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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
What does a low Braden score mean?
high risk of skin breakdown
26
Interventions for wound healing and prevention
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
27
Adequate nutrition for wound healing
monitor albumin and pre-albumin levels, high protein, high calorie, vitamins with moderate fat
28
Factors affecting healing
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
Key principles of wound management
assessment, cleaning, protection (from further damage)
30
yellow wound
could be slough (could indicate the wound is staying in an inflammatory stage) or purulent drainage
31
Black wound
might be eschar--dead skin; often needs to be removed in surgery
32
Beefy red wound
usually good, healing, granulation tissue
33
How to measure a wound
LxWxD in cm
34
what should a closed wound look like
well-approximated edges
35
what to document for drainage?
color, odor, amount, texture/consistency
36
Serous exudate
thin, clear, slightly yellow (like in blisters)
37
Sanguineous exudate
serum and RBCs, thick and reddish (bright--new, active bleed; dark--old blood)
38
How to chart tunneling?
Use Q tip to show depth and indicate location on the wound with a clock (ie at 7 oclock)
39
Serosanguinous exudate
serum and blood, watery, pale pink
40
Purulent
from infection; thick with WBCs, tissue debris, bacteria, creamier (yellow, tan, green, brown)
41
what is woven gauze used for?
exudate
42
when to use non-adherent material
don't want it to stick to skin or wound
43
When to use wet-to-dry/damp bandage
want some mechanical debridement; dries and pulls off dead skin
44
Tegaderm
transparent; use with caution bc can pull off good skin
45
Hydracolloid
swells in presence of exudate; change MAX 3 days, pulls away excessive drainage
46
Hydrogel
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
Alginates
nonadherent dressing that conforms to wound shape and absorbs exudate
48
Collagen
powder, paste, granules or gels that stop bleeding and promote healing
49
What dressings might you need an order for?
Collagen, alginates, hydrogel
50
Wound vac dressing
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
hemorrhage and sx
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
Fistula
abnormal or surgical opening that formed between 2 organs between organ tubes or organ and skin
53
adhesion
band of scar tissue that ties two places together
54
wound contractions
How the skin closes around the wound; abnormal contraction may results in holes under the skin
55
keloids
area of irregular fibrous tissue at the site of a wound; thick and raised, red or pinkish
56
Hematoma
local area of blood collection that appears red or blue
57
What to do in the case of an emergent hemorrhage
Notify HCP, apply pressure dressing, monitor VS
58
dehiscence
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
Risk factors for dehiscence
obesity, coughing, poor surgical technique, decreased blood flow
60
Evisceration
intrusion of visceral organs through the wound opening; significant inc in serosanguious fluid on the dressing
61
Sx of evisceration
sudden pop after straining, see visceral organs, increased sanguineous exudate through the bandage
62
risk factors for dehiscence and evisceration
diabetes, old age, chronic disease, cancer, vomiting, strain/cough, obesity, dehydration, malnutrition, abdominal surgery, infection
63
Nursing care for evisceration
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
Risk factors for infection
very young or old, chemo, malnutrition, chronic disease, poor wound care, immune suppressed, impaired oxygen
65
Infection prevention
good rest, use aseptic technique, nutrition, give antibiotics
66
s/s of infection
2-11 days post-surgery; pain, red, swell, purulent drainage, fever and chills, odor, inc pulse and RR, inc WBCs
67
Causes of hemorrhage
Clot dislodge, slipped suture, BV damage

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