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EXAM 2 - INTRO TO HC > EXAM 2 > Flashcards

EXAM 2 Flashcards

1
Q

Structures of the skin

A 
Epidermis
Dermis
Subcutaneous tissue
Hair
Nails
Sebaceous, sweat, and mammary glands
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2
Q

layers of skin from superficial to deep

A 
stratum corneum
stratum lucidum
stratum granulosum
stratum spinosum
stratum basale
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3
Q

the state of structurally intact and physiologically functioning epithelial tissues such as integument (including the skin and subcutaneous tissue) and mucous membranes

A

tissue integreity

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4
Q

antecedents of tissue integrity

A

good nutrition
lack of external trauma
adequate perfusion
limited pressure on site

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5
Q

attributes of tissue integrity

A

structurally intact and functioning integument

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6
Q

skin integrity risk factors

A 
prolonged pressure
poor hygiene
poor nutrition
incontinence
break in the skin
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7
Q

Categories of impaired tissue integrity

A 
trauma or injury
loss of perfusion
immunological reaction
infections and infestations
thermal or radiation injury
lesions
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8
Q

Primary prevention of skin integrity

A 
patient education
identifying risk factors
the importance of nutrition
mobility
keeping skin clean and dry
hygiene and skin care discuss
safety behaviors to prevent trauma
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9
Q

second prevention of skin integrity

A

providing pain management
repositioning
using barrier creams
checking incontinent patients frequently to keep skin clean and dry
manage hygiene
provide appropriate nutrients to promote health skin or for wound healing
administer medications
prevent spread of infections or infestations

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10
Q

tertiary prevention of skin integrity

A 
teach patient and care giver about home care
pressure relief
wound care
hygiene
incontinence care
pruritus relief
safety behaviors to prevent trauma
general skin care
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11
Q

thinner more permeable skin

A

infants

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12
Q

less subcutaneous fat than older adults and children puts infants at greater potential for what?

A

fluid loss

less effective temperature regulation

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13
Q

what is the texture of skin for young children

A

smooth and dry

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14
Q

when do the apocrine glands become functional

A

after puberty

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15
Q

increased apocrine sweat gland and sebaceous acctivity

A

adolescents

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16
Q

oily skin acne

A

adolescents

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17
Q

Changes occurring in the skin as a person ages

A 
skin becomes more fragile
delayed wound healing
decreased Vitamin D production
susceptible to dry skin
decrease in sensory perception
greater risk of hypothermia or hyperthermia
elasticity decreases
decreased perspiration
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18
Q

pharmacotherapy for tissue integrity

A 
pain medications
topical antibiotics
topical antifungals
topical steroids
medicated lotions or powders
bleach solutions
topical agents to promote healing
topical emollients
hydrocolloidal agents
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19
Q

positive outcomes of skin integrity

A 
protection from infection
adaptation to the environment
maintenance of fluid and electrolyte balance
regulation of acid-base balance
Vitamin D production
20
Q

physical and physiological clinical manifestations of impaired skin integrity

A 
itching
burning
pain
excessively dry, peeling skin
draining wound
Stage 1-4 pressure ulcer
tear in skin, abrasion, laceration
depression, low self-esteem
change in skin color, skin temperature
fluid and electrolyte imbalance
21
Q

Diagnostic tests for impaired skin integrity

A 
wound culture
tissue biopsy
black light or immunofluorescence
lab work such as chemistry and CBC
doppler if suspected perfusion issue
MRI and CT scans to detect deep tissue
22
Q

largest organ of the body

A

skin

23
Q

serves as a barrier or protective coating and protects us from infections, keeps us from losing fluid, and helps us manage temperature

A

skin

24
Q

help us detect pain, temperature, and touch

A

nerves of the skin

25
Q

why is it important for nurses to understand tissue integrity and the importance of the skin?

A

the nurse’s job is to maintain optimal skin integrity/tissue integrity and work individually and with others to manage care when that integrity is disrupted

26
Q

4 types of tissue

A

muscle
neural
connective
epithelial

27
Q

most important of the tissues related to tissue integrity?

A

epithelial

28
Q

impaired skin integrity can affect?

A

epidermis and dermis skin layers, but if it gets deep enough, it can damage underlying structures such as bones, joints, and muscles

29
Q

the ability of the body tissues to regenerate and/or repair to maintain normal physiological processes

A

tissue integrity

30
Q

negative consequences associated with tissue integrity

A 
pain
infection
altered body image
loss of fluid and electrolytes
decubiti
amputation
31
Q

positive outcomes associated with skin integrity

A 
protection from infection
adaptation to environment (sweating)
maintenance of fluid and electrolytes
regulation of acid-base balance
Vitamin D production (the sun)
protection from injury/trauma
32
Q

the scope of tissue integrity ranges from

A

intact skin and tissue to partial thickness injury to full thickness injury

33
Q

the process by which oxygen is transported to the cells and carbon dioxide is transported from the cells

A

gas exchange

34
Q

where does diffusion of respiratory gases occur?

A

at the alveolar capillary membrane

35
Q

the process of inhaling oxygen and exhaling carbon dioxide

A

ventilation

36
Q

disparities of ventilation

A

unavailability of oxygen
narrowed bronchi
obstruction of bronchi
inflammation of bronchi and alveoli

37
Q

obtainability and capability of hemoglobin to carry oxygen

A

transport

38
Q

disparities of transportation

A

anemia
blood loss - acute or chronic
destruction of red blood cells

39
Q

ability of blood to transport oxygen to cells and return carbon dioxide to alveoli

A

perfusion

40
Q

disparities of perfusion

A

decreased cardiac output
thrombi, emboli, vessel narrowing
vasoconstriction
blood loss

41
Q

occurs when the diffusion of gases becomes impaired

A

impairment of gas exchange

42
Q

gas exchange becomes impaired as a result of:

A

ineffective ventilation
reduced capacity for gas transportation
inadequate perfusion

43
Q

examples of gas exchange imbalance and impairment processes

A 
asthma
pneumonia: aspiration pneumonia
RSV/bronchiolitis
tracheoesophageal fistula 
COPD
44
Q

risk factors for impaired gas exchange

A 
age
smoking
immunosuppression
reduced state of cognition
brain injury
prolonged immobility
presence of prolonged medical conditions such as CF, HTN, COPD, CHF, CHD
45
Q

elements of respiratory assessment

A 
past medical history 
family history
current medications
lifestyle behaviors
occupation
social environment
problem based history

EXAM 2 - INTRO TO HC (1 decks)

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