Expected skin color + temp findings - Correct Ans--color variation (scars, genetic, age,
sun damage, pregnancy)
-temperature (environmental or chronic perfusion issue)
Unexpected skin color +temp findings - Correct Ans--Color (pallor, cyanosis, jaundice,
erythema, ecchymosis, hematoma, petechiae)
-hypo or hyperthermia
Skin integrity expected - Correct Ans--scars
-good hygiene
-chart the beginning of any sores
Skin integrity unexpected - Correct Ans--Lesions; need investigation
-Primary lesions are the direct result of something (a burn)
-Secondary lesions occur when a primary is untreated
-Obtain subjective history of new changes
-ABCDE
-infestation
Pressure wound staging - Correct Ans-1. Nonblanchable; intact skin with redness
2. Partial loss on outermost layers; shiny
3.Full thickness loss through subQ
4.Full thickness loss with necrosis or damage to bone/muscle
-nurses cannot stage, and they cannot be staged if the bottom is not visible
Pressure wound care - Correct Ans--Advocate for pain control
-Administer pain meds before wound changes
Primary pressure wound interventions - Correct Ans--Turn every 2 hours
-Can be delegated after inspection
-Maintain diet and hygiene
hair unexpected findings - Correct Ans--hair loss; alopecia
-uneven distribution
nails expected findings - Correct Ans--symmetrical
-smooth
-color appropriate for ethnicity
, - <3s cap refill
nail unexpected findings - Correct Ans--broken/missing
-clubbing (hypoxia)
->3s cap refill
-loosely attached
-color not appropriate
-brittle/thick
expected skin changes with age - Correct Ans--consider psychological impacted of
visible changes
-sun exposure= skin cancer
-less elasticity- skin tears
-collagen fibers stiffen; less fatty acids in the epidermis
-decreased sebum= dryness
-uneven pigmentation
-slower hair + nail growth
-nail discoloration (yellowing)/ changes in thickness
- decreased SUBQ tissues (loss of warmth and cushioning)
-wrinkling from UV exposure
health promotion for skin - Correct Ans--hygiene
-wound care
-balanced diet (protein and vitamin D)
-address skin breakdown (acne, dryness)
-sun exposure (avoid 10-)
-monthly self-checks
-1-2 years derm vists
lateral flexion - Correct Ans-
neck rotation - Correct Ans-
Shoulder Abduction - Correct Ans-
shoulder adduction - Correct Ans-
shoulder flexion - Correct Ans-
shoulder hyperextension - Correct Ans-
finger extension - Correct Ans-
finger adduction - Correct Ans-
finger abduction - Correct Ans-
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