Exam (elaborations)
NUR 216 Exam 2 Study Guide Exam Questions and Answers
- Course
- Institution
NUR 216 Exam 2 Study Guide Exam Questions and Answers
[Show more]
Content preview
NUR 216 Exam 2 Study Guide ExamQuestions and Answers
Assessment techniques for integumentary - -inspection and palpation
-Inspection and palpation in skin color: expected findings - --general
pigmentation even and consistent
-appropriate for each ethnicity: whitish pink for light or dark brown with
yellow or olive tones
-increased pigmentation if exposed to sun
-hyperpigmentation: birthmarks, sun damage, freckles, tan lines.
-HyPOpigmentation: scars, stretch marks, vitiligo.
-Inspection and palpation in skin color: unexpected findings - -pallor
erythema
cyanosis
juandice
-pallor - -loss of color
black skin tones are gray especially in mucous membranes.
Brown skin tones a change to yellow-brown.
pale skin tones a loss of redness undertones
best places to see are: conjunctivae, lips, buccal, and mucosa
Causes: Anemia, shock, lack of blood flow
-Erythema - -redness
hard to see on darker clients.
face, skin and pressure sore areas.
palpate skin for warmth and inflamed areas hard or tenderness
causes: inflammation/infection, vasodilation(dilation of blood vessels,
increases BP)
-Cyanosis - -light skin tones: bluish
palms and soles for darker skin tones.
brown skin tones change to a yellow.
black skin tones look grey.
best place to note in darker skin tones: mucous membranes and nail beds
Causes: hypoxia or impaired venous return
-Juandice - -yellowing of the skin
skin, sclera, mucosa membranes
causes: liver dysfunction/disease, RBC destruction
-temperature inspection for skin - -use dorsal of hand
,expected findings:
-skin is warm
-temperature is equal bilaterally
-moisture inspection for skin - -expected: dry
unexpected: diaphoretic (sweating heavily)
-texture inspection for skin - -expected: smooth
expected variations: acne, wrinkles, scars
unexpected: velvety skin (thyroid disease) roughness, dryness (xerosis),
flakiness (indicates dehydration)
-turgor inspection for skin - -dehydration or normal aging for a "tent"
clavicle location is ideal
-edema in skin - -accumulation of fluid in the tissue
-skin i shiny and taut
-most common in legs
-assess over a bony area
-assess in all areas arms, legs and abdomen.
+1 is trace 2mm rapid return
+2 is mild 4mm 10-15 second return
+3 is moderate 6mm prolonged return
+4 is severe 8mm prolonged return
double amount for mm amount
-vascular lesions - -results from blood leaking from blood vessels into the
dermis
-Petechiae: infection or trauma.
-Ecchymosis: trauma (collection of blood in dermis >3 mm in diameter, can
change colors during healing (lead).
-purpura: infection or bleeding disorder
-note the following for lesions - -color
height (above the skin)
shape
size (measured in cm)
-location and distribution on the body, if any exudate note the color and
odor. COCA (color, odor, consistency, amount)
-ABCDEs of melanoma - -A= asymmetry
B= border (irregular)
C= varies (brown, balck, tan)
D= diameter (usually >6mm)
E= evolving (looks different?)
, -flat lesions: macule - -freckles, mole, measles, scarlet fever
-flat lesions: patch - -birthmark, vitiligo, hormonal changes
-raised lesions: papule - -wart, elevated mole, skin tags
-raised lesions: plaque - -psoriasis, eczema
-raised solid lesions: - -tumor (neoplasm)
wheal (inspect bites, allergic reaction, hives
nodule(melanoma)
-raised, fluid lesions (vesicles) - -pustule (acne, cold sore)
cyst: cystic acne, sebaceous cyst
bulla: blister, medication reaction
-secondary lesions - -revolve from primary lesions and with time the
characteristics change:
-crust, scaling, ulcers
-pressure injuries/ulcers risk factors - -risk factors:
-elderly: thinning skin and less SQ fat
-excessive moisture (urinary issues or fecal)
-shearing and friction
-immobility
-obesity
-poor nutrition and hydration
-vascular disease (lack of circulation)
-sensory deficits
-edema
-chronic disease(DM, liver failure
-pressure points for injuries - -Supine:
back of head
shoulder
elbow
butt
heel
Side laying (lateral):
ear
shoulder
elbow
hip
thigh
leg
heel
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller Nursephil2023. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $12.49. You're not tied to anything after your purchase.
Can Stuvia be trusted?
4.6 stars on Google & Trustpilot (+1000 reviews)
81531 documents were sold in the last 30 days
Founded in 2010, the go-to place to buy study notes for 14 years now