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NUR 333 > E3 Integumentary System > Flashcards

E3 Integumentary System Flashcards

1
Q

What is the largest organ in the body?

A

Skin

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2
Q

What is the basal layer?

A

The innermost layer of the epidermis, continuously divides and proliferates.

Pushes old cells to surfacae to shed or slough off

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3
Q

What is the job of the Dermis?

A

Strength, Support, Protection

Contains capillaries, sweat glands, hair follicles, and nerve endings

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4
Q

What is the Primary purpose of the skin?

A

Protection & Sensory perception

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5
Q

A lesion is any

A

usual findings (wounds, rash, moles)

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6
Q

Turgor is a sign of

A

fluid status
(changes with age)

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7
Q

What does indurated mean?

A

hardness in the skin

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8
Q

Nonpitting vs Pitting Edema

A

Pitting- excess fluid build-up
Nonpitting- Usually injury related

Standing: legs, ankles, fett
Laying: really anywhere, even genitalia

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9
Q

What are good questions to ask for skin assessment?

A

Any changes? Color? Moisture? Texture?
History of skin issues?
Skin cancer risk factors
Is the swelling all the time or intermittent?
How much time do you spend in sun? Do you wear sunscreen?

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10
Q

Define Pallor & its Indications

A

Loss of color, in black skin tones can change to a grey color
-look particularly in mucous membranes
-Indication: Anemia (Low RBC), shock, lack of blood flow

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11
Q

Define Cyanosis & its indications

A

Bluish discoloration, in brown skin tones turn yellow-brown or grey
-Nail beds, lips, mucousa
-Indications: hypoxia, impaired venous return

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12
Q

Define Jaundice & Indications

A

Yellow discoloration
-Sclera, skin, mucous membrane
-Indication: liver dysfunction (RBC destruction)

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13
Q

Define Erythema & Indications

A

Redness, difficult to see in darker skin tones, palpate skin as well to look for warmth and texture changes
-Face, skin pressure prone areaas
-Indication: Inflammation, vasodilation, sun exposure, elevated temp
-Start of skin breakdown

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14
Q

Risk factors for impaired skin integrity

A

-Impaired sensory perception
-Impaired mobility
-Altered LOC
-Shear
-Friction
-Moisture

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15
Q

What types of pts are at risk for impaired sensory perception?

A

Spinal cord, injury
Anesthesia
Head Injury
Medications

They don’t notice skin is breaking down

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16
Q

What types of pts are at risk for impaired mobility?

A

Paralysis
Medications
Weakness

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17
Q

What types of patients are at risk for Altered LOC?

A

Anesthesia
Medications
Head injury

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18
Q

Define Shear

A

Stretch and damage capillaries: Ischemia
-Sliding movement of skin and subcutaneous tissue when muscle and bone are not moving (Dermal layers)

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19
Q

Define Friction

A

Two surfaces moving across one another (Outer layer)

20
Q

Define Moisture

A

Duration and amount of moisture determine risk
-Moisture softens skin making it more susceptible to damage
-Incontinence, wound drainage, diaphoretic

21
Q

What specific patients are at risk for impaired skin integrity?

A
  1. Older adults who have experienced a trauma =
  2. Spinal-cord injuries
  3. Nutritional deficits
  4. Those in long-term homes
  5. Acutely ill or those in hospice
  6. Individuals with diabetes
  7. Patients in ICU/critical care
  8. Incontinent
22
Q

Define pressure Injury

A

Describes impaired skin integrity relate to unrealized, prolonged pressure

23
Q

Define Localized injury

A

to area of prolonger pressure, can be related to a medical device (NC, Brace, cast, NG tube)

24
Q

Define ischemia

A

Pressure applied over a capillary (in the skin) exceeds normal capillary pressure

25
Q

What are the 3 major factors involved in pressure injury development?

A
  1. Pressure intensity
  2. Pressure duration
  3. Tissue tolerance
26
Q

What is pressure intensity?

A

How hard surface is that the skin is against

27
Q

What is pressure duration?

A

How long w/o repositioning

28
Q

What is Tissue intolerance?

A

Related to integrity of the tissue & supporting structures
-Low blood pressure, poor nutrition, aging, hydration status, all affect tolerance

29
Q

Define Deep Tissue Injury

A

Persistent non-blanchable deep red, maroon, or purple discoloration
-from intense prolonged pressure & shear forces at the bone/ muscle
-Can’t tell what layers are involved
-Deep tissue is NOT vascular or traumatic

30
Q

Define Unstageable pressure injury

A

Unable to tell stage of pressure injury due to it being obscured by infection or dying skin (Slough/eschar)

31
Q

Blanchable vs nonblanchable

A

Blanchable: turns lighter when pressed and then erythema returns (overcoming ischemia)

Nonblanchable: does not turn lighter in color when pressed; remains erythematous

32
Q

What is MASD?

A

Moisture associated skin damage
-incontinence related: r/t prolonged exposure to urine or stool

33
Q

Intertriginous dermatitis MASD?

A

inflammatory dermatitis r/t moist skin rubbing against each other (armpits, breast, fat folds, panace)
–> can crack and develop yeast

34
Q

Periwound/peristoma MASD

A

associated with wound or stomas and enzyme breakdown associated with the exudate
–> make sure to have a well fitting stoma appliance and keep skin dry around stoma

35
Q

Define wound

A

Disruption of the integrity and function of the tissuesA

36
Q

Acute wounds

A

-Proceeds through normal/timely repair process
-Results in return to normal/sustained function and anatomical integrity
-Ex. trauma/ surgical incision

36
Q

Chronic Wounds

A

-Wound that fails to proceed through normal healing process
-Does not return to normal function/ anatomical integrity
-Ex: Pressure ulcer, vascular insufficiency wound

37
Q

What are the factors that affect skin and wound healing?

A
  1. Nutrition
  2. Tissue perfusion
  3. Infection
  4. Age
38
Q

How does nutrition affect skin and wound healing?

A

-Deficiencies result in delayed healing
-Proteins, vitamin A, C, Zinc, & copper, are critical for wound healing
-Adequate calorie intake necessary
-Labs associated: serum albumin & prealbumin

39
Q

How does tissue profusion affect skin and wound healing?

A

-Ability to perfuse tissues with oxygenated blood crucial to wound healing
-Diabetes/ peripheral vascular disease are at risk for poor tissue perfusion

40
Q

How does infection affect skin and wound healing?

A

-Infection prolongs the inflammation and delays healing
-Indications that a wound is infected: purulent drainage, changes in color/volume/redness around the tissue, fever, or pain
-Low WBCs also can delay healing bc inability to fight

41
Q

How does age affect skin and wound healing?

A

-Aging affects all aspects of wound healing
-Delayed inflammatory responses, delayed collagen synthesis, and slower epithelization

42
Q

What does the braden risk assessment measure? What is the range

A

Lower score puts pts at higher risk for skin impairment

Range 6-23, Every shift is scored
<18 is staring risk

43
Q

What scale is used to determine skin integrity for critical care patients?

A

Jackson-Cubbin Scale

44
Q

What are interventions to prevent impaired skin integrity?

A
  1. Adequate nutrition
  2. Incontinence moisture management
  3. Positioning (Turn and mobilize)
45
Q

What should the HOB be elevated to to decrease friction and shear?

A

Less than 30 degrees if medically appropriate

NUR 333 (15 decks)

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