E3 Integumentary System Flashcards
What is the largest organ in the body?
Skin
What is the basal layer?
The innermost layer of the epidermis, continuously divides and proliferates.
Pushes old cells to surfacae to shed or slough off
What is the job of the Dermis?
Strength, Support, Protection
Contains capillaries, sweat glands, hair follicles, and nerve endings
What is the Primary purpose of the skin?
Protection & Sensory perception
A lesion is any
usual findings (wounds, rash, moles)
Turgor is a sign of
fluid status
(changes with age)
What does indurated mean?
hardness in the skin
Nonpitting vs Pitting Edema
Pitting- excess fluid build-up
Nonpitting- Usually injury related
Standing: legs, ankles, fett
Laying: really anywhere, even genitalia
What are good questions to ask for skin assessment?
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?
Define Pallor & its Indications
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
Define Cyanosis & its indications
Bluish discoloration, in brown skin tones turn yellow-brown or grey
-Nail beds, lips, mucousa
-Indications: hypoxia, impaired venous return
Define Jaundice & Indications
Yellow discoloration
-Sclera, skin, mucous membrane
-Indication: liver dysfunction (RBC destruction)
Define Erythema & Indications
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
Risk factors for impaired skin integrity
-Impaired sensory perception
-Impaired mobility
-Altered LOC
-Shear
-Friction
-Moisture
What types of pts are at risk for impaired sensory perception?
Spinal cord, injury
Anesthesia
Head Injury
Medications
They don’t notice skin is breaking down
What types of pts are at risk for impaired mobility?
Paralysis
Medications
Weakness
What types of patients are at risk for Altered LOC?
Anesthesia
Medications
Head injury
Define Shear
Stretch and damage capillaries: Ischemia
-Sliding movement of skin and subcutaneous tissue when muscle and bone are not moving (Dermal layers)
Define Friction
Two surfaces moving across one another (Outer layer)
Define Moisture
Duration and amount of moisture determine risk
-Moisture softens skin making it more susceptible to damage
-Incontinence, wound drainage, diaphoretic
What specific patients are at risk for impaired skin integrity?
- Older adults who have experienced a trauma =
- Spinal-cord injuries
- Nutritional deficits
- Those in long-term homes
- Acutely ill or those in hospice
- Individuals with diabetes
- Patients in ICU/critical care
- Incontinent
Define pressure Injury
Describes impaired skin integrity relate to unrealized, prolonged pressure
Define Localized injury
to area of prolonger pressure, can be related to a medical device (NC, Brace, cast, NG tube)
Define ischemia
Pressure applied over a capillary (in the skin) exceeds normal capillary pressure
