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NURS2518 : The Older Client > week 9 : tissue integrity > Flashcards

week 9 : tissue integrity Flashcards

1
Q

what concepts connect to tissue integrity?

A

nutrition
perfusion
gas exchange
elimination
thermoregulation
fluids and electrolytes
infection
pain
sensory perception
mobility

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2
Q

what is the major difference between young and old skin

A

subcut declines
fewer langerhans cells - related to immune response
thinner epidermis
flatter basement membrane
fewer melanocytes
diminished dermal blood supply

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3
Q

age related changes to the epidermis

A

thins - bruising increases
T cell function declines - increase risk for herpes and herpes simplex
Increase in skin renewal time and decrease in turnover of epidermal replacement - inflammatory response takes longer
Decrease in melanocytes and concentrated areas of melanocytes (lentigines and seborrheic keratoses)

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4
Q

age related changes to dermis

A

Dermis
◦ Thinner
◦ Provides a supportive layer of connective tissue made of collagen
◦ Collagen synthesis decreases
Decreased blood vessel
Skin temperature increases fragments
◦ Elastin thickens and
◦ Dermis supports hair follicles, sweat and sebaceous glands, nerve fibers, muscles and blood vessels

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5
Q

what are the age related changes related to hypodermis?

A

Fat distribution changes- layer of fat atrophies in some areas (hands, face, feet)
◦ Nails- slower growth, nails become thinner, fragile, brittle and more prone to splitting, more opaque
◦ Changes in hair colour- quality and distribution
◦ Reduced efficiency of sweat (eccrine) glands
◦ Reduction in sebaceous glands

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6
Q

what are some age related changes to hair and nails

A

determined by genetics
Most men lose hair (75% by age 70)
◦ Hair increases in men in the ears, nose and eybrows Women have decreased hair
◦ Women can lose hair in their lower legs that can be misinterpreted as peripheral vascular disease
Nails become more brittle, harder and thicker
Shape can change to become flat, or concave and vertical ridges can appear
Rate of nail growth decreased

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7
Q

Risk factors related to the individual:
cardiovascular problems - arterial/venous

A

arterial insufficiency
PAD (peripheral arterial disease)
risk factors: obesity, CAD smoking, HTN diabetes
* Increase risk related to slight trauma can cause arterial ulcer - between toes or tips of toes

venous insufficiency
risk factor: diabetes
edema in lower legs
explains brown color of lower legs
Skin tissue becomes vulnerable to trauma from minor assaults

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8
Q

what are some risk factors relate to ind: skin problems?

A

Xerosis
most common skin problem
more moisture escapes related to thinner epidermis
Causes: inadequate fluid intake, exposure to environment, nutritional deficiencies and smoking, drying soap, incontinence
Pruritus
Itchy skin can be a result of xerosis
Be alert for signs of infection
Causes: environmental, can be a sign of systemic disease
Herpes Zolster (shingles)
Rash occurs occurs along a nerve pathway (dermatone)
Clusters of papulovesclicles
Pain and tingling along nerve pathways
20% have Post herpatic neuralgia

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9
Q

risk factors related to ind: foot problems

A

Corns and Calluses

Bunions

Hammer toe

Fungal infection

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10
Q

what are corns and calluses?

A

◦ Growths of impacted skin that occur as a result of prolonged pressure
◦ People with diabetes, neurological impairment or poor circulation are at risk and need
considered treatment

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11
Q

what are bunions?

A

◦ Bony prominence
◦ heredity
◦ Walking can be compromised Foot problems
Hammer toe

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12
Q

what is a hammer toe?

A

◦ A toe that is permanently flexed
◦ Seen in conjunction with bunions

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13
Q

what is a fungal infection?

A

◦ Skin and nail can be affected
◦ Associated with degeneration of the nail plate
◦ Sides of the nail can dig into the skin like an ingrown toenail

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14
Q

what is the most common skin damage factor that can cause cancer?

A

THE SUN
risk of damage to the skin from the sun is higher with the older adult
* Preventable - sunscreen

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15
Q

what are some health risks related changes - individual risk factors that impact and environment?

A

photo aging
skin cancer
basal cell cancer
shamus cell cancer
malignant melanoma

decreased ability to manage environmental temperature variation
Decreased ability to stabilize fluids and electrolytes
Foot problems can cause impaired mobility

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16
Q

what are some interventions : education to reduce risk of impaired skin function

A

Maintaining Healthy Skin
* Thermoregulation/ electrolyte balance (keeping hydrated)
* Protection
* Inspection

Personal Care Practices
* Protection of epithelium of skin * Dryness, moisture
* Method of drying
* Protection of skin from injury * eg. falling
Preventing Sun Damage
* Protection – use at least SPF 15
Preventing injury from abrasive forces
* Protection of epithelium from shearing

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17
Q

what are some ways to reduce the risk of damage to skin?

A

Education on risk of photodamage and smoke damage
- sun protection

Education on observation of skin Recognize skin problems related to
change in moles
when in doubt, check it out

Cardiovascular disease (Peripheral artery disease and Venous insufficieny
Can lead to serious skin infections
* Mild dermatitis (inflammation of the skin), to ulceration and gangrene
* Prevent trauma to skin

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18
Q

what are some interventions to reduce risk in sin problems?

A

Xerosis
Keep skin hydrated
Treatment: treat dehydration and reduce environmental stressors (tepid bath rather than hot bath)
Environmental humidity at 60%
Use skin products that help retain moisture of the skin
Lubricants and oils, petroleum jells, zinc oxide (protects skin)
Pruritus
Reduce itching
Treat: rehydration of skin, cool compresses or baths with oatmeal, Epsom salts
Herpes Zolster
Prevention re: vaccines can prevent !Medical and Pain management
Antiviral medication and pain management Emotional support

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19
Q

Interventions to reduce risk for skin
integrity related to foot problems - assessment and care of toenails

A

assessment:
◦ Observation of gait
◦ Past medical history
◦ Assess feet

care of toenail:
Trim after bath
Nails trimmed straight across
Footcare of person with diabetes is done by a trained nurse or podiatrist
Diabetics should never have nails done at a commercial establishment
Ingrown toe nails require attention by a specialist
Footwear can improve symptoms of arthritis (firm soles may decrease pain associated with walking)

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20
Q

what are some intervention to reduce the risk related to foot problems?

A

Corns and Calluses
◦Oval corn pads, moleskins or lambswool, gelpads
◦Daily lubrication

Bunions
◦Medical management
◦Shoes that do not add pressure to the area

Hammer toe
◦ Non constricting footwear

Fungal infection
◦ Difficult to treat medically
◦ Keep feet try and hygiene

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21
Q

what is the definition of pressure injury?

A

“any lesion caused by unrelieved pressure that results in damage to underlying tissues. Pressure ulcers usually occur over a bony prominence and are staged to classify the degree of tissue damage observed”

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22
Q

how would you reduce the risk for pressure injury?

A

Identify risk
Monitor older adults who are at risk Prevention/Assessment – Nursing Interventions

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23
Q

select all that is true regarding the risk fo having pressure injury?
One of the top three safety concerns for the institutionalized patients
Preventable but remain prevalent in LTC settings
Associated with increased length of stay in hospitals
decreased mortality
Increased rate of bacteremia and multi- drug resistant organisms
Decreases social well being and quality of life
High treatment costs

A

everything true except increased mortality

24
Q

select all that it true: Risk factors for pressure injury

Frailty
Immobility and or neurologically impaired Acute illness
Weight loss
Poor nutrition (dehydration) Hypoproteinemia
Impaired sensory feedback system- Diabetes Moist skin
Sedated or unconscious
Ventilation requiring head of the bed elevation

A

true

25
Q

what are some of the bony prominences associated with the highest risk fo pressure injury

A

sacrum coccyx, knees heels and toes

26
Q

true or false: how to identify risk:
Assess for risk factors ple: Braden Scale
Close monitoring of skin
Initiate appropriate interventions (interprofessional collaboration) to prevent further skin breakdown and promote healing

A

true

27
Q

what do you recognize when monitoring skin conditions?

A

Observe and Assess- Skin condition
◦ Daily head to toe assessments of persons at risk focusing on bony prominences
◦ Hyperemia – redness (consider that this is more difficult to assess in darkly skinned people)
◦ Changes in temperature
◦ Assess existing pressure injuries with every
dressing change
◦ Assess pain and discomfort

28
Q

what are the different stages of dermal pressure ulcers?

A

stage I, Stage II, stage III stage IV and unstageable

29
Q

is this true regarding unstageable pressure ulcer?
Wound bed covered by necrotic tissue/ slough/eschar
Unable to accurately stage injury Depth unknown

A

yes

30
Q

what is a deep tissue pressure injury

A

A localized area of purple or maroon discoloured intact skin
A blood filled blister due to damage of underlying soft tissue from pressure &/or shear
An area which is painful, firm, mushy, boggy, warmer or cooler than adjacent tissue

31
Q

what are some Interventions to reduce risk for pressure injuries?

A

Occupational Therapist Physiotherapist
Dietician
Clinical Nurse Specialist

32
Q

true or false: effective interventions lead to:

Maintenance of intact and health skin
Absence of pressure injuries.
Reduce risk for skin cancer
Positive self esteem

A

true

33
Q

what is tissue intolerance?

A

Factors that impact the degree to which tissue is able to tolerate persistent pressure

34
Q

select all that is true regarding tissue intolerance:
Blood vessels are constricted by persistent pressure on the skin and underlying structures
Cellular respiration is impaired
Cells die from ischemia and anoxia
Variable between people and bodies
Inversely affected by moisture, friction, shearing, amount of pressure, age, nutritional status, anemia, and low arterial pressure

A

all true

35
Q

what are some clinical judgement steps that can be used to treat pressure injuries?

A

Recognize changes in the skin
Recognize risks for reduced skin integrity Intervention to treat pressure injury
Interventions to decrease risk
How do we know if what has been done is effective?

36
Q

what is the anatomy of the oral cavity?

A

oral cavity proper
oropharynx
nasal cavity
soft palate
hard palate
oral vestibule
lips
teeth
tongue
uvula

37
Q

true or false: oral health is more than good teeth

A

true

38
Q

select all that is true about the benefits of oral health
Oral health is associated with good quality of life for the older adult

Oral care reduces the risks of pneumonia, viral respiratory infections, acute respiratory distress syndrome, and sepsis

Good oral health contributes to bad nutritional status

May reduce the risk of post viral complications from COVID in older populations

Implementing oral care can reduce care worker’s burden

Missed oral care in the hospitalized older adult is associated with deconditioning: aspiration pneumonia, dysphagia, and sarcopenia

A

false; contributes to good nutritional status

39
Q

does good oral health lead to the ability to taste and enjoy food - ability to chew - ability to swallow - body image

A

true

40
Q

what is the scope of oral health?

A

oral health - mucous membranes, teeth, chewing

to

oral health - periodontitis

41
Q

select all that is true about the age related changes to the oral cavity:
Changes to the oral mucosa like other epithelial tissue but not exposed to radiation
Subject to trauma from mastication
Has a greater infectious burden
Loss of elastic fibers and thickening and disorganization of collagen in the connective tissue

A

all true

42
Q

select all that is true about the age related changes to the oral cavity:
Increase in function salivary glands primarily related to other pathological conditions and medications
(anticholinergic meds)

Decrease in blood vessels and nerves
Teeth have a decrease in enamel

Darker color of teeth

Healthy oral aging is associated with normal function and comfort Good oral health associated with healthy aging

A

first one is false your sucked

43
Q

what is gingivitis, periodontal disease and what are these examples of?

A

gingivitis - gums are swollen and red and may bleed

periodontal disease- increased severity of gum disease, infection and inflammation of the gum and bone that surround and support the teeth

examples of altered oral health

44
Q

what are some cues for altered oral health?

A

Tooth loss – edentulous
Bad breath
Painful chewing
Loss of teeth
Decreased enjoyment of food

45
Q

what are some individual risk factors to a decline in oral health?

A

health conditions: diabetes
functional decline: Older adult with moderate to severe impairment are at risk for reduced oral health
medications: over 500 meds cause dry mouth
mechanical ventilation and Oxygen therapy

46
Q

select all that is true regarding xerostomia: dry mouth
Increases the risk of oral plaque build up and is a problem common to older adults
Caused by decreased salivary flow
Presents as dry, red mucosa, fissured tongue, dry, cracked lips
Can result in build up of debris in mouth
Over 500 medications have this as an adverse medication affect

A

all true

47
Q

select all that is true regarding periodontitis: severe gum infection

Caused by bacterial dental plaque
Hardens into tartar the promotes bacterial infection
Build up results when there is poor oral hygiene

A

true

48
Q

what are some warning signs of bad oral health?

A

red swollen gums, loose teeth, sensitive teeth, teeth pulled away from gums

49
Q

what are some individual risk factors for poor oral health?

A

Smoking,
Poor oral hygiene
Stress
Malnutrition
Diabetes

50
Q

interventions to reduce risk fo oral health problems?

A

Regular oral exams
Teeth cleaning
Treatment of dental carries
Education on dental hygiene
Fluoride in water
No smoking programs
Access to good nutrition
Fluoride treatments

51
Q

what do you use to monitor in terms of oral health?

A

oral health assessment too (OHAT)
Lips
◦ Tongue
◦ Gums and Tissue
◦ Saliva
◦ Natural teeth
◦ Dentures
◦ Oral cleanliness
◦ Dental pain
◦ Dental examinations
◦ Family or guardian responses
◦ Oral health plan

52
Q

what can you use to assess oral cavity?

A

assess every 2 weeks
use flashlight
tongue depressor
Document, describe, report and report – lumps, red or white patches, red swollen gums, broken teeth, debris or food
Ability to perform oral hygiene
Impaired manual dexterity (OT may be helpful)

53
Q

what is the genera; care for gums and teeth?

A

Twice daily brushing – 2 minutes each time
* Twice a day flossing
* Electric better than regular
* Soft bristles to prevent oral mucousal injury
* Flouride should be a part of toothpaste
* Clean between teeth
* Use nonalchohol based mouthwash once a day
(Listerine)

54
Q

what is denture care?

A

Inflammation can result if dentures are not cared for Take out dentures over night
Use Denture toothpaste
Use soft toothbrush or denture brush Rinsed after every meal
Cleaned once a day
Cleansing of gums
Tongue scraping

55
Q

what are some interdisciplinary support for oral hygiene?

A

Dieticians
◦ Optimizing diet

Speech Language Therapy
◦ exercising perioral swallowing and speech muscles
◦ food/fluid staging and denture care

Occupational Therapist
◦ optimal position on bed or chair,
◦ use of feeding tools,

Dentists and dental hygienists
◦ Teeth cleaning and oral assessments

NURS2518 : The Older Client (13 decks)

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