new supply of cells for the upper layer and enables the skin to repair itself after an injury.

Which disease condition can be found more in fair-skinned patients than in those with more pigmentation in their skin? O Keloids O Melanoma O Nevus of Ota O Traction alopecia

O Melanoma Rationale Fair-skinned people are more prone to developing melanoma compared with people with more pigment in their skin. People with darker skin have an increased amount of melanin pigment produced by melanocytes. This increased melanin forms a natural sun shield for darker skin and results in a decreased incidence of skin cancer in these individuals. However, individuals with dark skin may have a higher incidence of keloids, Nevus of Ota, and traction alopecia.

The patient with acne vulgaris is prescribed isotretinoin. The nurse anticipates that which test will be performed before the patient begins taking the prescribed medication? O Vitamin D O Pregnancy test O Kidney function O Fasting blood glucose

O Pregnancy test Rationale Isotretinoin can cause severe birth defects and should not be taken if there is a chance a woman might be pregnant. Kidney function, vitamin D, and blood glucose are not affected by the drug

The nurse obtains a swab culture from a cellulitis infection of an adult patient. The nurse anticipates the culture will grow which causative species of bacteria? O Klebsiella pneumoniae O Staphylococcus aureus O Haemophilus influenzae O Streptococcus pneumoniae

O Staphylococcus aureus Rationale In adults, Staphylococcus aureus is the most common cause of cellulitis. In children, Haemophilus influenzae is the most common. Klebsiella pneumoniae and Streptococcus pneumoniae are not the most common causes of cellulitis.

Which assessment finding would indicate that the patient has a stage Il ulcer? O The ulcer involves full-thickness tissue loss, and subcutaneous fat is visible. O The ulcer is a localized area of skin that is intact with nonblanchable redness. O The ulcer is a shallow red-pink wound bed with partial thickness loss of dermis O The ulcer involves full-thickness tissue loss, with exposed bone, tendon, or muscle.

O The ulcer is a shallow red-pink wound bed with partial thickness loss of dermis Rationale A stage Il pressure ulcer involves partial-thickness loss of dermis. It appears as an open ulcer, usually shiny or dry, with a shallow red-pink wound bed without slough or bruising. A stage III pressure ulcer involves full-thickness tissue loss, in which subcutaneous fat is sometimes visible, but bone, tendon, and muscle are not exposed. A stage IV pressure ulcer involves full thickness tissue loss, with exposed bone, tendon, or muscle. A stage I pressure ulcer is a localized area of skin over a bony prominence that is intact with nonblanchable redness.

A patient with a herpes viral infection has frequent outbreaks of cold sores and is prescribed suppressive therapy with valacyclovir. The nurse finds that the patient is also prescribed ibuprofen for which purpose? O To manage chronic pain O To prevent pneumonitis O To provide topical relief O To manage inflammation

O To manage inflammation Rationale The patient is prescribed ibuprofen to manage inflammation that may be caused by cold sores. Systemic analgesics, such as codeine and acetaminophen, are given for pain management Pneumonitis cannot be prevented but can be treated with intravenous acyclovir. Local anesthetics, such as lidocaine, provide topical relief from discomfort.

What are the symptoms on a patient w/ herpes zoster infection?

Pain, burning, numbness or tingling. Sensitivity to touch. A red rash that begins a few days after the pain. Fluid-filled blisters that break open and crust over. Itching. The most common complication of shingles is long-term nerve pain called postherpetic neuralgia (PHN).

When assessing the patient's integumentary system, which dermatologic manifestation may indicate anemia? O Pallor O Cyanosis O Skin tags O Cherry angiomas

Pallor Rationale Pallor indicates anemia, whereas cyanosis, also known as blue discoloration, may result from a respiratory disorder. Skin tags and cherry angiomas are benign neoplasms related to aging.

Four Types of Grafts

Patient Teaching • Do not remove dressing unless ordered • Report changes in the graft to physician • Protect grafted skin from direct sunlight with a sunscreen lotion for at least 6 months • Keep surface of healed graft moistened daily 6-12 months • Wear a long elastic stocking for 4-6 months for grafts on lower extremities

What is the priority for a patient taking etanercept (Enbrel)?

Patients should be closely monitored for the development of signs and symptoms of infection during and after treatment with Enbrel. Enbrel should be discontinued if a patient develops a serious infection or sepsis. A patient who develops a new infection during treatment with Enbrel should be closely monitored, undergo a prompt and complete diagnostic workup appropriate for an immunocompromised patient, and appropriate antimicrobial therapy should be initiated. avoid live vaccines itching and erythema at the injection site

What is the treatment regimen for a patient with pernicious anemia?

Pernicious anemia usually is easy to treat with vitamin B12 shots or pills. If you have severe pernicious anemia, your doctor may recommend shots first. Shots usually are given in a muscle every day or every week until the level of vitamin B12 in your blood increases

lacto-ovo-vegetarian

Person who consumes all vegan items plus dairy products and eggs.

What are the signs/symptoms of fluid overload?

Rapid weight gain. Noticeable swelling (edema) in your arms, legs and face. Swelling in your abdomen. Cramping, headache, and stomach bloating. Shortness of breath. High blood pressure. Heart problems, including congestive heart failure.

Curling ulcer

Severe burn leads to acute gastritis due to decreased blood supply secondary to hypovolemia. Decreased blood supply inhibits ability to carry away excess acid from stomach.

What are the signs/symptoms of scabies? What are the treatment?

Signs and symptoms of scabies include: Itching, mainly at night: Itching is the most common symptom. ... Rash: Many people get the scabies rash. ... Sores: Scratching the itchy rash can cause sores. ... Thick crusts on the skin: Crusts form when a person develops a severe type of scabies called crusted scabies. treating scabies 2 most widely used treatments for scabies are permethrin cream and malathion lotion (brand name Derbac M). Both medications contain insecticides that kill the scabies mite. Permethrin 5% cream is usually recommended as the first treatment.

What are the teaching to reduced risk for melanoma?

Slip on a shirt. Slop on sunscreen. Slap on a hat. Wrap on sunglasses to protect the eyes and sensitive skin around them.

What are the risk factors for a patient with basal cell carcinoma?

Sun Exposure. Fair Skin. Personal History of Skin Cancer. Exposure to Industrial Compounds. Weakened Immune System. Age. Skin that freckles or sunburns easily can be a warning sign that you're at risk for basal cell carcinoma.

Alginate (Medihoney)

Supports removal of necrotic tissue and aids in wound healing. For wounds with moderate to heavy amounts of exudate or when light packing is needed.

Normal Mole Color:

Symmetrical borders are even one color smaller than 1/4 inch

What are the signs/symptoms if wounds are infected?

Symptoms of Wound Infections Pus. Pus or cloudy fluid is draining from the wound. Pimple. A pimple or yellow crust has formed on the wound. Soft Scab. The scab has increased in size. Red Area. Increasing redness occurs around the wound. Red Streak. More Pain. More Swelling. Swollen Node.

What are the teaching for antibiotic treatment?

Take antibiotics exactly as prescribed if you need them.Take them exactly as your doctor tells you. Do not share your antibiotics with others. Do not save them for later. Talk to your pharmacist about safely discarding leftover medicines.

While interviewing a female patient, the senior nurse finds that the patient is taking isotretinoin (Accutane) to treat acne. On further assessment, the patient states that she plans to conceive. Which is the most important nursing action? O Tell the patient to stop the medication, to avoid adverse effects on the fetus O Inform the patient that she can continue the medication because the acne has reduced O Teach the patient the process of taking the drug with food to minimize the side effects. O Inform the patient that an overdose of Accutane can have serious consequences during pregnancy

Tell the patient to stop the medication, to avoid adverse effects on the fetus Rationale The drug isotretinoin is used for treating acne. Isotretinoin (Accutane) can cause abnormal fetal development and so, it should not be used by women who are pregnant or are planning to become pregnant. While a nurse would normally discuss the drug's side effects and effectiveness on continuing the medication, these issues are not relevant if the patient is instructed to discontinue the medication while trying to conceive.

What is the priority before changing the dressing on a patient with severe wounds or burns?

The first priority in treating the burn victim is to ensure that the airway (breathing passages) remains open. Associated smoke inhalation injury is very common, particularly if the patient has been burned in a closed space, such as a room or building. Even patients burned in an open area may sustain smoke inhalation.

When is the greatest fluid loss from burn injury?

The greatest loss of plasma occurs in the first 12 hours after burn injury. The plasma loss then slowly decreases during the second 12 hours of the post-burn phase, although extensive leakage can continue for up to three days

What is curling ulcer?

The stress ulcers secondary to systemic burns are known as Curling ulcer, stress ulcers in patients with acute traumatic brain injury are known as Cushing ulcer. The gastric body and fundus are common locations for stress ulcerations but can also be seen in antrum and duodenum

Which Vitamin has antioxidant affect? What is an antioxidant?

The three major antioxidant vitamins are beta-carotene, vitamin C, and vitamin E

angiomas

Tumors consisting principally of blood vessels or lymph vessels

squamous cell carcinoma

Type of skin cancer more serious than basal cell carcinoma; often characterized by scaly red papules or nodules.

What are the interventions for a patient with vancomycin-resistant enterococcus (VRE)?

Vancomycin-resistant enterococci infections are treated with antibiotics, which are the types of medicines normally used to kill bacteria. VRE infections are more difficult to treat than other infections with enterococci, because fewer antibiotics can kill the bacteria. doctor will order antibiotics that may be given by mouth or into a vein through an IV (intravenously). Sometimes more than one antibiotic is prescribed to help stop the infection.

What is Vitamin K? Where is it synthesized?

Vitamin K is a nutrient that the body needs to stay healthy. It's important for blood clotting and healthy bones and also has other functions in the body. If you are taking a blood thinner such as warfarin (Coumadin®), it's very important to get about the same amount of vitamin K each day. However, the chief source of vitamin K is synthesis by bacteria in the large intestine, and in most cases, absence of dietary vitamin K is not at all deleterious.

Vitamin K:

blood clotting & bone development required intestinal antidote for warfarin Food Source: green leafy vegetables, cauliflower, cabbage Anything leafy green Deficiency: 2nd deficiency w/ severe malabsorption or abx that kills intestinal bacteria. Given to babies don't have intestinal bacteria

Sanguineous

bloody

Phosphorus:

bone formation, acid-base balance, inverse relation to calcium (one is high the other is low), Ph balance 7.35-7.45, phosphorus will be elevated with patients with kidney failure Food Source: dairy, fish, organ meats, nuts, pork, beef, chicken, whole grains, cereals Deficiency: < deep tendon reflex, bone pain Toxicity: muscle weakness, +Chovostek's or Trousseaus sig

Ecchymosis

bruising

Vitamin B1 (Thiamin):

enable the body to use CHO as energy (GI, Nervous & Cardiac) Important to transform from food to energy (glucose to energy), given to alcoholics Food Source: pork, nuts, wholegrain, cereals, legumes Deficiency: beriberi , poor appetite, found in alcoholics, constipation, symptoms of confusion

Isotonicity:

equal osmotic pressure • Clinical applications: loss of isotonicity through vomiting or prolonged diarrhea

abalative

excision or removal of diseased body part

macules

flat spots on the skin, such as freckles

exudate

fluid, such as pus, that leaks out of an infected wound

Iron:

functional part of hemoglobin Food Source: liver, meats, egg yolk, whole grains, dark green leafy, enriched grain, legumes Deficiency: anemia (check lab values hemoglobin) Toxicity: most common side effect of constipation, turns tool black or green

Alopecia

hair loss

keratin

hard protein material found in the epidermis, hair, and nails

HeType1 (HSV-1)

he cause of the cold sore (fever blisters) on mouth lips or nose Characterized by vesicle rupture & encrust •Symptoms of general malaise & fatigue •Typically occur after an acute illness or infection •Tingling, burning, Pain

Vitamin B2 (Riboflavin):

helps the body convert food into fuel Food Source: milk, lean milk, fish, grains Deficiency: cracked lips, red tongue

You know the therapy for pernicious anemia is effective by checking what lab test?

hemoglobin tests

What is the teachings for a patient w/ genital herpes?

herpes is transmitted through contact with persons infected with HSV. herpes may be transmitted with or without blisters. antivirals don't cure or prevent herpes; they just reduce symptoms.

pediculosis

infestation with lice

wheals

itchy, elevated areas with an irregular shape; hives and insect bites are examples

incomplete proteins

lack one or more essential amino acids Found in grains, legumes, nuts, and seeds, edamame, spinach, broccoli, legumes, nuts

lacto-vegetarian diet

lacto-vegetarians eat milk, cheese, and dairy foods, but avoid meat, fish, poultry, and eggs

Which food are high in protein?

lean meats - beef, lamb, veal, pork, kangaroo. poultry - chicken, turkey, duck, emu, goose, bush birds. fish and seafood - fish, prawns, crab, lobster, mussels, oysters, scallops, clams. eggs. dairy products - milk, yoghurt (especially Greek yoghurt), cheese (especially cottage cheese)

Stage 3 care of burns

long-term rehabilitation phage, burn wound treatment, returning to baseline as possible

Superficial spreading melanoma

lower extremities, back

Vitamin D (Calciferol):

maintain calcium, phosphorus homeostasis acts like a hormone Food Source: sun exposure, milk, fish oils, cereals, Deficiency: Rickets (bones bend), osteoporosis

Chloride:

maintain water & acidbase balance Food Source: table salt Toxicity: from severe dehydration

basal cell carcinoma

malignant tumor of the basal cell layer of the epidermis

Potassium:

muscle action (affects the heart), insulin D50 if they have levels of potassium (do not have to be diabetic) release Food Source: avocados, bananas, cantaloupe, orange, strawberries, tomatoes, carrots, spinach, fish, port, beef, potatoes Deficiency: anorexia, leg cramps, and distention 3.5-5 Normal level Toxicity: muscle vomiting, irregular HR, palpitation, cardiac dysrhythmia

Magnesium:

muscle action (heart) Food Source: whole grains, avocados, canned white tuna fish, cauliflower, oatmeal, green leafy vegetables, milk, peanut butter, potatoes Deficiency: twitching, hypertension, muscle weakness Toxicity: GI symptoms

Anions:

negative charge • Chloride [Cl−], bicarbonate [HCO3−], phosphate [PO43−], and sulfate [SO42−])

urtica

nettle, burn

Vitamin B3 (Niacin):

niacin plays a role in converting carbohydrates into glucose, metabolizing fats and proteins, and keeping the nervous system working properly. Food Source: meat, poultry fish, whole grains, cereals, peanuts Deficiency: Pellagra, weakness, poor appetite, found in alcoholics, four D's Patient teaching: your urine will turn bright yellow Toxicity: skin flushing, burning/tingling

Cations:

positive charge • Sodium [Na+], potassium [K+], calcium [Ca2+], and magnesium [Mg2+]

Marsmus

progressive emaciation caused by lack of protein and calories

complete proteins

proteins that contain all nine of the essential amino acids found in animal origin and tofu

Acids and bases:

refers to hydrogen ion concentration, pH of 7 is neutral • Acid: compound has more hydrogen ions, can release extra hydrogen ions when in solution • Base: compound with fewer hydrogen ions, can accept hydrogen ions when in solution

debridement

removal of foreign material and dead or damaged tissue from a wound

Vitamin B12 (Cobalamin):

required for hemoglobin synthesis, important for iron levels, hemoglobin tests for levels to see if working, used for anemia not listed as cobalamin Food Source: soy milk, meat liver, intrinsic factor necessary for absorption, if there is no intrinsic factor you will be on IM for life. Deficiency: Pernicious Anemia • IM injection monthly • lifetime • will have activity intolerance, pale appearance

tinea capitis

ringworm of the scalp

pruitus

severe itching

pustulant vesicles

small, circumscribed elevations of the skin that contain pus

nevi

small, dark skin growths that develop from melanocytes in the skin; also known as moles

Stage 1 care of burns

the emergent phase, onset of injury until the patient stabilizes. Hypovolemic shock is the major concern for up to 48hrs after a major burn resuscitate with IV to keep hydrated. How do we know its working UO will be at least 30 ml/hr

Iodine:

the healthy thyroid gland, component of thyroid hormone (Thyroxine T4) Food Source: iodized salt, seafood Deficiency: goiter (enlarger thyroid gland) can lead to hypothyroidism

Stage 2 care of burns

the intermediate or acute (or diuretic) phase, begins 48-72 hours after the burn injury, the greatest concern is circulatory overload the result from the fluid shift back from the interstitial spaces into the capillaries

Total Energy Expenditure

the sum of the energy used for basal metabolism, activity, processing food, deposition of new tissue, and production of milk •To maintain daily energy balance: •Food energy intake = body energy output •Intake > output = Weight gain (extreme: obesity) •Intake < output = Weight loss (extreme: anorexia)

homograft (allograft)

tissue for grafting that is taken from donor of the same species (generally from a cadaver in humans)

Autograft

transplantation of healthy tissue from one site to another site in the same individual

Zinc:

wound healing, immune system Food Source: meat, seafood legumes, whole grains Deficiency: poor wound healing, impaired taste & smell

Burns

• 400,000 people each year seek medical attention for burns • 40,000 are hospitalized for burns each year • 3,400 die from burns each year • Thermal burns are the most common type of burn injury • Skin destruction depends on the burning agent, the temperature, condition of the skin & duration of contact. • Burns cause dramatic changes beginning in the first few minutes to the first 12 to 24 hours after • Depends on 2 factors: the extent of the body surface burned & the depth • Traditionally burns have been classified as first-, second-, and third-degree • Is measured in terms of the total body surface area (TBSA) • May also be classified as • Superficial-thickness injuries • Partial-thickness injuries • Full-thickness injuries All items

Wound Documentation

• Amount and color of drainage on old dressing • Length, width, diameter, and depth of wound • Sinus tracts and their length • Color of wound • Appearance of surrounding skin • Type of dressing applied • Type of drain if present • Red hazardoug bag • Pain and tolerance to dressing change • Picture of wound to compare • Treatment performed • Cleanse the wound with wet sterile gauze from the center of the wound outward. • Medication given prior or medication for healing • Types of wound cleanser used

Acid-Base Balance

• An acceptable pH (degree of acidity or alkalinity ) must be maintained in body fluids to support life. • Achieved by chemical and physiologic buffer systems • Acidity/alkalinity expressed in terms of pH

Prevent infection

• Apply topical antimicrobials. • silver sulfadiazine • Correct Shave body hair around wounds. • Correct Administer a tetanus toxoid booster. • Correct Cover the wounds with a sterile dressing. • Correct Have all visitors wash hands upon entering the room.

Minerals

• Are components of hormones, cells, tissues & bones • Acts as a catalyst for chemical reaction & enhancers of cell functions

Nursing Process for the Patient with an Integumentary Disorder

• Assessment • Diagnosis • Ineffective airwal clearance • Deficient fluid volume • Impaired skin integrity • Decreased cardiac output • Risk for aspiration • Impaired swallowing • Impaired verbal communication • Disturbed sleep pattern • Anxiety • Pain • Deficient knowledge • Risk for infection

3. Maturation

• Begins 3wks to 1 year

Rehabilitation phase

• Begins at admission • Goal is to promote independence • Addresses both social and physical skills & may take years • Physical therapy for positioning, skincare, exercise, ambulation & ADLs • Set realistic short term goal • Encourage patient to talk about fears and concerns • Assess family interactions • Helping family cope

Wet to Moist Dressings

• Change frequently, to prevent from drying out • Favored for wound healing • Preserve fragile granulating tissue

Third intention

• Delayed closure for irrigation or removal of debris & exudates Heals from the inside out

Nursing Responsibilities for Drain Care

• Empty drain q8hrs or when they become ½ or 2/3 full • Compress for suction • Monitor for bleeding • Report significant increase in the amount and presence of purulent drainage to the MD immediately • Prevent dislodging the tube

Antidiuretic Hormone (ADH) Mechanism

• First-line defense against hypovolemia • ADH is also called vasopressin

burns 3

• Fluid shift back to the vascular compartment in approximately 48-72 hours (beginning of the diuretic stage) • Risk for fluid overload • Monitor VS, urinary output & LOC • May experience smoke inhalation (damage the cilia & mucosa) • Atelectasis may occur • Signs of respiratory distress (inhalation injury): hoarse voice, productive cough, agitation, tachypnea, flaring nostrils, intercostal retractions, brassy cough, grunting, guttural respiratory sounds, sooty sputum

Second Intention

• Great tissue loss w/ Irregular edges heals from the inside out • Ex: Pressre injury

Types of Drains

• Hemovac: Active drain uses suction • Jackson-Pratt: Active drain uses suction • T-tube: drain uses gravity • Protect skin from drainage • Empty q8-12hrs • Monitor stool • Penrose: Open drain; not commonly used because can provide pathway for pathogens

Buffer Systems

• Human body has many buffer systems • Relatively narrow pH range (7.35 to 7.45) is compatible with life • pH < than 7 are acidic, pH > 7 are alkaline

Water intoxication

• Infants • Psychiatric patients (psychogenic polydipsia) • Patients on psychotropic drugs • Endurance athletes who are not replacing electrolytes

2. Fibroblast

• Last 2-4wks • Granulation tissue & scar forms

1. Inflammatory

• Last 3-5 days • Local edema, pain, redness & warmth

Burns Nursing Interventions

• Prioritizing nursing care using ABCs • Respiratory pattern • High protein & high calorie • Vital signs • Circulation • Intake & output • Ambulation • Bowel sounds • Inspection of wound • Mental status

Emergent phase Burns

• Priority is airway. • Suspect inhalation injury • Establish airway • Begin fluid resuscitation • Insert a Foley catheter • Insert an NG tube • Treat pain • Monitor vital signs • Provide immunization (Tetanus) prophylaxis as needed

Medical Management Burns

• Stop, drop & roll • Do not apply ice to the burns - cause vasoconstriction - increasing depth of burn • Rinse the chemical burn • Electrical burn has an entry point & exit point • Most electrical burns result in cardiac arrest - begin cardiopulmonary resuscitation & cardiac monitoring

Burns 2

• The greatest fluid loss occurs w/in the first 12 hours. • Capillary hyperpermeability that lasts 24 hours - resulting in edema & vesiculation (blistering) • Proteins, plasma & electrolytes shift from the vascular to the interstitial compartment (third spacing) • Greatest threat to life because cell become dehydrated (hypovolemic shock & ARF may occur) • RBC remain in the vascular system causing falsely elevated hematocrit levels. • Acute dehydration is present & renal perfusion is seriously compromised. • May lead to burn shock • The rapid loss of fluid places a strain on the heart - low perfusion to the vital organs (refer to a burn center) At-risk the first 48 hours

Rehabilitation phase Patient Teaching

• Wound care • Signs/symptoms of complications • Dressings • Exercises • Clothing • ADLs • Social skills • Do not use lotion containing lanolin - will cause clusters • Avoid direct sunlight • Test water before getting into the shower • Bathe twice a day w/ mild soap • Discoloration and scarring are normal during healing

First intention

• Wound edges are approximated w/ little tissue loss • Ex: Surgical incision

Evisceration

• a life-threatening situation, exposure of abdominal contents can lead to necrosis of the intestines or overwhelming sepsis. Serosanguineous drainage is a sign of evisceration dehiscence. Interventions: • Low Fowler's w/ knees bent • Notify PHCP • Cover wound w/ sterile towel moistened w/ normal saline • Prepare for surgery • Take VS

Impetigo Contagiosa Interventions

•Abx (erythromycin & cephalosporin) •Topical abx(Bactroban) •Antiseptic soaps to remove crusted exudate •Primary goal is to prevent glomerulonephritis •Preventing the spread of disease

Cellulitis Interventions

•Administer antibiotic •Monitor & treat pain •Monitor change •Change dressings •Monitor nutrition & hydration status •Immobilized & elevate

Psoriasis Medical Management

•Aimed at slowing the proliferation of epithelial layers of the skin •Topical steroids (hydrocortisone, bethamethasone) & keratolyticagents (decrease shedding)- monitor blood sugar •Photochemotherapy •Methotrexate and Vitamin D reduce proliferation

Fungal Infections of the Skin

•Antifungal drugs (Fulvicin, Grifulvin) •Antifungal soaps & shampoo (Tinactin, Lotrimin AF, Monistat-Derm, Desenex, Mentax) •Protect the involved area from trauma & irritation •Keep it clean and dry •Warm compresses •Tinea pedistreated w/ warm soaks using Burow'ssolution, wearing sandals or going barefoot to help decrease foot moisture

Psoriasis

•Autoimmune disease •Skill cells divide more rapidly than normal •Severe scaling results from the rapid cell division

Proteins

•Builds & repair tissues •Regulate fluid balance •Maintain acid-base balance •Produce antibodies •Provide energy •Produce enzymes & hormones •Complete vs Incomplete proteins •Animal products & tofu

inflammatory Eczema

•Chronic inflammatory disorder of the integument •Associated with allergies to food or clothing

Acne Vulgaris Assessment, Treatment, and Nursing Interventions

•Comedones(blackheads) and pustules are found on the skin of the face, back, or chest •Medical management can involve topical, systemic, or intralesionalmedications •Nursing interventions should focus on promoting self-esteem and teaching preventive care

Herpes Zoster (Shingles)

•Commonly referred human herpesvirus type 3 •Caused by the same virus as chickenpox (varicella) •Manifest as skin lesions of small vesicles along a peripheral nerve route (spinal ganglia) •Can result in eye complications (blindness), deafness, brain inflammation & death. Do not treat if you have never had chickenpox or pregnant

Pediculosis Interventions

•Contact precaution •Nit comb •Lindane (kwell), Permethrin 1% (RID) •Assess family •Highly contagious •Prevent reinfection •Secondary infection •Impetigo

Scabies Interventions

•Contact precaution •Treat family or anyone in contact •Permethin 5% apply all over the body, leave for 12 hours and wash off •Highly contagious •Prevent reinfection

Adulthood

•Energy needs plateau as full growth achieved •BEE then declines 1% to 2% per decade, reducing energy needs •Rapid decline occurs at age 40 (men) and 50 (women)

Eczema interventions

•Entry for infections •Take temperature •Prevent secondary infection

Growth periods

•Extra energy needed to build new tissues •Greatest growth is infancy and adolescence •Pregnancy and lactation also require increased energy intake

Impetigo Contagiosa

•Highly contagious •Common in children •Characterized by macules that turn to vesicles then rupture & form a dried exudate, honey-colored crust that can be easily removed. •Face, hands, arms & legs •Itching, pain, low-grade fever •Malaise•>WBC

Chemical Digestion: GI secretions

•Hydrochloric acid & buffer ions are needed to produce the correct pH that is necessary for enzymatic activity. •Digestive enzymes to break down other nutrients •Mucus lubricate and protect the mucosal tissues that line the GI tract and help to mix the food mass •Water & Electrolytes carry & circulate products of digestions •Bile emulsifies fat into smaller pieces to expose more surface area

Factors That Influence Basal Energy Expenditure

•Lean body mass •Growth periods •Body temperature•Hormonal status •Disease state

Pediculosis

•Lice & nits •Contact precaution •S/S: itching, erythema Use permathin 1% and nit comb to remove

Mechanical digestion: GI motility

•Mastication •Muscle at the base of the tongue facilitate the swallowing process •Esophagus: automatic peristaltic waves •Gravity helps with the movement of food •Gastroesophageal sphincter muscle relaxes: one-way valve •Villi •Surface villi motions stir and mix chyme, which also exposes nutrients for absorption

Herpes Zoster (Shingles) Interventions

•Pain control & preventing complications•Infection, blindness •Acyclovir w/in 72 hours reduces pain & duration of the virus •Airborne Precaution •Steroids •Lotions (kenalog, Lidex), Atarax •to relieve pruritus & inflammation •Zostavax vaccine to prevent •Inhibiting spread of disease •Chickenpox •Vitamin C to promote healing •Dressing •Avoid pregnant women

Acne Vulgaris

•Papulopustularskin eruption that involves the sebaceous glands •Occurs primarily in adolescents

Eczema Assessment

•Pruritus •Scratching

Herpes Zoster (Shingles) Manifestations

•Rash occurs in the thoracic region, lumbar, cervical & cranial region •Vesicles erupt in a line along the involved nerve •Vesicle rupture & form a crust & the serous fluid in the vesicles may become purulent •lasts 7-28 days •Pain is severe (burning & knifelike, extreme tenderness & pruritusoccur •Can be fatal with a compromised immune system.

Vegetarian Diets Interventions

•Refer to a dietician •Vitamin B12 •Intrinsic factor

Psoriasis Nursing Intervensions

•Rest & measures to promote psychological well-being •Education of the disease process •Moisturize•Avoid triggers •Stress, overuse of ETOH, streptococcal infections, beta-blockers, Ace inhibitors

Energy Output

•Total energy demands determined by: •Basal energy expenditure: Factors affecting basal metabolism (lean body mass (male > female muscle mass), growth period, body surface area, extreme temperature, thyroid hormone, stress, drugs, caffeine, genetic makeup) •Physical activity •Thermic effect of food: 5 -10% total energy needs for metabolism

Etanercept (Enbrel)

•Used to treat psoriasis •< T-cells- decreases t cell high risk for infection •Take temperature

Absorption in the Large Intestine

•Water: main absorptive task of large intestine is to absorb water; small amount remains for feces •Dietary fiber: contributes bulk to help form feces •Macronutrients and micronutrients: absorbed through lymph or blood •Minerals, vitaminsand waterare already small enough to be absorbed by the body without being broken down, so they are not digested.