NURS204 Exam 2 Study Guide PDF

lOMoARcPSD|14885695 NURS204-EXAM2 - Exam 2 study guide, I passed with a 90% Foundations Of Nursing Practice (Holy Family University) Scan to open on Studocu Studocu is not sponsored or endorsed by any college or university...

lOMoARcPSD|14885695 NURS204-EXAM2 - Exam 2 study guide, I passed with a 90% Foundations Of Nursing Practice (Holy Family University) Scan to open on Studocu Studocu is not sponsored or endorsed by any college or university Downloaded by Noel Varghese ([email protected])  lOMoARcPSD|14885695 10/20/2021 Exam #2 Outline SKIN INTEGRITY AND WOUND CARE I. Integumentary system assessment and interventions 1.) Assessment a.) Physical: skin, hair, nails ➔ Skin: inspect and palpate- from head to neck to trunk, arms, legs and back (color temperature, moisture, texture, thickness, vascularity, bruising, skin mobility, turgor) ➔ Hair: inspect and palpate scalp and hair for surface characteristics, hair distribution, texture, quantity, and color. Inspect facial and body hair. 1. Surface characteristics: smooth without flaking, scaling, redness, or lesions 2. Should be shiny and soft 3. Quantity and quality: balding patterns and hair loss 4. Texture and color ➔ Nails: inspect nails for shape, contour, color, consistency, thickness, and cleanliness. 5. Edges: smooth and round 6. Shape and contour: flat and slightly rounded 7. Consistency: note grooves, depressions, pitting, and ridges 8. Color: pink, blanched in light-skinned clients; yellow/blown with vertical lines in the dark-skinned clients b. Equipment ➔ Strong direct lighting ➔ Small centimeter ruler ➔ Penlight; adequate lighting ➔ Gloves ➔ Stethoscope (auscultation) c. Changes and variations with age ➔ Slower wound healing ➔ Elder patients are more prone to skin breakdown ➔ Thinning ➔ Temperature regulation ➔ wrinkling/loss of elastin/collagen ➔ Reduced muscle tone d. Cultural considerations ➔ Blanching does not occur in darker skinned patients ➔ Patients with dark skin can’t be assessed for pressure injury by skin color ➔ Melanoma is 20x higher in whites than blacks and 4x higher in hispanics. Downloaded by Noel Varghese ([email protected])  lOMoARcPSD|14885695 10/20/2021 ➔ Light Skin ◆ Pallor (white or pale) ◆ Erythema (red or bright pink) ◆ Cyanosis (dusky blue) ◆ Jaundice (yellow sclera, hard palate of mouth) ➔ Dark Skin ◆ Pallor (yellow-brown, grey) ◆ Erythema (purplish tint) ◆ Cyanosis ( dark, dull,lifeless) ◆ Jaundice ( Hard and soft palate, palms of the hands) e. Selected variations: eg., acne,psoriasis, etc. ➔ Acne: Inflammatory papulopustular skin eruption, usually on face, neck, shoulders, and upper back ➔ Psoriasis: A chronic skin disease which results in sclary, often itchy areas in patches ➔ Alopecia: partial or complete loss of hair; baldness ➔ Eczema: Dermatitis (aka eczema) is inflammation of the skin, typically characterized by itchiness, redness, and a rash f. Normal integumentary findings ➔ Striae: silver or pink