1. Know basis skin assessement, including where to check for jaundice and cyanosis in patients from different race.

The basic physical assessment consist of: skin, nails, and hair. Skin: Evenly pigmented; no petechiae, purpura, lesions, or excoriations. Warm good skin turgor. Nails: Pink, oval, adhere to nail bed with 160 degree angle Hair: Shiny and full: amount and distribution appropiate for age and gender. No flaking of scalp, forehead, or pinna. Appropiate place to check for jaundice (yellowish skin-caused by liver, billiary problems) sclera, fingernails, palms of hands and oral mucosa in White Race. ***Dark people have a normal yellow of sclera and this is an expected finding*** Cyanosis: seen in patients with poor oxygen. Grayish blue tone, earlobes, lips, mucus membrane, palms and soles (whites). Ashen and gray color mostly seen in conjuctiva, mucous membranes and nail beds (Dark skinned).

2. Know changes in the skin for the elderly and when to refer. Table 23-1 Skin turgor should be assessed under the clavicle in the elderly, and the back of the hands in younger people. Decrease subcutaneous fat, muscle laxity, degeneration of elastic fibers, collagen stiffening. Decreased extracellular water, surface lipids, and sebaceous gland activity Decreased activity of apocrine and sebaceous glands Increased cappilary fragility and permeability Increased focal melanoma cytes in basal layer with pigment accumalation Diminshed blood supply Decreased proliferation capacity Decreased immunocompetence

3. Know health promotion to avoid sun damage. Sun exposure : long term exposure will cause changes in the dermis, resulting in prematire aging.

The Sun is most dangerous from 10 am to 2 pm Inform patients of the danger of using tanning booths( as dangerous as sun exposure) Sunscreen should be applied 20 TO 30 MIN before going outdoors, even in cloudy weather. The SPF value of all sunscreens decrease with time after application therefore should be reaaplied every 2 hours in a sufficient amount.

4. Know the health promotion for a patient with basal cell carcinoma. Basal Cell Carcinoma is a change in basal cells; no maturation or normal keratinization; continuing division of basal cells and formation of enlarging mass; related excessive sun exposure, genetic skin type, x-ray radiation, scars, and some type of nevi. Skin Self Examination: A- ASYMMETRY, B- BORDER IRREGULARITY, C- COLOR CHANGE, D- DIAMETER OF 6MM OR MORE, E- EVOLVING IN APPEARANCE ***Some basal cell carcinoma are pigemnted with curked borders and opaque appearnace and may be misinterpreted as a melanoma. A tissue biopsy is usually done to confirm the diagnosis. Usually surgically removed.

5. Know risk factors for malignant melanoma. Know the teaching for a patient using UVA therapy. Risk factors include chronic UV exposure without protection or overexposure to artificial light such as a tanning booth. Persons with fair skin and eyes have less melanin and thus less protection from the UV radiation.

6. Know the drugs that cause photosensitivity. Antidepressant (Amitriptyline) Antidysrhythmic (Amiodarone) Anitmicrobials ( Tetracycline, Sulfamethoxazole, Azithromycion, Ciprofloxacin.

7. Know Impetigo and the treatment for it. Impetigo is a group A-B hemolytic streptococci. Primary or secondary infectrion. Very contagious. Clinical presentation: vesiculopostular lesion that devlop thick honeycolored crust, surrounded by erythema, pruritic. Most commonly seen in face as primary infection. Patient should be placed on contact precautions (must wear gloves). Treatment: Systemic- Antiobiotics, PO Penicillin, IM Erythromycin. Local Treatment: warm saline, soap and water to remove crust, Bactroban.

8. Know candidiasis and treatment for it as well as patient teaching and who is at highest risk.

Infection caused by Candida Albicans also known as Moniliasis, higher risk HIV Infection, Chemotherapy, radiation, organ tarnsplantation. Clinical presnetation: mouth: cheesy plaque. vagina: vaginitis with red edematous, painful vaginal wallm white patches, pruritus,painful urination and intercourse. skin: diffuse papular erythematous rash with pinpoint satellite lesions around edges. Treatment: Antifungals ( Ketoconazole, Fluconazole) Sexual abstinence or use of a condom, and keep areas clean and dry.

9. Know ABCDE and what to do if abnormal. Individuals should consult their health care provider immediately if their moles or lesions show any signs of ABCDE. Skin Self Examination: A- ASYMMETRY, B- BORDER IRREGULARITY, C- COLOR CHANGE, D- DIAMETER OF 6MM OR MORE, E- EVOLVING IN APPEARANCE. Any sudden or progressive change or increase in the size, color, or shape of a mole should be evaluated.

10. Know what increased pigmentation in the skinfold are an indication of. ********** Hyperpigmentation, brownish, velvety lesions of acanthosis nigricans. This skin condition may occur in skin folds such as the axilla (armpit - pictured here), neck, and other areas. In adults, it may be associated with hormonal problems, internal malignancy, obesity, and drugs. 11. Know how to properly obtain a culture from a wound. Culture should be taken before the first dose of antibiotics are given. Cultures could be taken by needle aspiration, tissue culture, or swab technique. Physicians will obtain needle and tissue punch biopsy samples. As a nurse, you can obtain cultures using the swab technique. Concurrent swab specimen are obtained from wounds using wound exudates (taking sample before wound is cleaned), Z- techniques (rotating culture swab over the cleansed wound bed surface in 10-point Z-track fashion) and Levines technique (rotating a culture swab over the cleansed 1-cm area near the center of the wound using sufficient pressure to extract wound fluid from deep tissue layers) .

12. Know how an incision is supposed to look post op day 1. ******** You may notice

some soreness, tenderness, tingling, numbness, and itching around the incision. There may also be mild oozing and bruising, and a small lump may form. This is normal and no cause for concern.
13. Be familiar with shift to the left, what does it mean and what do you expect to be done .*****

-The shift to the left indicates that the patient probably has a bacterial infection, and the nurse will plan to obtain wound cultures and start

antibiotic therapy. Wet-to-dry dressing changes may be ordered based on the characteristics of the wound, but these will be started after the wound culture and initiation of antibiotic therapy. The nurse will continue to monitor the wound, but additional actions are needed as well.
14. Know dressing type for a red, yellow and black wound. Red Wounds- clean wound with NS. Transparent dressing like Tegaderm, Opsite. Cover with sterile dressing. Yellow Wounds- absorpotive dressings, work by drawing excess drainage from wound surface. After dressing is saturated discard and clean wound with NS. Hydrocolloid dressing should be applied to yellow wounds. (Dressing are good for up to 7 days unless leakage happens) Black Wounds- debridement of the noviable, eschar tissue.

15. Know stage ulcers. Stage I- Intact skin nonblanchable redness of a localized area usually over a bony prominence. (Area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue). Stage II- Partial-thickness loss of dermis manifesting as a shallow open ulcer with a redpink wound bed, without slough. May also manifest as an intact or open/ruptured serum-filled blister. (Manifest as shiny or dry, shallow ulcer without slough or bruising) Stage III- Full-thickness tissue Subcutaneous fat may be visible but bone, tendor, and musclesare not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. (Areas of significant adiposity can develop extremely deep stage III pressure ulcers. Bone/tendon is not visible or directly palpable. Stage IV- Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on osme parts of the wound bed. Often include undermining and tunneling. (Can extend into muscle and/or supporting strcutures making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable). Unstageable Ulcer- Full-thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of te wound, the true depth, and therefore stage, cannot be determined.

16. Be familiar on how to do wet to dry dressings.

Usally used when there is oozing from the skin. Oozing means presence of an infection and/or inflammation. Salt water or a prescribed solution is used on the skin by soaking or applying compresses to a larger area. Place the prescribed dressing materials into fresh solution and squeeze until no longer dripping; then apply it to the affected area, avoiding normal skin tissue. If the desired effect is drying, soaking or compresses are left in place for 20 min, three times daily for 2 to 3 days.

17. Know how to differienate which patient needs faster care by the RN. ****** 18. Know dehisence. Dehisence- seperation and disruption of previously joined wound edges. Usually occurs when a primary healing site bursts open. May be caused by: infection, weak granulation tissue, obesity, and pocket of fluid.

19. Know patient teaching if the patient is going for outpatient procedure. Because pateints are being discharged earlier after surgery and many have surgery as outpatients, it is important that the patient, the family, or both know how to care for the wound and perform dressing changes. Wound healing may not be complete for 4 to 6 weeks or longer. Adequate rest and good nutrition should be continued throughout this time. The patient should understand the signs and symptoms of infection. The patient should note changes in wound color and teh amount of drainage Health care provider should be notified of any signs of abnormal wound healing.

20. Know what St. John Worth does in relation to anesthesia. ******** - an increased risk of cardiovascular collapse and/or delayed emergence,

increases effects of sedation. St. Johns wort: prolong anesthetic agents.

22. Know operative consent, how to obtain it, and what to do if patient is not ready . MD MUST EXPLAIN THE PROCEDURE THE RN IS ONLY THERE AS A WITNESS WHEN SIGNING A CONSENT.

23. Know pre operative teaching. Provision of sensory, process, and procedural information. Instruction about deep breathing, coughing, and ambulating postoperatively. Information about pain management, including the use of some type of pain-rating scale. Understanding varying cultures, backgrounds and experience

Documentation of all teaching in chart

24. Know what to do if patient is NPO in reference to insulin. Serum or capillary glucose tests should be completed the morning of surgery to determine baseline levels. It is important to clarify with the patients surgeon or ACP whether the patient should take teh usual dose of insulin or oral hypoglycemia agents on the daay of surgery. ACP practitioner vary the usual insulin dose based on the patients currnet status and history of glucose control. Regardless, of the preoperative insulin orders, the patient glucose levels will be assessed periodically and managed, if necessary, with regular (short acting, rapid-onset) insulin.

25. Know why atropine (Istopatropine) is given before surgery. Atropine is an anticholinergic, it decreases oral and respiratory secretions

26. Know normal pulse rate, normal K, normal NA, normal HGB, normal HCT. Normal pulse rate 16-20 bpm Normal K 3.5- 5.0 mEq/ L Normal NA 135- 145 mEq/ L Normal HGB: Males 39% - 50% Females 35 %- 47% Normal HCT : Males 13.2-17.3 g/dL Female 11.7-15.5 g/dL 27. Know Actinic Keratosis. Also known as solar keratosis, consist of hyperkeratotic papules and plaques occuring on sun-exposed areas. Actinic keratoses are premalignant skin lesions that affect nearly all of the older white population. (Flat or elevated, dry, hyperkeratotic scaly papule; possibly flat, rough, or verrucous (wartlike). TX: Cryosurgery, chemical peeis, laser resurfacing, topical application pf 5-FU over entire area for 14-28 days or topical application of imiquimod (Aldara) for 16 weeks, photodynamic therapy followed by light irradiation; recurrence possible even with adequate treatment.

28. Know Cellulitis, causative agent, how to treat it, complications and nursing interventions. Cellulitis, is mostly seen in diabetic and cardiac patients. Its the inflammation of the subcutaneous tissue. Primary or secondary. Uuslally caused by Staphylococcus Aureus. Site appears to be hot, tender, erythematous and edematous area with diffuse borders, chills, malaise and fever (systemic symptoms) be careful in diabetic paients they can easliy develop osteomyelitis. TX: requires hospitilazation: sysytemic antiobiotic therapy (usually IV) progression to gangrene if left untreated. This is a red flag disease

and must be retaken very serious. 29. Know Herpes Zoster, everything. Shingles asscoiated with chicken pox. Activation of the varicella zoster virus , incidence increases with age; contagious to anyone who has not had varicella or who id immunocompromised (elderly, HIV, infants, cancer patients, organ transplant patients). Linear distribution along a dermatome, grouped vesicles and resembling ckicken pox. Unilateral- this is the hallmark. TX: Acyclovir within 72 hr of clincila presentation to prevent post hepatitic neuralgia ( COMPLICATION OF THIS DISEASE) There is a vaccine to prevent .

30. Know Tinea Pedis. Atheletes foot- Common in teenage boys. Interdigital scaling and maceration, scaly plantar surfaces sometimes with erythema and blistering. May be pruritic, possibly painful. TX: Topical antifungal cream, spray. Advise patient to keep area clean adn dry.

31. Know Psoriasis, everything. Autoimmune chronic dermatitis that involves excessively rapid turnover of epidermal cells, family predisposition, usually occur before age 40. (Not Contagious). Sharply demarcated silvery scaling plaques on reddish colored skin commonly on the scalp, elbow, knee, burning, and painful. TX: Goal is to reduce inflammation and suppress rapid turnover of epidermal cells. Topical Corticosteroids, UVB UVA rays, Methotrexate, Adalimumab.

32. Know macule, papule, plaque, wheal. Macule: Circumscribed, flat area with a change in skin color ( freckles, petechiae, measles, flat moles) Papule: Elevated, soild lesion (wart, elevated moles, lipoma, basal cell carcinoma). Plaque: Circumscribed, elevated, superficial, solid lesion. (Psoriasis, seborrheic and actinic keratoses). Wheal: Firm, edematous, irregular shaped area (insect bite, urticaria).

33. Now lichenification, telangiectasia. Lichenification is thickening of the skin with accentuated normal skin markings (repeated scratching, rubbing, and irritation usually due to pruritus or neurosis) Telangiectasia is visible dilated, superficial, cutaneous small blood vessels, commonly found on face and thighs (Aging, acne, sun exposure, alcohol, liver failure,

corticosteroids, radiation, certain systemic diseases, skin tumors.