care of patient with integumentary & musculoskeletal disorders
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care of patient with integumentary & musculoskeletal disorders - Marcador
care of patient with integumentary & musculoskeletal disorders - Detalles
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Pruritus | The symptoms of itching, tingling, or burning |
Vesicle | Circumscribed elevation of the skin filled with serious fluid; smaller than 0.5 cm at the corner of the mouth, on the lips, or on the nose |
Exudate | Fluid, cells, or other substances that have been slowly exuded, or discharged, from cells or blood vessels through small pores or breaks in cell membranes |
Excoriation | Injury to the surface layer of the skin caused by scratching or abrasion |
Macules | Small flat blemishes flush with the skin surface |
Pustulant vesicles | Small, circumscribed elevations of the skin that contain pus |
Suppuration | Production of purulent material |
Papules | Small, raised, solid skin lesions less than 1 cm in diameter |
Urticaria | The presence of wheals or hives in an allergic reaction, commonly used by drugs, food, insect bites, inhalants, emotional stress, or exposure to heat or cold |
Wheals | Round elevation of the skin; white in the center with a pale red periphery |
Pediculosis | Lice infestation |
Keloid | An overgrowth of collagenous scar tissue at the site of the skin wound |
Verruca | Is a benign, viral, warty like skin lesion with a rough, papillomatous (nipple like) growth pattern |
Nevi | (singular, nevus) or moles, are pigmented, congenital skin blemishes that are usually benign but may become cancerous |
Alopecia | The loss of hair |
Contractures | Shortening or tension of muscles that affects extension |
Curling's ulcer | A duodenal ulcer that develops 8 to 14 days after severe burns on the surface of the body; the first sign is usually vomiting of bright red blood |
Rule of nine | Determines the TBSA burned; divides the body into multiples of nine |
Eschar | Black, leathery, crust (i.e. a slough) that the body forms over burned tissue; eschar can harbor microorganisms and cause infection |
Debridement | Removal of damaged tissue and cellular debris from a wound or burn to prevent infection and to promote healing |
Autograft | Surgical transplantation of any tissue from one part of the body to another location in some patients |
Homograft (allograft) | The transfer of two tissues between tow genetically dissimilar individuals of the same species, such as the skin transplant from another person who is not an identical twin ( often a cadaver) |
Heterograft (xenograft) | Tissue is from another species, such as a pig or cow used as a temporary graft |
Arthrocentesis | Is the puncture of a pt joint with a needle and the withdrawal of synovial fluid for diagnostic purposes |
Ankylosis | The accompanying fixation of the joint |
Tophi | Calculi containing sodium rate deposits that develop in periarticular fibrous tissue, typically in its with gout |
Sequestrum | A fragment of necrotic bone that is partially or entirely detached from the surrounding or adjacent healthy bone |
Fibromyalgia | Is a chronic syndrome or unknown origin that causes pain in the muscle, bones or joints |
Arthrodesis | Surgical fusion of a joint; it can be performed when severe joint destruction has occurred |
Arthroplasty | Total joint replacement; repair or refashioning of one or both sides, parts, or specific tissue within a joint ; often is required on the elbow, knee, or shoulder joint to restore or increase mobility |
Bipolar hip replacement (hemiarthroplasty) | Prosthetic implant used to replace the femoral head and the neck in hip fractures when the vascular supply to the femoral head is or may become compromised |
Colles fracture | Fractures of the distal portion of the radius within 1 inch of the wrist joint; commonly occurs when a person attempts to break a fall by putting the hands down |
Open reduction with internal fixation (ORIF) | A surgical procedure allowing fracture alignment under direct visualization while using various internal fixation devices applied to the bone |
Crepitus | Sound that resembles the crackling noise heard when rubbing hair between the fingers or throwing salt on an open fire. it is associated with gas gangrene, the rubbing of bone fragments, or the crackles of a consolidated area of lung in pneumonia |
Compartment syndrome | Is a pathologic condition caused by the progressive development of arterial vessels compression and reduced blood supply to one of the body's compartments, typically in an extremity |
Volkmann's contracture | Is a permanent contracture( with clawhand, flexion of wrist and fingers, and atrophy of the forearm |
Paresthesia | Numbness or tingling |
Blanching test | Meaning to whiten or pale, is a test of the rate of capillary refills, which is a signal of circulation; aka capillary nail refill test |
Scoliosis | Curvature of the spine |
Kyphosis | A rounding of the thoracic spine ( hump-backed appearance) |
Lordosis | An increase in the curve at the lumbar space region that throws the shoulders back, resulting in a sway-backed gait |
What is hair loss | Alopecia |
What is the function of melanin | Another skin protein, it forms a protective shield that guards the keratinocytes and nerve ending from ultraviolet light |
What are the epidermis cells of the skin | Stratum germinativum, stratum corneum, melanocytes |
What is the definition of a keloid | An overgrowth of collagenous scar tissue at the site of a skin wound; the collagen tissues become raised, hard and shiny; the keloid can be red, pink or flesh color |
What does sebum do | Lubricates the skin and hair that covers the body; also inhibits bacterial growth |
What should you teach a pt with type two herpes | It may still be transmitted by viral shedding even during periods of remission; frank discussion concerning safe sexual practices, including condoms, are indicated |
What is the antibiotic for Herpes Zoster | Acyclovir, orally & IV; ideally within 72 hr of development of symptom; reduces pain and duration of the virus |
If a staff member gets the symptoms of shingles, what should you do? | Any staff who has symptoms consistent with herpes zoster should be removed from active duty; health care staff who have not received 2 doses of varicella vaccine may be contagious for 8-12 days and should be moved to another duty location away from patients |
What should you do if a pt has impetigo? | Highly contagious; interventions are aimed at the disrupting the course of the disease and preventing the spread of infection; penicillin is one of most common antibiotics; the lesions are soaked with antiseptic solution, and the dried exudates is removed with a special instrument |
When you see a spiral fracture on an x-ray its usually associated with what type of force? | Break or coil around the bone, sometimes called a torsion fracture and results from a twisting force |
Trauma severe enough to fracture the pelvis can also be injury to what | Vital abdominal organs, such as the bladder, vagina, uterus, liver, spleen, intestines may also be damaged; |
Because the pelvis has a rich blood supply, a fracture can result in | Extensive blood loss; as much as 1-4 liters |
If a pt has shingles what should you do when giving meds | Contact precaution and airborne precautions |
In PQRST what does the "S" stand for | Severity of the signs and symptoms |
What is accutane used for and what should you tell the pt | It reduces the sebum production and abnormal keratinization of gland ducts; women of child bearing age should receive counseling about the need for reliable methods of contraception with medication; adverse reaction is destructive effect on fetal development, depression |
What is phantom pain | A pain felt in the area of the missing extremity as if it were still present. Phantom pain occurs because the nerve tracts that register pain in the amputated area continue to send the message to the brain; this is normal |
When do you give Fosamax | First thing in the morning, with 6-8 oz of plain water, 30 minutes before other meds, beverages or food |
What is systemic lupus | Is an autoimmune disorder characterized by inflammation of almost any body part. It is a chronic, multisystem inflammatory disorder that occurs when the body produces antibodies against its own cells. |
Risk factors for fat embolism | Long bone and pelvic fractures, crush injuries, and hip replacement surgery; it can occur within 48 hours of the injuries |
What is the function of the skin | Aids excretion of waste products; has nerve ending tht provide sensory info r/t pain, heat&cold, touch, pressure, vibration; insulates body and protect from trauma through subq layer of fat; prevent dehydration; protect from pathogenic organisms & foreign substances; natural barrier against infections; regulate temp; synthesizes vitamin D |
What is a butterfly rash | It occurs over the nose and cheek and along the eyelid area in 10-50% of pt with acute cutaneous lupus erythematosus |
Define macule | Is a flat, circumscribed area that is changed in color; <1 cm in diameter. Example: freckles, flat moles (nevi), petechiae, measles, scarlet fever |
Define papule | Is an elevated, firm, circumscribed area; <1 cm in diameter. Examples: warts (verrucae), elevated moles, lichen planus. |
Define wheal | Is an elevated, irregularly shaped area of cutaneous edema; solid, transient; variable diameter. Example: insect bites, urticaria, allergic reaction |
Define pustule | Elevate, superficial lesion; similar to a vesicle but filled with purulent fluid; example: impetigo, acne |
Define keloid | Is an irregular shaped, elevated, progressively enlarging scar; grows beyond the boundaries of the wound; caused by excessive collagen formation during healing. Example: keloid formation after surgery. |
Define excoriation | Is loss of epidermis; linear hollowed-out crusted area. Example: abrasion or scratch, scabies. |
Define fissure | Linear crack or break from the epidermis; may be moist or dry; examples: athletes foot, cracks at the corner of the mouth |
Define ulcer | Is loss of epidermis and dermis; concave; varies in size. Example: pressure sores, stasis ulcer. |
Define atrophy | Atrophy is thinning of skin surface and loss of skin markings; skin translucent and paper-like. Examples: striae; aged skin |
What is the deadliest cancer | Malignant cancer |
What is the major function of the skin | The body's protector, first line of defense against infection and injury protecting the internal organs |
What should be the goal for a pt that has lupus | Relief of symptoms, remission of the disease, early alleviation of exacerbations, and prevention of untoward complications |
A pt is getting an MRI ( magnetic resonance imaging) what do they need to remove | All metals, such as jewelry, clothing w/ metal fasteners, glasses, hair clips, and pt w/ metal prostheses such as heart valves, orthopedic screws, or cardiac pacemakers may not be allowed to undergo MRI, depending on the type of metal used |
What metal are safe during an MRI | Titanium is typically safe |
Why would a person who have been involved in an explosion, such as military personnel, be excluded from getting an MRI | Due to metal shrapnel embedded in the body |
A sensation of cold or fear causes these muscles to contract making the hair stand up right in dimpling in the skin around it is known as what | Piloerection is the correct term but, commonly know as "goosebumps" or "gooseflesh" |
Define melanocytes | The cells give rise to the pigment melanin, a black or dark brown pigment occurring naturally in the hair, the skin, and the iris and choroid of the eye |
Stage 1 pressure injury is | A localized area of the skin, typically over a bony prominence, that is intact with nonblanchable redness |
Stage 2 pressure injury is | Involves partial thickness loss of epidermis, it appears as a shallow open injury, usually shiny or dry with a red-pink wound bed w/out slough or brusing |
Stage 3 pressure injury is | Involves full thickness tissue loss, subcutaneous fat is sometimes visible, but bone, tendon, and muscle are not exposed |
Stage 4 pressure injury is | Involves full thickness tissue loss with exposed bone, tendon, cartilage or muscle |
Unstageable pressure injury is | Involves full thickness tissue loss, a wound base covered by slough ( yellow, tan, gray, green, brown) and eschar in the wound bed that is usually tan, brown or black |
Herpes type 1(HSV-1) | Causes cold sores, often referred to as fever blisters, usually associated with febrile conditions; the infection is generally self limiting, it usually clears up by itself requiring no treatment |
HSV-1 is characterized by what | A vesicle commonly know as a cold sore, usually erythematous and edematous ( red and swollen), it produces a burning pain when the vesicle ruptures; usually occurs after an acute illness or infection |
A person who has previously had what virus will also get shingles | Chickenpox; the varicella virus lies dormant until the persons resistance to the infection becomes lowered |
Risk factors for shingles include | Suppressed immunity, aging, infection and stress |
What does the shingle virus cause | An inflammation of the spinal ganglia and produces skin lesions of small vesicles along the peripheral nerve fibers of the spinal ganglia |
Define cellulitus | Occurs when bacteria enters the body through a break in the skin, such as a cut, scratch, or insect bite that is not cleansed with soap and water; infection is usually superficial, but may spread & become life threading as the infection invades deeper tissues, lymph nodes and blood stream |
Define impetigo | A highly contagious inflammatory disorder, more common in younger children but can affect any age; lesions start as macules & develop into pustulant vesicles and then rupture and from dried exudate |
Nursing interventions for impetigo | Are aimed at disrupting the course of the disease and preventing the spread of infection |
How do you stop the disease from progressing with impetigo | Antibiotics are used to arrest the disease process, systemic parenteral penicillin is one of the most commonly used antibiotics |
How are the lesions removed from impetigo | Soaked with an antiseptic solution, and the dried exudate is removed with a special instrument |
What is lice (pediculosis) | A parasitic disorder of the skin |
How is pediculosis transmitted | It can occur anywhere, lice are transmitted by close contact with infected individuals or their personal items such as hats, clothing and grooming items |
What do lice do once they find a host | Seek blood, they can only live 1-2 days without blood source; they leave their eggs (nits) on the skin surface attached to hair shaft |
Clinical manifestation of lice | Nits or lice can be seen on the body, pinpointing, raised red macule, pinpoint hemorrhages, and severe pruritus confirm the diagnosis |
After the lice-killing shampoo and rinse are used, the lice & nits will not simply fall off; they must be picked with a nit comb. What about the peptides agents in the shampoo do you need to know | They cannot be used under the age of 2 yrs or pregnant women |