What is erythema? Redness of the skin May be more difficult to see in darker skinned patients
When does erythema occur? Can be caused by multiple factors; Pressure Infection Vascular disease A sign of early healing in some cases
What might indicate erythema? Skin & close inspection/assessment wil...
NUR 514 Exam 2 Questions and
Complete Solutions
What is erythema? ✅Redness of the skin
May be more difficult to see in darker skinned patients
When does erythema occur? ✅Can be caused by multiple factors;
Pressure
Infection
Vascular disease
A sign of early healing in some cases
What might indicate erythema? ✅Skin & close inspection/assessment will better help
determine the cause of the tissue
What is acanthosis nigricans? When does it occur and where would you see it?
✅Acanthosis occurs in the body folds and creases such as the neck, groin, and axilla.
It is the velvety darkening of the skin.
This suggest diabetes mellitus
What is jaundice? ✅A yellow coloring of the skin or eyes, ranging in hues from pale
yellow to a pumpkin color.
Why does jaundice occur? ✅Occurs particularly in the sclera, oral mucosa, palms, and
soles
In darker skinned patients if is best to check the sclera or then gums to notice jaundice
What is cyanosis? ✅Blue-tinged coloring of the skin, may also appear dull and lifeless
in darker skin
Why does cyanosis occur and where will you see it? ✅Coloring is especially noticeable
in the perioral, nail bed, and conjunctival areas.
Results from poor circulation or inadequate oxygenation
What is pallor? ✅Is the loss of color (pale in color)
Why does pallor occur? ✅Could be seen in arterial insufficiency, decreased blood
supply and anemia.
Where do you see pallor? ✅-Could be noticeable when a patient pulls down their
eyelids and it remains colorless.
-Patient hand could also be pallor in color, lacking pink in the skin
, -May be harder to see in very light skinned patients
-often patient can look pale or grayish
What are some interventions nurses use to prevent pressure injuries? ✅-keep skin
clear and dry
-investigate and manage incontinence
-do not vigorously rub patient skin
-turning patients every 2 hours who need an assist
-using pillows in bony prominences to help prevent pressure injuries
-use transfer aids to reduce friction and shear
Write an nursing diagnosis-actual, related to the skin ✅Skin integrity impaired related
to open wound on left heel as evidenced by stage 2 pressure ulcer measuring 6cm in
diameter
Write a risk for diagnosis related to the skin ✅Risk for skin integrity impairment related
to poor nutrition, incontinence and immobility
What does the PUSH test assess for? ✅Measure pressure unloved healing, using
length and width, exudate amount, and tissue type
0-closed/resurfaced
1-epithelial tissue
2-granulation tissue
3-slough
4-necrotic tissue/eschar
What does the Braden scale assess for? ✅It is meant to predict a person's risk for
pressure sores using sensory perception, moisture, activity level, mobility, nutrition, and
friction/ shear each on a scale of 1-4
What do you do to test for skin mobility and hydration? What is an abnormal result? ✅-
To test for mobility you pinch the skin over the clavicle and look for quick recoil.
-easily pinched skin has a high degree of mobility
- skin that does not recoil immediately signals dehydration
-less than 2 seconds is moderate, more than 2 severe, and greater than 3 seconds
recoil is called tenting and is serious dehydration
Is skin of an elderly patient more dry or moist? Why? ✅Skin tend to dry as we age
related to the decrease in functioning sebaceous glands that secrete oils that moisturize
the skin
If you suspect a skin fungus, what test would you do to confirm? ✅If you suspect a
fungus, you would shine a wood light (UV light filtered through a special glass) on the
lesion.
-blue-green fluorescence would indicate a fungal infection
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 twishfrancis. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $9.99. You're not tied to anything after your purchase.
