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MedSurg Final Study Guide Question 1 - Review study guides for Exam I , II , and III Question 2 - Review the

Med/Surg I workbook (aka study guide) for male and female reproductive Question 3 - Review medications given for acne and side effects If I had to take a guess AND THIS IS ONLY MY PERSONAL GUESS, this question will look something like What is the priority assessment for a patient about to start taking Accutane for acne? and the answer will involve taking a pregnancy test because Accutane can cause serious damage to a fetus. That is just my guess and I will put all of the information on acne drugs here that I found in the book on pages 459 & 460 1. 2. 3. 4. Topical benzoyl peroxide (or other antimicrobials) No side effects listed Topical retinoids no side effects listed Systemic antibiotics no side effects listed Isotretinoin (Accutane) a. Can cause serious damage to fetus b. Should not donate blood while taking or for 1 month following treatment c. Contraindicated for women who are pregnant or who are intending to become pregnant while on the drug d. Linked to liver function test abnormalities e. Liver function, cholesterol, triglycerides, and depression should be monitored.

The first three are intended to suppress new lesions and to minimize scarring. Accutane is used for severe nodulocystic acne tp possible provide lasting remission.

Question 4 - Review skin condition in elderly p439 Table 23-1 on page 439 Changes in skin Decreased SQ fat, muscle laxity, degeneration of elastic fibers, collagen stiffening. Related findings in assessmentincreased wrinkling, sagging breasts and abdomen, redundant flesh around eyes, slowness of skin to flatten when pinched together (tenting) Decreased extracellular water, surface lipids, and sebaceous gland activity. Related findings in assessmentdry, flaking skin with possible sings of excoriation caused by scratching Decreased activity of apocrine and sebaceous glands. Assessment findingsdry skin with minimal to no perspiration, skin color uneven Increased capillary fragility and permeability. Assessment findingsevidence of bruising Increased focal melanocytes in basal layer with pigment accumulation. Assessment findingssolar lentigines on face and back of hands

Diminished blood supply. Assessment findingsdecrease in rosy appearance of skin and mucous membranes; skin is cool to touch; diminished awareness of pain; touch, temperature, and peripheral vibration Decreased proliferative capacity. Assessment findingsdiminished rate of wound healing Decreased immunocompetence. Assessment findingincrease in neoplasms Changes in hair Decreased melanin and melanocytes. Findinggray or white hair Decreased oil. Findingdry, coarse hair; scaly scalp Decreased density of hair. Findingthinning and loss of hair; loss of hair in outer half or outer third of eyebrow and back of legs Cumulative androgen effect; decreasing estrogen levels. Findingfacial hirsutism (ex. Older women with hairy chins); baldness Changes in nails Decreased peripheral blood supply. Findingthick, brittle nails with diminished growth Increased keratin. Findinglongitudinal ridging Decreased circulation. Findingprolonged return of blood to nails on blanching Rate of age-related skin changes influenced by: hereditary, a personal history of sun exposure, hygiene practices, nutrition, and general state of health Skin changes directly related to aging include: decreased turgor, thinning, dryness, wrinkling, vascular lesions, increased skin fragility, and benign neoplasms

Question 5 - How do you assess various lesions Before I get into the book stuff, here are the things she said in class that sounded like test clues regarding skin lesions: For dark-skinned patients, look at the palms and nailbeds (skin is lighter there) to assess color changes. The book states the most reliable areas in which to assess erythema, cyanosis, pallor, and jaundice are the areas of least pigmentation, such as the sclerae, conjunctivae, nail beds, lips, and buccal mucosa. There is a box on page 442 that reinforces this as well. turgor = a pinch on the back of the hand tenting = dehydration Nursing Diagnosis for the elderly = risk for injury related to skin tearing Vesicles are more clear-fluid filled, like chicken pox, while pustules are more like pimples. Wheals are like mosquito bites and are treated with benadryl. nystatin and myconazole are for treating yeast infections. herpes zoster (shingles) follows a nerve route through dermatomes so it will look streaky.

Besides that, assessing skin is a lot like assessing other areas of the body. Getting a complete medical history and list of medications is listed, and then keep the following in mind during the objective portion of the exam: private room w/ good lighting patient comfortable systematic approach, compare symmetrically general exam first, then focus on lesions use the metric system and appropriate terminology. If you find a lesion, record its color, size, distribution, location, and shape. Dont forget about the pneumonic ABCDEFG, which stands for asymmetry, borders, color,

diameter, evolving/elevated, firm, growing.

Question 6 - Understand skin infections and how to treat them. There was alot of information.. Tried to put the most important. I will ask her specifically what we need to know for this question and get back to everyone.. Bacterial Infections Occur when balance b/w the host and microorganisms is altered Can occur as primary infection following break in skin or can occur as secondary infection to already damaged skin (Staphylococcus aureus) Predisposing factors: moisture, obesity, atopic dermatitis, systemic corticosteroids and antibiotics, chronic disease (diabetes) Good hygiene and health inhibit, drainage is infectious Good skin hygiene and infection control practices needed to keep from spreading Treatment Table 24-4 (pg 454); most seem to need antibiotics and warm moist compresses Viral Infections Virus infects cell, skin lesion may develop Lesions can occur as result from inflammatory response to viral infections Most common Herpes simplex, herpes zoster, and warts Treatment (Table 24-5 (pg. 456)) Herpes: symptomatic medications, antiviral agents Verruca: removal (surgery, liwuid nitrogen, etc) Plantar Warts: topical immunotherapy, cryosurgery, duct tape, salicylic acid Fungal Infections Skin, hair and nails may become infected (candidiasis and tinea unguium) Appearance of microscopic hyphae (threadlike structures) indicates fungal infection Treatment (table 24-6 (pg 457)) Antifungal creams, oral antifungal Candidiasis Keep skin area clean and dry

Powder on nonmucosal surfaces to prevent recurrence

Question 7 - How do you obtain cultures for various infections? Blood: (pg 240) Collect blood culture samples before beginning antibiotic therapy. Where available, a phlebotomy team should draw the samples. Percutaneously drawn samples need skin preparation with adequate skin contact and drying time using alcohol or tincture of iodine or alcoholic chlorhexidine (10.5%) rather than povidone-iodine. Cervical, Vaginal, and Urethral: (pg. 1302) Specimens of vaginal, urethral, or cervical discharge are cultured to assess presence of gonorrhea or Chlamydia. Rectal and throat cultures may also be taken, depending on data obtained from sexual history. Skin: (pg. 446) Test identifies fungal, bacterial, and viral organisms. For fungi, scraping or swab of skin performed. For bacteria, material obtained from intact pustules, bullae, or abscesses. For viruses, vesicle/bulla and exudate taken from base of lesion. Stool: (pg. 916) Tests for the presence of bacteria including Clostridium difficile. Urine: (pg. 1114) Confirms suspected urinary tract infection and identifies causative organisms. Normall, bladder is sterile, but urethra contains bacteria and a few WBCs. Wound: (pg. 199) Concurrent swab specimens are obtained from wounds using (1) wound exudates, (2) Ztechnique, and (3) Levines technique. Wound exudate: samples visible wound exudates from the wound bed before cleansing. Z-technique: rotating a culture swab over the cleansed wound bed surface in a 10-point Z-track fashion. Levines technique: rotating a culture swab over a cleansed 1-cm2 area near the center of the wound using sufficient pressure to extract wound fluid from deep tissue layers.

Question 8 - Understand patient teaching related to skin biopsy Skin Biposy is found in Chapter 23, p. 445-446. (See table 23-9, biopsy for information) For the four different types of biopsy (punch, excisional, incisional, and shave), make sure that the patient understands the purpose of their test. Have them sign the consent form, explain about the necessity of proper site prep/cleaning (ie, prevent infection), type of anesthesia to

be used with the biopsy,what their particular biopsy entails (punch-takes a full thickness sking biopsy, excisional-skin will be closed with subcutaneous and skin sutures, incisional-wedge shaped incisions make into the lesion, typically used for very large specimens, and shavethe use of a single edged razor blade to shave off superficial lesions). Explain to them that how much they bleed during and post procedure will vary with the type of biopsy that they have. Explain the use of bandaging following the procedure (varies from a bandaid to pressure dressing, dependent upon the type of biopsy). Finally, the nurse will give the patient their specific postprocedure instructions. Question 9 - Review the table on lesions and characteristics Page 441, table 23-4 Primary lesions Macule -circumsicribed, flat area with a change in skin color -<0.5cm in diameter -if lesion, >0.5cm, it is a patch -Examples: -freckles, petechiae, measies, flat mole (nevus), caf au lait spot, vitiligo (complete depigmentation) Papule -elevated, solid lesion -<0.5cm in diameter -if lesion is >0.5cm in diameter, it is a nodule -Examples: -wart (verruca), elevated moles, lipoma, basal cell carcinoma Vesicle -circumscribed, superficial collection of serous fluid -<0.5cm in diameter -Examples: -varicella (chickenpox), herpes zoster (shingles), second-degree burn Plaque -circumscribed, elevated, superficial solid lesion ->0.5cm in diameter -Examples: -psoriasis, seborrheic and actinic keratosis Wheal -firm, edematous, irregularly shaped area -diameter variable -Examples: -insect bite, urticarial Pustule -elevated, superficial lesion filled with purulent fluid -Examples: -acne, impetigo

Page 442, table 23-5 Secondary lesions Fissure -linear crack or break from the epidermis to dermis -dry to moist -Examples -athletes foot, cracks at corner of mouth Scale -excess, dead epidermal cells produced by abnormal keratinization & shedding -Examples: -flaking of skin after a drug reaction or sunburn Scar -abnormal formation of connective tissue that replaces normal skin -Examples: -surgical incision, healed wound Ulcer -loss of the epidermis and extending into dermis -crater-like -irregular shape -Examples -pressure ulcer, chancre Atrophy -depression in skin resulting from thinning of the epidermis or dermis -Examples -aged skin, striae Excoriation -area in which the epidermis is missing, exposing the dermis -Examples: -abrasion, scratch

Question 10 - Look up lichenification and understand Lichenification is a thickening of skin as a result of the proliferation of keratocytes with accentuation of the normal markings of the skin. Lichenification is caused by chronic scratching or rubbing of the skin and is often associated with atopic dermatoses and pruritic conditions. Although any area of the body may be affected, the hands, the forearms, shins, and nape of the neck are common sites. Treatment of the cause of the itching is the key to prevent of lichenification. Excorations may be evident in the lichenfied skin as a result of persistent pruritus and scratching.

Question 11 - Know your burns the degrees Thermal Burns Caused by flame, flash, scald, or contact with hot objects Most common type of burn Chemical Burns Tissue injury or destruction from acids, alkalis, and organic compounds- chemicals (household cleaners, hydrochloric, oxalic and hydrofluoric acid), Alkalis (oven and drain cleaners, fertilizers, heavy industrial cleaners), phenols (chemical disinfectants, gasoline, creosote) Tissue destruction can last up to 72 hours Alkali burns are much most difficult to treat than acid burns due to not being neutralized by tissue fluids Alkalis cause protein synthesis and liquefaction Remove clothing as soon as possible Smoke and Inhalation Injury Inhalation of hot air or noxious chemicals cause damage to tissues in respiratory tract, can cause airway collapse Gases may be cooled to body temp before reach lung tissue Respiratory mucosa may have damage but seldom happens due to vocal cords and glottis, act as protective mechanism Redness and swelling occur when damage is present Smoke inhalation injuries are major predictor of mortality in burn patients 1. Carbon monoxide poisoning- cause of majority of deaths at fire scene CO displaces O2 on Hemoglobin molecule causing carboxyhemoglobinemia, hypoxia Death occurs at CO levels greater than 20% Skin is Cherry Red Treat with 100% O2 1. Inhalation injury above the glottis Upper airway injury-inhalation of hot air, steam or smoke Mucosal burns of oropharynx and larynx- redness, blistering, edema Mechanical obstruction may occur Clues that there is upper airway injury- presence of facial burns, singed nasal hair, hoarseness, painful swallowing, darkened oral and nasal membranes, carbonaceous sputum, history of being burning in an enclosed space and clothing burns around chest and neck 1. Inhalation injury below glottis Lower airway injury- usually due to chemicals Tissue damage related to duration of exposure to smoke or chemical Clinical manifestations- pulmonary edema (may not appear until 12-24 hours after burn) then show as acute respiratory distress syndrome (ARDS)-can drown Electrical Burns

Intense heat generated from an electric current Direct damage to nerves and vessels, causeing tissue anoxia and death Severity depends on voltage, tissue resistance, current pathways, surface area in contact with current, and length of time current flow was sustained Most damage is below the skin Patient is at risk for dysrhythmias or cardiac arrest, severe metabolic acidosis and myoglobinuria Can cause immediate cardiac standstill or ventricular fibrillation- delayed arrest may happen without warning during first 24 hours after injury

1st degree (Superficial) Superficial epidermal damage, tactile and pain sensation intact Clinical appearance- erythema, blanching on pressure, pain and mild swelling, no vesicles or blisters May be caused from superficial burn or quick heat flash 2nd degree (Deep) Epidermis and dermis involved to varying depths Epithelial regeneration still intact, remain viable Clinical appearance- fluid filled vesicles (red, shiny, wet), severe pain due to nerve injury, mild to moderate edema May be caused by flame, flash, scald, contact burns, chemical, tar, electric current 3rd and 4th degree All skin elements and local nerve endings destroyed Coagulation necrosis present Surgical intervention required for healing Clinical appearance- dry, waxy white, leathery, or hard skin; visible thrombosed vessels; insensitivity to pain; possible involvement of muscles, tendons, and bones

Question 12 - Understand what can happen to burn patient after the burn This one is pretty vague, so not sure exactly what shes going for but these are the highlights from lecture and the book Airway (this was emphasized repeatedly) airway may become occluded following burn, even it is open at one point, may not continue to be the case Shock fluid third spacing can lead to drop in bp, sending pt into hypovolemic shock (bp <90 systolic) emergent phase Edema fluid shifts (emergent phase) DVT immobility can lead to clots either Lovenox, SCDs or graduated compression stockings used Electrolyte imbalance from fluid shifts (emergent phase) then diuresis in acute phase. May

lead to LOC changes, cardiac issues (K+ imbalances) Infection skin is first line of defense, without it risk of infection increases significantly (acute phase) Contractures and scarring (rehab phase) positioning, exercise and splinting used to prevent, as well as grafts in extreme burns Emotional changes fear, anxiety, anger, guilt, depression may be experienced by burn patient. Communication with family, caregivers, and burn team is essential.

Question 13 - Be able to calculate per the Parkland formula Parkland Formula p. 483 Table 25-12 Formula - 4mL lactated Ringer's solution per kilogram (kg) of body weight per percent of total body surface area (%TBSA) burned = total fluid requirements for 1st 24 hours after burn 4 mL x weight in kg x % TBSA = total fluid requirements for 1st 24 hours Application 1/2 of total in first 8 hrs 1/4 of total second 8 hrs 1/4 of total third 8 hrs Example: 70 kg patient with 50% TBSA burn 4 mL x 70 kg x 50% TBSA = 14,000 mL in 24 hours 1st 8 hrs = 7000 mL 2nd 8 hrs = 3500 mL 3rd 8 hrs = 3500 mL For more examples see the discussions from the burn week (I think week 7), just make sure you actually figure the % TBSA, if it's not given.

Question 14 - How do you monitor that a patient is receiving enough fluid There was not a whole lot of information provided in the book or on the ppt slides for this, but this is the information I could find related to this Most accurate thing to do to monitor for efficient fluids is to watch for signs of hypovolemic shock (clinical manifestations found on p. 1721 Table 67-4)

o Decreased preload, stroke volume, and capillary refill o Increased respirations decreased respirations present in late hypovolemic shock o Decreased urine output o Pallor, cool and clammy intact skin o Decreased cerebral perfusion causes anxiety, confusion, and agitation o Absent bowel sounds o Decreased hemoglobin and hematocrit levels, increased specific gravity of urine, and changes in electrolytes o Decreased blood pressure, increased pulse Im guessing that another way to ensure they are receiving enough fluid is to monitor for signs of dehydration. Im not sure if the signs for a patient with just dehydration are equivalent to signs found in burn patients though. But just in case, the signs for dehydration are found on p. 309 Table 17-4. Some of them overlap with the signs of hypovolemic shock. o Restlessness, drowsiness, lethargy, confusion o Thirst, dry mucous membranes o Decreased skin turgor, decreased capillary refill o Postural hypotension, increased pulse, decreased cerebrovascular perfusion o Decreased urine output, concentrated urine o Increased respirations o Weakness, dizziness o Weight loss daily weights o Seizure, coma Question 15 - Understand nutrition and burns p 486 Once fluid replacement has been addressed, nutrition takes priority in the initial emergent phase. Early and aggressive nutritional support can mean the difference between life and death, optimize wound healing and minimize the negative effects of catabolism and hypermetabolism. Enteral feedings are necessary for patients who can not physically eat. Patients with large burns, more than 20% TBSA can develop a paralytic ileus within the first few hours of tube feeding because of the body's systemic response to major trauma. Checking bowel sounds is very important, at least every 8 hours. Failure to supply adequate calories and protein leads to malnutrition and delayed healing.

Question 16 - Care planning for burn patient An extensive table showing collaborative care is on page 482 but it contains a lot of information. For burn victims, their survival depends on rapid and thorough assessment. Many burn victims will also suffer respiratory dysfunctions due to the inhalation of hot air which can damage the lung tissue. Most of them will need to be intubated if the burn is severe. If it is just a burn localized to the leg, for example, this would not be necessary.

People suffering from burns will also have significant fluid loss that should be monitored. An IV access will obviously need to be started and cared for throughout the clients stay. If the patient has burns greater than 15% TBSA, at least two large-bored IV access routes must be obtained. They will need to be receiving large quantities of fluids and possibly blood and that is the reason for the two access points. To determine the TBSA, use the Parkland (Baxter) formula. Colloidal solutions such as albumin are normally given. Silver sulfadizine cream is put on gauze that is then applied to the burn. Once the patient is in a stable condition, the wound can begin to be cleaned. During debridement, necrotic skin is removed as well as any foreign materials that may have lodged within the skin during the accident. This is sometimes done on a cart shower (picture on page 484). Im assuming that the patient would be pumped full of pain medication before this process was done. When caring for a patient with severe burns, its important to remember that infection is the most serious threat to further tissue injury and possible sepsis. Signs and symptoms of infection need to be monitored for and reported immediately to the caregiver. Sometimes the patients burn wound will be left open and covered with antimicrobial cream but it can also be covered with dressing. This is a sterile process and the dressings will need to be changed anywhere from ever 12-24 hours to once every 14 days. It seems that the most popular form is using moist dressings. Remember to use your PPEs when cleaning a patients wound. Coverage is the primary goal for burn wounds. There is rarely enough unburned skin in the major burn patient for immediate skin grafting. Some parts of the body, such as the face, hands, eyes arms, and ears, need more attention and care if they are burned. Ears especially, should be kept free of pressure because they already have poor vascularization. Gauze can be tucked behind the ears. Try and keep the patients hands and arms elevated up on a pillow to reduce fluid loss and to minimize edema. Urine output should be closely monitored and routine lab tests should be run to monitor fluid and electrolyte balance. ABGs are drawn to determine adequacy of ventilation and perfusion in all patients with suspected or confirmed inhalation injury.

Question 17 - Care plan and positioning for patients with burns

Question #16 is about the care plan for a burn patient so Im not going to do it again, I will just do the various positions listed for burn patients. There are a few different positions listed in the book to use with burn patients depending on what you are trying to accomplish/treat. Burned limbs should be elevated above the level of the heart to decrease edema. This can be done by placing hands and arms on pillows or placing feet and legs in splints. When treating possible smoke inhalation without intubating the patient, patient should be placed in a high fowlers position (unless contraindicated). Patient with ear burns cannot use pillows due to pressure they place on the ears so the head can be elevated using a rolled towel placed under the shoulders. Patient with neck burns also cannot use a pillow so they can sleep with their head hanging slightly over the top of the mattress to encourage hyperextension. These are all I could find. If I forgot anything, please add!!

Question 18 - Assessment of circumstantial burns. Circumstantial Burns Not too sure what she is talking about here. Ill just emailed her for clarification, so if it changes Ill update the information. These are assessment findings for the following. P 477 479 Thermal Burns Partial thickness superficial Redness Pain Moderate to severe tenderness Minimal edema Blanching with pressure Partial thickness deep Moist blebs, blisters Mottled white, pink to cherry-red Hypersensitive to touch or air Moderate to severe pain Blanching with pressure Full-thickness (3rd and 4th degree_) Dry, leathery eschar Waxy white, dark brown, charred appearance Strong burn odor Impaired sensation when touched absence of pain with severe pain in surrounding tissues

Lack of blanching with pressure

Electrical Burns Leathery, white, or charred skin Burn odor Loss of consciousness Impaired touch sensation Minimal or absent pain Dysrhythmias Cardiac arrest Location of contact points Diminished peripheral circulation in injured extremity Thermal burns if clothing ignites Fractures or dislocations from force of current Head or neck injury if fall occurred Depth and extent of wound difficult to visualize, assume injury greater than what is seen Chemical Burns Burning Redness, swelling of injured tissue Degeneration of exposed tissue Discoloration of injured skin Localized pain Edema of surrounding tissue Tissue destruction may continue up to 72 hours Respiratory distress if chemical inhaled Decreased muscle coordination Paralysis So I just got back a message from her. She basically gave us an answer to the exam. She said it should have said circumference burn instead of circumstantial. The book says that sometimes burns can act as a tourniquet. You need to give probably fluids to correct it. about an hour ago Thus...the question "The patient does not have a pulse...the nurse plans to"....."administer IV fluids"