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Foundations 1 > immobility and integumentary > Flashcards

immobility and integumentary Flashcards

(64 cards)

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1
Q

subcutaneous layer

A
  • deepest layer
  • protective cushion
  • capillary beds/blood supply
  • oil glands
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2
Q

dermis layer

A
  • middle layer
  • first defense between body and environment (infection)
  • no blood supply
  • keratinized
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3
Q

skin changes in older adults

A
  • loss of heat (subQ thins)
  • less cushion to protect
  • easily torn (loss of elasticity)
  • dry skin (sebaceous glands decrease)
  • brusising (subq thins)
  • higher risk for infection (decrease immune function)
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4
Q

interventions for skin care

A
  • reposition Q 2 hrs
  • use draw sheet/board to move
  • assess incontinence/keep bedding dry
  • assess skin Q shift or more
  • water temp 90-115 F
  • limit showers and baths
  • avoid alcohol based products
  • increase fluids
  • avoid powders
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5
Q

pressure intensity

A

amount of pressure exerted on body

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6
Q

pressure duration

A

how long that pressure is there

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7
Q

non-blanching hyperemia

A
  • NOT GOOD
  • blood moves out (white) and doesn’t return (stays white)
  • stage 1 pressure injury
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8
Q

blanching hyperemia

A
  • GOOD

- Blood moves out of capillary bed (white) then returns (red)

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9
Q

assessments that indicate ischemia

A
  • change in color (red or white)
  • reduced sensation (numbness, pain)
  • warm or cool skin
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10
Q

ischemia

A

pressure constricts blood vessels causing decrease perfusion and nutrients and build up of waste. cells starve and die leading to necrosis

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11
Q

tissue tolerance

A

how well tissues can stand pressure and how well it recovers

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12
Q

stage 1 pressure injury

A
  • skin intact
  • non-blanching
  • warmth
  • redness
  • edema
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13
Q

stage 2 pressure injury

A
  • shallow opening
  • intact
  • blister
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14
Q

stage 3 pressure injury

A
  • full thickness tissue lost
  • slough
  • edges cant heal
  • tunneling
  • fat showing
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15
Q

stage 4 pressure injury

A
  • full thickness tissue lost
  • exposed tendon or bone
  • slough
  • tunneling
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16
Q

unstageable pressure injury

A
  • too much slough to see edges
  • cant get accurate measurement
  • need to debree first
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17
Q

Friction VS Shearing

What are some interventions?

A

friction
skin against surface

shearing

  • deep tissue damage
  • boney prominences
  • pressure moving one way, body moving the other-
Interventions 
HOB 30 or less
-use draw sheet
-mechanical lifts
-wrinkle-free sheets
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18
Q

granulation tissue

A
  • red
  • moist
  • scar tissue
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19
Q

maturation wound healing stage

A

collagen scar continues to reorganize and regain strength (1 month-1 yr)

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20
Q

proliferation wound healing stage

A

filling of the wound with granulation tissue, necessary for healing and formation of scar tissue

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21
Q

inflammatory wound healing stage

A

histamine secreted causing inflammation/vasodilation then WBC move into tissues to prevent and fight infection

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22
Q

hemostasis wound healing stage

A

-injured blood vessels constrict and platelets gather to stop bleeding

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23
Q

tertiary intention healing

A
  • intentionally left open

- high infection risk

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24
Q

secondary intention healing

A
  • granulation tissue

- longer to heal

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25
primary intention healing
- edges are together - quick healing - scar tissue
26
chronic wound
- takes longer to heal - higher infection risk - not healing correctly
27
acute wound
- surgical incision | - going to get better
28
slough
- soft yellow or white - has to be removed before it can heal - dead tissue - creamy
29
eschar
- black or brown | - necrotic
30
risk factors for impaired skin
1. altered sensory perception 2. poor nutrition 3. impaired mobility 4. shearing 5. incontinence 6. casts 7. age 8. chronic illness 9. medications
31
nutrition for impaired skin
- high calories - high protein - increase fluids -chicken, fruits, cheese, PB
32
lab values for tissue healing
- O2 level for adequate tissue perfusion - wound culture - albumin (3.5-5 g/dL) - hemoglobin - RBC - total protein (6.4-8.3 g/dL)
33
nursing interventions to prevent pressure injuries
- assistive devices for repositioning and transfers - asses incontinence - braden scale - clean skin w pH balance cleanser - inspect skin Q shift - assess boney prominences - encourage activity - nutrition - increase fluids - moisture barrier - reposition
34
isotonic exercise
active movement, muscle shortening and lengthens-ROM Benefits-muscle tone, strength, cardiac and muscle function, increase bone building Push-ups, pull-ups, crunches, sit ups
35
isometric exercise
muscle contractions without moving the joint or the length of the muscle Plank
36
isokinetic exercise
muscle contractions with restrictions or resistance Lifting weights
37
aerobic exercise
increase heart and blood flow, by using oxygen Walking, jogging, etc
38
Effects of Exercise on musculoskeletal
Decreases risk of falls Improves overall strength, muscle mass, improves gait, coordination, bone density
39
Effects of Exercise on Cardiovascular
Increases stroke volume, resting heart rate decreases Strengthens muscle tissue Perfusion, circulation
40
Effects of Exercise on Respiratory
Respiratory rate increases More toxins are being released More gas exchange occurs Better stamina
41
Effects of Exercise on Gastrointestinal
Increases blood flow to the GI tract Increase peristalsis decrease acid reflex
42
Effects of Exercise on Metabolic/Endocrine
Increase BMR(metabolism) Uses more glucose
43
Effects of Exercise on Urinary
Limits the blood flow to the kidney, lower your BP Increasing the muscle tone of the bladder wall - Making it easier to release the urine - Don't urinate-UTI
44
Effects of Exercise on Immune
Boost your immune system -More likely to respond to the issue Decrease inflammation - Through the lymphatic system - -Works through muscle contractions to move the lymph throughout the body
45
Effects of Exercise on Psycho-neurologic
Release of positive good endorphins - serotonin - Positive mood overall Reduce stress Improves sleep quality
46
Effects of Exercise on Cognitive
Increases ability to remember things Helps with problem solving, paying attention Builds nuero connections Improves brain density
47
Effects of Exercise on Spiritual Health
Helps clear stress, gives purpose Bodys response to that particular time and whats going on in that moment
48
Maslows hierarchy of needs
(level 1) Physiological Needs(breathing, food, water, sex, sleep, homeostasis, excretion) (level 2) Safety and Security(security of body, employment, resources, morality, family, health, home) (level 3) Relationships/love and belonging(friendship, family, intimacy) (level 4) Self Esteem(self-esteem, confidence, achievement, respect of others, respect by others) (level 5) Self Actualization(morality, creativity, spontaneity, problem solving, lack of prejudice, acceptance of facts)
49
effects of immobility on Cardiovascular system
Fluid impact-edema Skeletal muscle pump-becomes weaker, but has to work harder and increase HR to equal out for SV decrease Stroke Volume-decreases bc less BV, all in tissues Cardiac deconditioning Postural Hypotension
50
effects of immobility on Respiratory system
Decrease in depth and rate of respirations-decreased TV Atelectasis (collapsed alveoli)-decreased gas exchange Poor exchange of O2 and CO2 = acid base imbalance Movement of secretions in the respiratory tract is decreased, causing secretions to pool leading to respiratory congestion-cilia dont work as well, decrease ability to expel Hypostatic pneumonia
51
effects of immobility on hematological system
Blood Viscosity: thickness and stickiness of the blood, will be high bc all the fluid is in the tissues Erythropoiesis: the formation of new RBC -Stimulated by low O2, or a low amount of RBC, wont be stimulated bc no great need for O2 Oxygen transport: moving oxygen usually via hemoglobin Virchow's Triad
52
virchow's triad
describes the three broad categories of factors that are thought to contribute to thrombosis(the formation of the blood clot) Venous stasis: slow blood flow Hypercoagulability: easily forming a blood clot Blood vessel damage-causing inflammation
53
effects of immobility on musculoskeletal
Muscles-atrophy Connective tissue Contractures: limitation in the passive range of motion, caused by the stiffness of connective tissue within the body Bone-osteoporosis, Ca is leaving the bone, need wt bearing exercise
54
effects of immobility on endocrine system
Cortisol secretion -Stress, increases, sympathetic, fight or flight Metabolic changes Glucose intolerance: results in higher blood glucose levels- less muscle mass to take in the glucose with the insulin receptor sites Mineral/electrolyte
55
effects of immobility on integumentary system
Capillary pressure Ischemia: restriction in blood supply to tissues, causing a shortage of oxygen that is needed for cellular metabolism (to keep tissue alive) Nutrition
56
effects of immobility on immune system
inflammation: heat, redness, pain - increases risk -decrease in lymphatic flow
57
Effects of immobility gastrointestinal
lowers Appetite Peristalsis: movement of food/chyme through the GI tract -lowers Motility: capable of movement -lessens
58
Effects of immobility renal
Retention -less likely to release urine Calculi(kidney stones) -more likely to have kidney stones, have more Ca in blood
59
Effects of immobility psychological
depression, mental illnesses
60
hydrogel dressing
moisture dressing | autolytic debridement
61
hydrocolloid dressing (duoderm)
prevents friction and shear
62
alginate (sorbsan)
absorbs drainage
63
foam (mepliex)
thermal protects against exudate most likely used on bottom
64
transparent adherent dressing
skin tear on arm

Foundations 1 (8 decks)

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