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What are the 6 functions of skin?
- fluid balance
- temperature regulation
- vitamin D production
- immune response
What are 7 normal aging changes?
- Thinning of skin
- uneven pigmentation
- wrinkling, skin folds, and decreased elasticity
- dry skin
- diminished hair
- increased fragility and increased potential for injury
- reduced healing ability
What is a primary lesion?
Initial lesion, characteristic of disease itself
Describe all the stages of pressure ulcers (5)
- I Erythema, does not blanch with pressure, skin temp elevated
- II Skin breaks, abrasion, blister or shallow crater, edema persists, ulcer drains, partial-thickness wound
- III Ulcer extends into sc tissue, necrosis/drainage, full thickness
- IV Ulcer extends into underlying muscle and bone, deep pockets of infection develop, necrosis/drainage, full-thickness
- V DTI (deep tissue injury localized area discolored, purple, intact skin, or bloodfilled blister. d/t underlying soft tissue damage from pressure ulcer or shear. May evolve rapidly, & immediate
What changes occur that affect function with aging?
Mobility- changes in bone remodeling lead to decreased bone density, loss of muscle mass, deterioration of muscle fibers and cell membranes, leads to degeneration in the function and efficiency of joints
What can cause hyperpigmentation of the skin?
What diagnostic obtains tissue for microscopic exam
Cutaneous signs of patient with kaposi sarcoma, oral candidiasis and CD4 < 3 is an indicator of what systemic disease?
What increases the incidence of pruritus in elderly?
- systemic illness
- multiple medications
- occult malignancies
patient is instructed to avoid situations that cause vasodilation. What are some examples?
- Exposure to overly warm environment
- Ingestion of alcohol or hot foods and liquids
- Avoid activities that result in perspiration
- Maintain the room cool and humidified
- Avoid vigorous scratching
- Trim nails to prevent skin damage and infection
What is a common infectious bacterial dermatosis?
What is a common viral skin infection and how does it manifest?
Herpes zoster- shingles
Identify 8 benign skin tumors
- Neurofibromatosis : Von Recklinghausen's Disease
What are nursing diagnoses associated with skin disorders
- Impaired tissue integrity
- Deficient fluid volume and electrolyte losses
- risk for imbalanced body temp
- Acute pain
- deficient knowledge
What toxic severe form of erythema multiforme has a mortality rate of 30-35% triggered by reaction to medications?
TEN Toxic Epidermal Necrolysis
What nursing diagnosis are associated with TEN
- Impaired tissue integrity (oral, eye and skin) r/t epidermal shedding
- Deficient fluid volume and electrolye losses r/t loss of fluids from denuded skin
- Risk for imbalanced body temp (hypothermia) r/t heat loss
- Acute pain r/t denuded skin, oral lesions and possible infection
- Anxiety r/t physical appearance of the skin and prognosis
What is taught to patients to assess moles?
- B-Irregular border
- C- Variegated color
What is commony used to repair surgial defects from excisional skin, tumors, covering denuded skin (burns) and to cover wounds with insufficient skin to permit wound closure?
- Skin grafts
What is refractive errors?
- Impaired vision imparied from shortened or elongated eyeball that prevents light rays from focusing sharply on the retina
- Blurred vision occurs- corrected with glasses or contact lenses
What is the best visual acuity of 20/400 to no light perception
Coping with blindess involves what three types of adaptions?
What are risk factors for Glaucoma
- Family history of glaucoma
- Thin Cornea
- Afraican American Race
- Older age
- CV disease
- Migrane syndromes
- Nearsightness (myopia)
- Eye trauma
- Prolonged use of topical or systempic corticosteroids
What manifests an acute onset of redness, burning, (papillary formation, conjuctival irritation, injectionint he fornices) and discharge
How is a hearing loss assessed?
- social Withdrawl
- Indecision and procrastination
- False pride
- Lonliness and unhappiness
- Tendency to dominate the conversation
What are risk factors for acute otitis media?
- Age- Younger than 12 months
- Chronic URI
- medical conditions predisposing to ear infections (down syndrome, cystic fibrosis, cleft palate)
- Chroni exposure to secondhand smoke
What disease has an abnormal inner ear fluid balance caused by malabsorptioni n the endolymphatic sac or a blockage in the endolyphatic duct?
Most common surgical procedure for chronic otitis media?
- Purpose- to reestablish middle ear function, close perforation, prevent recurrent infection and improve hearing
What is labyrinthitis
- Inflammation of the inner ear
- Can be bacterial or viral in origin
- Bacterial-rare d/t antibiotic therapy
- Viral ism ost common dx, little known about this (affects hearing and balance)
Female reproductive system consists of external and internal pelvic structure, also included is the ____ and _____ of the endocrine system
hypothalamus and pituitary gland
Follicular phase- Ovum enlarges as type of cyst called ____ until it reaches the surface of the ovary where transport occurs
fatigue, low back pain, painful breases, and feeling of abd fullness. irritability, fear of losing control, binge eating and crying spells
Painful menstruation, occurs at time of menarche or shortly after. crampy pain begins before or shortly after onset of flow. Pelvic exam normal. Result from excessive production of prostaglandins, causing painful contraction of uterus and arteriolar vasospasm. secondary dysmennorrhea, pelvic path endometriosis, tumor, or PID
Absence of menstrual flow
young women older than 16y have not begun to mestruate with evidence of sexual maturation, or young women who have not begun to show development by 14y
Abscence for 3 cycles or 6 months after normal menarche. Caused by pregnancy, emotional upset, eating disorder or excessive exercise. (obesity, anorexia and bulimia can all affect this)
prolonged or excessive bleeding at time of reg. flow. Young women- endocrine disturbance- later in live inflammatory disturbances, tumors of uterus or hormonal imbalance.
Vaginal bleeding between reg menstrual periods- may be a sign of cancer, benign tumors of uterus, or other gynecologic problems
Bleeding 1 year after menses cease at menopause must be investigated. r/o malignant condition (assumed until proven otherwise)
Clinical manifestations of menopause
- Atrophy of breast tissue and genital organs
- Loss in bone density
- Vascular changes
Spontaneous abortion- miscarriage happens in 1 out of ever ____ conceptions
The number one cause of vision loss in people over the age of 60 is
AMD (macular degeneration) no cure.
Visual acuity of ___/___ is legal blindness
Loss of peripheral vision
Risk factors for blindess
- Diabetic retinopathy
- Macular degeneration
- Eye infection, inflammation, or injury
- Brain tumor
an ophthalmoscope is used to examine the back part of the eye (fundus), including the retina, optic disc, macula, and blood vessels
used to measure the intraocular pressure (normal is 10-21 mmHg) elevated with glaucoma, especially angle-closure glaucoma
Cataract risk factors
- Excessive sun exposure
- Chronic corticosteroid use
A nurse is collecting data for a client who has a detached retina of the left eye, what would the nurse expect to report?
Seeing dark spots
If a client has prebyopia, what visual deficit should the nurse expect the client to report
some possible causes of the client's reduced vision including cataracts, glaucoma, and terinopathy. presbyopia causes decreased vision during the 5th decade of life
A nurse if reinforcing teaching for a client who has just had a cataract removed from the right eye and an inteaocular lens implanted. What should the nurse include
- Wear sunglasses outside
- Do not engage in sexual intercourse until your provider has verified that your eye has healed
- Manage eye pain with acetaminophen
- Take a stool softener to prevent constipation
A nurse is caring for a client in an extended care facility who has macular degeneration. Which ADL will the client require the greatest amount of assistance?
Conductive hearing loss
Occurs when there is an alteration in the middle ear and sound waves are blocked before reaching the inner ear
Sensorineural hearing loss
occurs when there is an alteration in the inner ear that involves cranial nerve VIII and/or cochlear damage
Inner ear disorders
- Hearing loss
- Dizziness or vertigo
Objective data with inner ear disorders
- Poor balance
A nurse has been assigned to care for a client diagnosed with meniere's disease. Which precaution should the nurse inform the AP about prior to providing AM care
Observe the client for dizziness when ambulating
Paps should be given...
at age 21 or within 3 years of becoming sexually active, until age 30, if all negative, every 2-3 years
Atypical squamous cells of undetermined significance (considered mildly abnormal)
Atypical squamous cells of which high-grade squamous intrapithelial lesions cannot be excluded (indicates high risk of being precancerous)
low-grade squamous intrepithelial lesion (indicates mild abnormality that demonstrates early changes in shape and size of squamous cells)
high-grade squamous intraepithelial lesion (indicates a more sever abnormality in size and shape of cells that can progress to invasive cancer)
indicates the presence of precancerous cells in the glandular tissue
VDRL, and RPR tests are to check for
a protrusion of the posterior bladder through the posterior vaginal wall. it is caused by weakened pelvic muscles and/or structures
a protrusion of the anterior rectal wall through the posterior vaginal wall. It is called by a defect of the pelvic structures, a difficult delivery, or a forceps delivery
- Urinary frequency and/or urgency
- Stress incontinence
- Report of frequent UTI's
- Sense of vaginal fullness
S/S of rectocele
- Sensation of a mass in the vagina
- Pelvic pressure or pain
- Pain with intercourse
- Pain the back or pelvis
Cervical Cancer risk factors
- Early sexual activity (before 18)
- Client and/or male partner has had multiple sexual partners
- Male partner who had a female partner with cervical cancer
- Low economic status
- Family history of cervical cancer
- African American
- Chronic cervical inflammation/infections
- Infection with HPV, which is associated with 90% of cases
- history of STD's
- Infection with HIV or other immunosuppressive disorders
- Cigarette smoking
- Intrauterine exposure to diethylstilbestrol during pregnancy
s/s cervical cancer
- Painless vaginal bleeding between periods
- Water, blood-tinged vaginal discharge
- Unexplained weight loss
- Pelvic pain
- Pain during and after intercourse
Risk factors of endometrial cancer
- Over 55 years
- Unopposed estrogen hormone replacement therapy
- Use of tamoxifen to prevent breast cancer
- Late menopause
Risk factors for ovarian cancer
- over 40 years of age
- nulliparity or first pregnancy after 30 years
- Family history of ovarian, breast, or colon cancer
- History of dysmenorrhea or heavy bleeding
- High-fat diet (possible risk)
- Hormone replacement therapy
- Use of infertility medications
- Older adult clients following surgery for cancer
S/S of ovarian cancer
- Abdominal pain or swelling
- Abdominal discomfort (dyspepsia, ingigestion, gas, distention)
- Abdominal mass
- urinary frequency
What instructions should a nurse reinforce a client concerning kegal exercises for conservative management of a cystocele or rectocele?
- Perform exercises at least 4 times a day
- Hold the contraction for 6-10 seconds
- Perform exercises in, lying, sitting and standing positions
- Tighten pelvic muscles for a count of 10
A nurse is preparing to discharge a client who has had an anterior and posterior colporrhapy. What instructions should the nurse reinforce
Do not engage in intercourse for at least 6 weeks
oscillating mov't of the eyeball
blind areas in the visual field
Type I allergy response
Anaphylactic reaction characterized by vasodilation, increased capillary permeability, smooth muscle contraction, and eosinophilia. may include laryngeal stridor, angieoedema, hypotension, and bronchial, GI or uterine spasms, or hives. extrinsic asthma, allergic rhinitis, systemic anaphylaxis.
Type II allergy response
cytotoxic reaction, involves binding either IgG or IgM antibody to a cell-bound antigen, may lead to eventual cell and tissue damage. Examples- myasthenia gravis, goodpasture's syndrome, pernicious anemia, hemolytic disease of the newborn, transfusion reaction and thrombocytopenia.
Type III allergy response
Reaction is marked by acute inflammation resulting from formation and deposition of the immune complexes. The joints and kidneys are susceptible to this king of reaction which is assoc. with lupus, erythemotosus, serum sickness, nephritis, and RA. S/S urticartia, joint pain, fever, rash and adenopathy (swollen glands)
Type IV allergy response
A delayed, or cellular reaction occurs 1-3 days after exposure to an antigen, results in tissue damage, involves activity by lymphokines, macrophages and lysozymes. Erythema and itching are common. Contact dermatitis, graft-versus-host disease, hashimoto's thyroiditis, and sarcoidosis
Skin tests for allergic reaction
- Epicutaneous- scratch or prick test
the direct admin of the suspected allergen to the sensitive tissue, such as the conjuctiva, nasal or bronchial mucosa, or gastrointestanal tract (by ingestion) with observation
RAST is a radioimmunoassay that measures allergen specific IfE. A sample of the pt's serum is exposed to a variety of suspected allergen particle complexes. Values 2+ are considered significant.
prostatitis may be caused by
infectious agents (bacteria, fungi, mycoplasma, or other conditions, urethral stricture, benign prostatic hyperplasia. E. Coli is the most commonly isolate organism.
4 types of prostatitis
- actue bacterial prosatitis- type I
- chronic bacterial prostatitis- type II
- Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS)- type III
- asymptomatic inflammatory prostatitis -type IV
- Type III occurs in more than 90% of cases
sudden onset of fever, dysuria, perineal prostatic pain and severe lower urinary tract symptoms: dysuria, frequency, urgency, hesitancy and nocturia
How is hydrocele diagnosed
ultrasound- transillumination, hydrocele transmits light, hernias do not
condition in which the foreskin is constricted so that it cannot be retracted over the glans' can occur congenitally or from inflammation and edema
Assessment of testicular cancer
blood tests for AFP and beta-hCG. Inguinal orchiectomy is the standard way to establish the diagnosis of testicular cancer. Other staging tests to determine the extent of the disease in the retroperitoneum, pelvis, and chest include CT scans.
Nursing mgmt of testicular cancer
monitor pts response to poss. effects, of surgery, chemo, and radiation.
Testicular cancer teaching
patients may be required to endure a long course of therapy and will need encouragement. educate about the importance of adhering to follow up appointments. Quit smoking, limit alcohol, healthy diet, most couples should use birth control for 18-24 months after chemo
Erectile dysfunction-psychogenic causes- anxiety, fatigue, depression, pressure to perform, negative body image, absence of desire, privacy and trust and relationship issues, organic causes- CVD, endocrine disease (diabetes, pituitary tumors, testosterone deficiency, hyperthyroidism and hypothyroidism), cirrhosis, chronic renal failure, ....
benign prostatic hyperplasia (enlarged prostate) may lead to lower urinary tract symptoms, s/s frequency, urgency, nocturia, hesitancy in starting urination, decreased and intermittent force of stream and sensation of implete bladder emptying, abdominal straining with urination a decrease in volume of urine, recurrent UTI's
fatigue, anorexia, nausea, vomiting, and pelvic discomfort
Superficial spreading melanoma
occurs anywhere on the body and is the most common form of melanoma. usually on the trunk and lower extremities. Lesions tend to be circular, with irregular outer portions. may be flat or elevated and palaple
slowly evolving, pigmented lesion that occurs on exposed skin areas, especially the dorsum of the hand, the head and the neck
accounts for 1% of diagnosed breast cancer. Symptoms usually include scaly, erythematous, pruritic lesion of the nipple. Often represents ductal carcinoma in situ of the nipple but may have an invasive component. Prognosis favorable
Breast self exam should be performed_____
5-7 days after menses begin for premenopausal women and once monthly for postmenopausal women
Common fungal infection- ringworm
To obtain a speciman for diagnosis of ringworm (tinea)
the lesion is cleand and a scapel or glass slide is used to remove scales from the margin of the lesion
Contagious fungal infection of the hair shaft- common in children, oval, scaling, erythematous patches, brittle hair that breaks easily
body- begins with a red macule, which spreads to a ring of papules or vesicles with central clearing, found in clusters. Very pruritic- pets may be the source.
(groin, jock itch) begins w/ small, red scaling patches, which spread to form circular elevated plaques. Very pruritic, clusters of pustules may be seen around borders
athlete's foot- soles of one or both feet have scaling and mild rewdness with maceration in toe webs. More acute infections may have clusters of clear vesicles on dusky base
(toenails, affects about 50% of adults) nails thicken, crumble easily, lack of luster. Whole nail may be destroyed.
Secondary skin lesions-
Loss of superficial epidermis that does not extend to dermis; depressed, moist area, ruptured vesicles, scratch marks
Skin loss extending past epidermis; necrotic tissue loss, bleeding and scarring possible- stasis ulcer of venous insufficency, pressure ulcer
Linear crack in the skin that may extend to dermis- chapped lips or hands, athletes foot
Flakes secondary to desquamated, dead epithelium that may adhere to skin surface- color varies- dandruff, psoriasis, dry skin, pityriasis rosea
Dried residue of serum, blood, or pus on the skin surface, residue left after vesicle rupture- impetigo, herpes, eczema
hypertrophied scar tissue secondary to excessive collagen formation during healing
Thin, dry, dransparent appearance of epidermis, loss of surface markings
Thickening and roughening of the skin or accentuated skin marking that may be secondary to repeated rubbing, irritation or scratching- contact dermatitis
Infestation of the skin by an itch mite
swimmers ear- trauma to the skin and ear canal allowing infection, bacterial and fungal.
s/s otitis externa
fever, cellulitis, lumphadenopathy- discharge of a yellow or green and foul smelling. in fungal infections, hairlike black spores may be visible
Cranial nerve VIII
associated with sensory- hearing and equilibrium
misperception or illusion of motion of the person or the surroundings
an involuntary rhythmic movement of the eyes