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NSG 2321 > Integumentary System > Flashcards

Integumentary System Flashcards

1
Q

What is the Primary Function of the Skin?

A

Protection

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2
Q

Which of the following are age-related changes in the hair and nails? (select all that apply)

a. Oily Scalp
b. Scaly Scalp
c. Thinner Nails
d. Thicker, brittle nails
e. Longitudinal ridging

A

b, d, e

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3
Q

The nurse assessed the client’s skin lesions as firm, edematous, and irregularly shaped with variable diameter. What are these lesions called?

A

Wheals

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4
Q

On inspection of the client’s skin, the nurse notes the complete absence of melanin pigment in patchy areas on the client’s hands. What is the assessment finding called?

A

Vitiligo

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5
Q

Individuals with dark skin are more likely to develop which of the following?

a. Keloids
b. Wrinkles
c. Rashes
d. Skin Cancer

A

A. Keloids

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6
Q

Under what circumstance is diagnostic testing recommended for skin lesions?

a. When a health history cannot be obtained
b. When a more definitive diagnosis is needed
c. When percussion reveals abnormal findings
d. When treatment with precribed medication has failed

A

B. When a more definitive diagnosis is needed

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7
Q

When assessing self-care habits in relation to the skin, what does the nurse question the client about?

a. Joint pain
b. Use of sunscreen products
c. Recent changes in exercise products
d. Family history of melanoma

A

B. Use of sunscreen products

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8
Q

During the physical examination of a client’s skin, which of the following would the nurse do?

a. Use a flashlight if the room is poorly lit
b. Note cool, moist skin as normal findings
c. Pinch up a fold of skin to assess for turgor
d. Perform a lesion specific examination first and then general inspection

A

C. Pinch up a fold of skin to assess for turgor

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9
Q

Epidermis

A
  • Outer layer of the skin
  • Relatively thin
  • No lymphatic or vascular structures
  • Superficial
  • Breaks easily
  • Sheds/Regenerates every 28 days
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10
Q

Dermis

A

Connective tissue below the epidermis

Highly vascular

Contains nerves, lymphatic vessels, hair follicles, sebaceous glands, and specialized cells such as mast cells and macrophages that protect the body from external stimuli

Wound will bleed with injury

Variety of thickness

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11
Q

Subcutaneous Tissue

A

While not part of the skin it attaches to the skin to underlying tissues such as muscle and bone

Contains loose connective tissue and fat cells that provide insulation, cushioning, temperature regulation, and energy storage

The distribution of subcutaneous tissue varies with gender, heredity, age, and nutritional status

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12
Q

Skin Appendages

A

Skin appendages include the hair, nails, and glands

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13
Q

What is the primary role of the integumentary system?

A

to protect the underlying tissues of the body from the external environment

The skin acts as a barrier against invasion by bacteria and viruses and prevents excessive water loss

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14
Q

What does fat do in the integumentary system?

A

The fat in the subcutaneous layer, insulates the body and provides protection from trauma

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15
Q

How does the skin regulate heat loss?

A

The skin regulates heat loss by responding to changes in internal and external temperature with vasoconstriction, vasodilation, and excretion of sweat

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16
Q

What provides sensory information in the skin?

A

Nerve endings and receptors located within the skin provide sensory information on environmental stimuli to the brain related to pain, temperature, touch, pressure, and vibration

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17
Q

What is some subjective data that needs to be collected for the Integumentary system?

A

Past medical history

Medications

Surgery or other treatments
Family history (ie., skin cancer)

Nutritional History (ie., vitamins that are essential to healthy skin such as vitamin A, D, and E. Food allergies that cause rashes.

Hydration Status

Social, Environmental, and Occupational Health History (ie., contact dermatitis)

Cognitive-Perceptual (ie., the patients perception to cold, pain, and touch. Joint pain and the mobility of joints)

Coping Abilities

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18
Q

What is some objective data that the nurse should collect for the integumentary system?

A

Inspection & Palpation

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19
Q

What do you inspect with the integumentary system?

A

Pigmentation, vascularity, bruising and the presence of lesions or discolouration

Nail beds, oral mucosa

Note the presence of tattoos and piercings

The colour, size, height, distribution, location, and shape of any lesions should be noted

Distribution and quantity of hair

Clubbing to nails

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20
Q

What does palpating the skin provide information about?

A

Palpating the skin provides information about temperature, turgor and mobility, moisture, and texture

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21
Q

What is a Punch Biopsy?

A

Provides full-thickness skin for diagnostic purposes

Includes dermis and some fat

Suturing may or may not be done

Scalpel blades

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22
Q

What is an Excisional Biopsy?

A

Skin closed with subcutaneous and skin sutures

Useful when good cosmetic results or entire removal or both are desired

Take a measurement with regards to the skin- called the “Safety Margin”

Ex: Take a border from around mole and then sent to a lab for diagnostics

The hope is to find “Clear Borders”

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23
Q

What is an incisional biopsy?

A

Wedge shaped incision made in lesion too large for an excisional biopsy. Useful when larger specimen than shave biopsy is needed

Ex: Skin Tag is snipped from the top of the skin.

Does not go any lower than the epidermis

Localized freezing, no deep freezing

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24
Q

What is a shave biopsy?

A

Single-edged razor blade used to shave off superficial lesions or small sample of a large lesion

Provides a thin specimen for diagnostic purposes

​​Shave off the epidermis and a bit of the dermal layer

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25
What do cultures do for the skin?
Tests fungal, bacterial, and viral organisms For bacteria= material is obtained from intact pustules or abscesses
26
What is Wood's Lamp Test (Black Light)?
Identifies certain conditions on your skin, scalp, and hair. It’s often used to diagnose fungal, bacterial and parasitic infections. Uses ultraviolet (UV) light to make certain cells show color or appear fluorescent
27
What is the mechanism of cell death?
The mechanisms of actual cell death may include the deterioration of the nucleus (nuclear shrinking), karyolysis (dissolution of the nucleus), disruption of cell metabolism, the rupture of the cell membrane
28
What does microbial invasion often result in?
Microbial invasion often results in cell injury and death
29
How does infection occur?
Infection occurs when pathogens invade and multiply in body tissue
30
What is apoptosis?
Programmed Cell Death
31
When does apoptosis occur?
Occurs in some regenerating tissues to create homeostasis , such as bone marrow, skin, and gut epithelium
32
What is necrosis?
tissue death that occurs as a result traumatic injury, infection, ischemia, or exposure to a toxic chemical that causes a local inflammatory response, which results from the release of intracellular contents after the rupture of the outer membrane of the dead cells
33
Defense against injury: Mononuclear Phagocyte System
Phagocytic cells located in various tissues and organs The functions of the macrophage system include recognition and phagocytosis of foreign material such as microorganisms, removal of old or damaged cells from circulation, and participation of the immune response
34
Defense Against Injury: Inflammatory Response
A biological response to cell injury caused by pathogens, irritants, or chronic health conditions (ie., arthritis)
35
What does the intensity of the inflammatory response depend on?
The intensity of the response depends on the extent and severity of the injury and on the reactive capacity of the injured person
36
What happens to the inflammatory agent during the inflammatory response?
-the inflammatory agent is neutralized and diluted - necrotic materials are removed - An environment suitable for healing and repair is established
37
Defense Against Injury: Inflammatory Response What occurs after cell injury as a vascular response?
After cell injury, vasoconstriction occurs to prevent bleeding by the movement of platelets to adhere to the vessels of the injured area forming a blood clot This then releases Histamine which causes vasodilation
38
What part of the blood releases histamine?
Causes vasodilation to stop blood flow to the wound- platelets release histamine by causing some vasodilation to the area to fight off infection
39
Defense Against Injury: Inflammatory Response In the Cellular Response, what do neutrophils do?
First leukocytes to arrive at the site of inflammation They phagocytize (engulf) bacteria, other foreign material, and damaged cells When dead neutrophils accumulate with other cell debris this collects and forms pus
40
Defense Against Injury: Inflammatory Response In the Cellular Response, what do monocytes do?
Usually arrive at the site within 3-7 days after the onset of inflammation Assists with phagocytosis of the inflammatory debris Macrophages play an important role in cleaning the area before healing can occur Essential in orchestrating the healing process
41
Defense Against Injury: Inflammatory Response In the Cellular Response, what do lymphocytes do?
Arrive later at the site of injury (lymphocytes play a crucial role in mediating inflammation and the immune response as well as creating antibodies to things) 1) Neutrophils arrive (leukocytes) 2) Monocytes Arrive (macrophages) 3) Lymphocytes arrive
42
Defense Against Injury: Inflammatory Response In the Cellular Response, what do Eosinophils & Basophils do?
More selective role in inflammation Eosinophils are released during an allergic reaction. They release chemicals that act to control the effects of histamine and serotonin They are involved in phagocytosis of the allergen antibody complex Eosinophils contain highly caustic chemicals that are capable of destroying a parasites cell surfaces
43
What happens to the cellular response during cell injury?
Higher neutrophils Higher monocytes As the healing progression they will have higher macrophages If the patient has an allergic reaction or an anaphylactic reaction (Increase in eosinophils and basophils)
44
What are Kinins during an inflammatory response?
Kinins are proteins in the blood that cause inflammation and affect blood pressure (especially causing blood pressure to go down). They also increase blood flow throughout the body. Make it easier for fluids to pass through small blood vessels. (involved in the vascular and pain response during tissue injury)
45
Defense Against Injury: Inflammatory Response What does the chemical mediator Prostaglandin do?
Control processes such as inflammation, blood flow, and the formation of blood clots
46
What do NSAIDs like Ibuprofen and ASA do to prostaglandins in the inflammatory response?
NSAIDs like advil are used to treat many acute and chronic conditions by inhibiting prostaglandin synthesis ASA blocks platelet aggregation and has anti-inflammatory action
47
What do corticosteroids do to prostaglandins in the inflammatory response?
Corticosteroids are inhibit prostaglandins
48
What is the local manifestations of inflammation?
Redness Heat Swelling Pain
49
In the local manifestations of inflammation what is pain caused by?
caused by nerve stimulation by the chemical released such as histamine and prostaglandins as well as the pressure from fluid exudate
50
What are the systemic manifestations of inflammation?
Malaise, nausea, and anorexia, fever, increased pulse and respiratory rate.
51
What is acute inflammation?
The healing occurs in 2-3 weeks usually and leaves no residual damage
52
What is chronic inflammation?
Lasts for weeks, months, or even years Ex., rheumatoid arthritis, osteomyelitis, and TB
53
In the healing process, what is regeneration?
The replacement of lost cells and tissues with cells of the same type
54
In the healing process, what is repair?
is healing as a result of lost cells being replaced by connective tissue Usually results in scar formation Repair healing occurs by primary, secondary , or tertiary intention
55
What is primary intention in regard to repair in the healing process?
This healing takes place when wound margins are neatly approximated, as in surgical incisions or a paper cut
56
What are 3 phases of healing in primary intention?
Initial (Inflammatory) Phase Granulation (Proliferation/Reconstructive) Phase Maturation and Scar Contraction
57
Healing Process: Primary Intention Initial (Inflammatory) Phase
Lasts 3-5 days The edges of the incision are aligned and sutured (or stapled) in place
58
How long do sutures and staples typically stay insitu for?
Sutures and Staples are left in for 10-14 day Take every other staple out to prevent the wound from dehiscing and then place steri-strips
59
Healing Process: Primary Intention Granulation (Proliferation/Reconstructive) Phase
Lasts from 5 days to 3 weeks At this stage fibrous or scar tissue begins to develop During this phase the wound is pink and vascular Body produces brand new cells Increase of cells and reconstruction of cells and tissues
60
Healing Process: Primary Intention Maturation and Scar Contraction
Overlaps with the granulation phase Begins 7 days after the injury and continues for several months or years Scar formation or the the scar disappears
61
Healing Process: Secondary Intention What is secondary intention?
Wounds with wide or irregular wound margins that cannot be approximated will heal with secondary intention
62
Healing Process: Secondary Intention Examples of Secondary Intention
chronic wounds such as venous leg ulcers, and wounds caused by trauma or pressure
63
Healing Process: Secondary Intention What are some characteristics of Secondary Intention?
Irregular margins or the wound is wider The edges cannot be brought together to be approximated Maturation, Proliferation, and maturation takes longer to occur due to the wound Slough Tissue- non-viable tissue → needs to be debrided (chemically debride or surgically debride, or medical maggots)
64
Healing Process: Tertiary Intention When does tertiary intention occur?
Occurs when the wound is left intentionally open because if the wound is closed immediately, healing could be impaired due to contamination (ex., animal bite or foreign material), infection or high risk of infection, edema or poor circulation
65
Healing Process: Tertiary Intention How is tertiary intention treated?
The wound is later closed surgically after the tissue is controlled or resolved Usually results in a larger and deeper scar Ex., Vac Therapy
66
Healing Process: Tertiary Intention What is tertiary intention?
Delayed primary intention
67
How are wounds Classified?
- By cause (Surgical wound, non-surgical wound) - By pathology (vascular, pressure diabetes related) - By duration (Acute vs. Chronic) - By level of contamination (Is it infected?) - By type of tissue involved (Superficial, partial thickness, or full thickness) - By wound bed colour (Necrotic/black, yellow, or mixed colour)
68
Complications of Healing: Adhesions
Bands of scar tissue that for between or around organs They may develop in the abdominal cavity or between the lungs and pleura Adhesions in the abdomen may cause an intestinal obstruction
69
Complications of Healing: Contractures
Wound contraction is an important part of healing. This process may become abnormal when contraction is excessive, which results in deformity, or contracture
70
When do contractures typically occur?
Shortening of muscle or scar tissue, especially over joints, results from excessive fibrous tissue formation Contractures frequently occur in burn injuries, when extensive skin and subcutaneous tissue are lost
71
Complications of Healing: Dehiscence
The separation and disruption of previously joined wound edges. It usually occurs when the primary healing site bursts open
72
Complications of healing: Evisceration
Occurs when the wound edges separate o the extent that intestines protrude through the wound (this is a medical emergency - soak gauze with normal saline and place it on the protruding organ)
73
Complications of Healing: Excess granulation tissue
Portrudes above the wound
74
Complications of Healing: Fistula
An abnormal passage that forms between organs or a hollow organ and the skin
75
Complications of Healing: Infection
Increased risk of infection when it contains necrotic tissue, when the blood supply is decreased, when the immune function is depressed, or if a patient is malnourished, or has multiple stressors, or is diabetic.
76
Complications of Healing: Hemorrhage
Bleeding is normal immediately after tissue injury and ceases with clot formation
77
Complications of Healing: Keloids
Keloid Scars form when the body produces excess collagen
78
What is a pressure injury?
Localized injury to the skin and the underlying soft tissue, usually over a bony prominence, as a result of excessive or prolonged pressure, shear, and tissue deformation
79
How are pressure injuries staged?
They are staged according to the deepest level of tissue damage
80
Stages of Pressure Ulcers: Stage One
Intact skin with a localized area of nonblanchable erythema, which may appear darkly pigmented Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visible changes
81
Stages of Pressure Ulcers: Stage Two
Partial thickness loss of skin with exposed dermis The wound bed is viable, pink, or red, moist, and may also appear as an intact or ruptured serum filled blister Neither adipose or deeper tissues are visible If you take your index finger and press on the red area and there is no blanching then that means that there is inadequate blood flow
82
Stages of Pressure Ulcers: Stage Three
Full thickness loss of skin, in which adipose is visible in the ulcer and granulation tissue and rolled wound edges are often present Slough or eschar, or both may be visible Undermining or tunneling may occur
83
Stages of Pressure Ulcers: Stage Four
Full thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer Slough, eschar, or both may be visible Rolled edges, undermining, or tunneling, or a combination of these often occur Depth varies based on anatomical location
84
What makes pressure ulcers unstageable?
If slough or eschar obscures the extent of tissue loss If the slough or eschar are removed, a stage 3 or 4 pressure injury is revealed When you cannot see the wound bed
85
What is the Braden Scale (Risk Assessment)?
Patient is assessed on a subscale of 6 things: sensory perception, moisture, activity, mobility, nutrition, and friction and shear Scores can range from 6 to 23 The lower the score, the higher the patients risk of developing a pressure injury
86
What are some nursing interventions for Pressure Ulcers?
Patient should be assessed on admission and periodic intervals throughout their hospital admission The patient should be repositioned frequently (Q2H) Air bed that changed patients pressure on the bed Foam dressings Wheelchair cushions Padded commode seats Heel boots (foam, air) Nutrition (Do we need to get an order for a dietician? Increase their protein intake) Mobilization (Maybe we need to get PT/OT involved) Maybe provide a wheelchair user with gloves to prevent blisters and calluses from forming Healing- requires consistency and timelines
87
What are some overarching Nursing Management Considerations for the Integumentary System?
- Observation & Vital Signs - Fever - RICE - Wound Management
88
What is R.I.C.E?
R.I.C.E (rest, ice, compression, and elevate) - 20 minutes on and 20 minutes off with ice - For swelling we initially use ice - When wrapping an injury you wrap distal to proximal to mimick venous return (wrap from the bottom up) - Always elevate above heart level
89
Skin Infections and Infestations: Bacterial Infections: Cellulitis What is cellulitis?
Deep inflammation of subcutaneous tissue due to enzymes produced by bacteria
90
Skin Infections and Infestations: Bacterial Infections: Cellulitis How do you assess cellulitis?
Draw a line of demarcation to ensure that the redness does not travel up the leg Measure the diameter of the affected area to make sure that it does not increase Assess pulse on affected limb
91
Skin Infections and Infestations: Bacterial Infections: Cellulitis What are the clinical manifestations of Cellulitis?
Hot Tender Erythematous Edematous area with diffuse borders Chills, malaise, and fever
92
Skin Infections and Infestations: Bacterial Infections: Cellulitis How do you treat cellulitis?
Moist, heat, immobilization and elevation Systemic ABX therapy Progression of gangrene is possible if left untreated
93
Common Infestations and Insect Bites: What are clinical manifestations of bed bugs?
Wheal surrounded by vivid flare Firm urticaria transforming into persistent lesion Severe pruritus Often the bites will be in groups of threes Usually feed at night
94
Common Infestations and Insect Bites: What is the treatment and prognosis of bed bugs?
Environmental treatments include steam cleaning vacuuming, heating, freezing, washing, and disposal of items Severe itching possibly necessitates use of antihistamines and corticosteroids - or if they are itching and the skin opens and an infection occurs, antibiotics may need to be given
95
Common Infestations and Insect Bites: What is scabies?
Mite penetrates the skin and deposits eggs
96
Common Infestations and Insect Bites: How is scabies transmitted?
Transmission by direct physical contact, only occasionally by shared personal items
97
Common Infestations and Insect Bites: What are the clinical manifestations of scabies?
Severe itching, especially at night, usually not on the face Presence of burrows, especially in interdigital webs, flexor surface of the wrists, genitalia, and anterior axillary folds Erythematous papules (may be crusted), possible vesiculation, inter digital web crusting Track Lines (migration patterns)
98
Common Infestations and Insect Bites: What is the treatment and prognosis of scabies?
Topical lotions/creams (the topical cream provides a barrier and kills the scabies that are underneath) Treat all sexual partners and cohabitants Treat environment with plastic covering for 5 days Launder all clothes and linen with bleach Antibiotics if secondary infections are present

NSG 2321 (6 decks)

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