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Fundies > Integumentary System > Flashcards

Integumentary System Flashcards

1
Q

What to assess for skin?

A

color, moisture, temperature, texture, turgor, vascularity, edema, lesions

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2
Q

the Skin and its functions

A

biggest organ of the system; protects and does sensory perception

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3
Q

Where to look for color changes on dark skin?

A

Lips, palms, mucus membranes

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4
Q

How may pallor look on dark skin?

A

Gray color

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5
Q

Jaundice

A

yellow color in sclera and mucus membranes that may indicate liver dysfunction (and RBC death)

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6
Q

Where to look to assess jaundice in dark skin?

A

Palms

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7
Q

What does erythema indicate?

A

inflammation, vasodilation, sun exposure, warm temperature

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8
Q

Risk factors for impaired skin integrity

A

impaired sensory perception, immobility, altered LOC, LOPS, shear, friction, moisture, trauma, brace/cast/medical device, spinal cord injury, movement deficit, long term care, acutely ill or hospice, diabetes, incontinence, pt in ICU

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9
Q

shear

A

sliding movement of skin and SQ tissue when muscle/bone doesn’t move

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10
Q

Friction

A

2 surfaces sliding against each other

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11
Q

Pressure injuries cause

A

unrelenting prolonged pressure

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12
Q

Why does tissue ischemia occur with pressure injuries?

A

pressure is applied over a capillary and exceeds normal capillary pressure

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13
Q

3 major factors involved in pressure injuries

A

Pressure intensity, pressure duration, tissue tolerance

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14
Q

blanchable

A

turns light when pressed and goes back to red

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15
Q

nonblanchable

A

red skin that does not turn white when pressed

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16
Q

Deep tissue injury

A

persistent nonblanchable deep red, purple, or maroon color where you can’t tell what layers are involved

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17
Q

Unstageable pressure injury

A

obscured by slough/escar or infection, can’t determine depth

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18
Q

moisture associated skin damage

A

incontinence related prolonged exposure to urine/stool

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19
Q

intertriginous skin

A

inflammatory dermatitis related to skin rubbing (often in folds and under breasts)

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20
Q

Periwound/periostomal

A

Skin around the wound or stomach that can b/d from GI contents or moisture on it

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21
Q

Wound

A

disruption of integumentary and tissue function

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22
Q

acute wound

A

heals within normal timeline, returned to sustained function and integrity

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23
Q

chronic wound

A

abnormal healing process (pressure injury, diabetic ulcer)

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24
Q

Factors affecting skin and wound healing

A

nutrition, tissue perfusion, infection, extreme ages

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25
Q

What does a low Braden score mean?

A

high risk of skin breakdown

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26
Q

Interventions for wound healing and prevention

A

Q2 turns, Q1 if in the chair, adequate nutrition, keep pt dry, use lift to avoid friction, use special mattresses, aleve dressings, administer pain meds and anti-biotics, remove staples and sutures as ordered, DOCUMENT THOROUGHLY

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27
Q

Adequate nutrition for wound healing

A

monitor albumin and pre-albumin levels, high protein, high calorie, vitamins with moderate fat

28
Q

Factors affecting healing

A

age, slow turgor, dec WBCs, fragile skin, dec circ and oxygen, infection, dec tissue absorption, dec collagen and immune function, mal nut, dehydration, overall wellness, dec Hgb, chronic disease

29
Q

Key principles of wound management

A

assessment, cleaning, protection (from further damage)

30
Q

yellow wound

A

could be slough (could indicate the wound is staying in an inflammatory stage) or purulent drainage

31
Q

Black wound

A

might be eschar–dead skin; often needs to be removed in surgery

32
Q

Beefy red wound

A

usually good, healing, granulation tissue

33
Q

How to measure a wound

A

LxWxD in cm

34
Q

what should a closed wound look like

A

well-approximated edges

35
Q

what to document for drainage?

A

color, odor, amount, texture/consistency

36
Q

Serous exudate

A

thin, clear, slightly yellow (like in blisters)

37
Q

Sanguineous exudate

A

serum and RBCs, thick and reddish (bright–new, active bleed; dark–old blood)

38
Q

How to chart tunneling?

A

Use Q tip to show depth and indicate location on the wound with a clock (ie at 7 oclock)

39
Q

Serosanguinous exudate

A

serum and blood, watery, pale pink

40
Q

Purulent

A

from infection; thick with WBCs, tissue debris, bacteria, creamier (yellow, tan, green, brown)

41
Q

what is woven gauze used for?

A

exudate

42
Q

when to use non-adherent material

A

don’t want it to stick to skin or wound

43
Q

When to use wet-to-dry/damp bandage

A

want some mechanical debridement; dries and pulls off dead skin

44
Q

Tegaderm

A

transparent; use with caution bc can pull off good skin

45
Q

Hydracolloid

A

swells in presence of exudate; change MAX 3 days, pulls away excessive drainage

46
Q

Hydrogel

A

watery bandage that meets exudate and does autolytic debridement; used for small amounts of exudate; give moist wound bed and decreases pain, prevent b/d in high pressure area; for infection, deep wound, necrotic tissue

47
Q

Alginates

A

nonadherent dressing that conforms to wound shape and absorbs exudate

48
Q

Collagen

A

powder, paste, granules or gels that stop bleeding and promote healing

49
Q

What dressings might you need an order for?

A

Collagen, alginates, hydrogel

50
Q

Wound vac dressing

A

foam with occlusive dressing connected to negative pressure and suction; brings nutrients and tissue perfusion to the area; good for large wounds and bad locations (near moisture and stool); need order for and change every 3 days

51
Q

hemorrhage and sx

A

in surgical wounds; greatest risk 24-48 hours after surgery; can cause internal bleeding noted by swelling, distention, sanguineous exudate; can be an emergency

52
Q

Fistula

A

abnormal or surgical opening that formed between 2 organs between organ tubes or organ and skin

53
Q

adhesion

A

band of scar tissue that ties two places together

54
Q

wound contractions

A

How the skin closes around the wound; abnormal contraction may results in holes under the skin

55
Q

keloids

A

area of irregular fibrous tissue at the site of a wound; thick and raised, red or pinkish

56
Q

Hematoma

A

local area of blood collection that appears red or blue

57
Q

What to do in the case of an emergent hemorrhage

A

Notify HCP, apply pressure dressing, monitor VS

58
Q

dehiscence

A

partial or total rupture or separation of a sutured wound usually with exposed layers of skin; usually found 2-11 days post-surgery; tx with wet to dry

59
Q

Risk factors for dehiscence

A

obesity, coughing, poor surgical technique, decreased blood flow

60
Q

Evisceration

A

intrusion of visceral organs through the wound opening; significant inc in serosanguious fluid on the dressing

61
Q

Sx of evisceration

A

sudden pop after straining, see visceral organs, increased sanguineous exudate through the bandage

62
Q

risk factors for dehiscence and evisceration

A

diabetes, old age, chronic disease, cancer, vomiting, strain/cough, obesity, dehydration, malnutrition, abdominal surgery, infection

63
Q

Nursing care for evisceration

A

cover wound with sterile towel or gauze with sterile technique, DON’T try to reinsert wounds, position supine with knees bent, keep calm, keep pt NPO in case of surgery

64
Q

Risk factors for infection

A

very young or old, chemo, malnutrition, chronic disease, poor wound care, immune suppressed, impaired oxygen

65
Q

Infection prevention

A

good rest, use aseptic technique, nutrition, give antibiotics

66
Q

s/s of infection

A

2-11 days post-surgery; pain, red, swell, purulent drainage, fever and chills, odor, inc pulse and RR, inc WBCs

67
Q

Causes of hemorrhage

A

Clot dislodge, slipped suture, BV damage

Fundies (8 decks)

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