MODULE H - INTEGUMENTARY SYSTEM

Question 1

AVOIDABLE PRESSURE INJURY

Answer 1

one that develops from improper use of the nursing process

Question 2

BEDFAST

Answer 2

Confined to bed

Question 3

BONY PROMINENCES

Answer 3

Areas of the body where the bone is close to the skin,
e.g. elbows, shoulder blades, sacrum

Question 4

DEEP TISSUE PRESSURE INJURY

Answer 4

Purple or deep red localized area of discolored INTACT skin or blood fill blister
. usually due to damage of underlying soft tissue from pressure and /or shear

Question 5

DERMATITIS

Answer 5

inflammation of the skin

Question 6

DERMIS

Answer 6

The layer of skin under the epidermis

Question 7

ECZEMA

Answer 7

RED, ITCHY AREA ON THE SURFACE OF THE SKIN

Question 8

EPIDERMIS

Answer 8

The outer layer of the skin

Question 9

FRICTION

Answer 9

rubbing of one surface against another;
skin is dragged across a surface

Question 10

INTEGUMENTARY SYSTEM

Answer 10

.the skin
. the largest organ in the body
. the largest system in the body
. provides a protective covering for the body

Question 11

PRESSURE INJURY (PRESSURE ULCER)

Answer 11

any lesion caused by unrelieved pressure that results in damage to underlying tissues

Question 12

PRESSURE INJURY (STAGE 1)

Answer 12

.INTACT SKIN
.redness over a bony prominence

Question 13

pressure injury ( stage 2)

Answer 13

. skin loss ( partial-thickness)
may see a blister
or shallow reddish pink ulcer
blister may be intact or open

Question 14

PRESSURE INJURY STAGE 3

Answer 14

.SKIN LOSS ( full thickness)
.skin gone
.may see subcutaneous fat
.slough( dead soft tissue, often moist and varies in color- white yellow green or tan)
could be attached or stringy loose

Question 15

Pressure injury stage 4

Answer 15

.full-thickness skin and tissue loss
.with muscle, tendon,and bone exposure;
.slough and eschar (thick, leathery dead tissue that may be
loose or attached to skin); often black or brown

Question 16

Shear ( skin on skin)

Answer 16

.when layers of skin rub up against each other;
.or it could be when skin remains in place, but tissues underneath move and stretch causing damage to
capillaries and blood vessels

Question 17

Shingles (or Herpes Zoster)

Answer 17

.a disease caused by a virus,
.most common in people over 50,
.with signs that include a rash or blisters on one side of the body,
.burning pain, numbness, and itching

Question 18

Stasis Dermatitis

Answer 18

a skin condition affecting lower legs and ankles that occurs from
a buildup of fluid under the skin and causes problems with circulation

Question 19

The 30-degree lateral position

Answer 19

. position of a resident when the bed is not raised more
than 30 degrees
. pillows are placed under the head, shoulder, and leg to lift the hip at about a 30-degree angle to avoid pressure on the hip

Question 20

Unavoidable pressure injury

Answer 20

a pressure injury occurs despite efforts to
prevent one through proper use of the nursing process

Question 21

Unstageable pressure injury

Answer 21

full-thickness tissue loss with injury covered by slough and/or eschar

Question 22

3 layers of the skin

Answer 22

1. epidermis
2. dermis
3. subcutaneous fat

Question 23

EPIDERMIS

Answer 23

.the outer layer;
.has living and dead cells;
.living cells push dead cells up as they divide and
dead cells flake off;
. living cells contain pigment that
give the skin its color;
.*does not have blood vessels
.and only few nerve cells

Question 24

DERMIS

Answer 24

.inner layer;
.made up of connective tissue;blood vessels, nerves, sweat glands, oil glands, and
hair roots located there

Question 25

Subcutaneous (fatty) tissue

Answer 25

1. thick layer of fat 2. connective tissue

Question 26

Integumentary System – Function

Answer 26

1. Protects the body from injury and pathogens 2* Regulates body temperature 3* Eliminates waste through perspiration 4* Contains nerve endings for cold, heat, pain, pressure and pleasure 5* Stores fat and vitamins

Question 27

Integumentary System – Normal Findings

Answer 27

Warm, dry Absence of breaks, rash, discoloration, swelling

Question 28

Integumentary System – Changes Due to Aging

Answer 28

1* Skin is thinner, drier, more fragile 2* Skin loses elasticity 3* Fatty layer decreases so the person feels colder 4* Hair thins and may gray 5* Folds, lines, wrinkles, and brown spots may appear 6* Nails harden and become more brittle 7* Reduced circulation to the skin, leading to dryness and itching 8* Development of skin tags, warts and moles

Question 29

Integumentary System – Variation of Normal

Answer 29

* Breaks in skin * Pale, white or reddened areas * Black and blue areas * Changes in scalp or hair * Rash, itching or skin discoloration * Abnormal temperature * Swelling * Ulcers, sores, or lesions * Dry or flaking skin * Fluid or bloody drainage

Question 30

Shingles (Herpes Zoster)

Answer 30

.Caused by a virus; .Same virus that causes chickenpox; .virus is inactive in nerve tissue and can become active years later; .Most common in people over 50 * Signs – rash or blisters on one side of the body, burning pain, numbness, and itching; .lasts about 3 to 5 weeks; * Infectious until lesions are crusty * Nurse aide’s role – per the directive of care plan, keep rash covered until crusty, remind the resident to wash hands often and avoid scratching or touching rash; the vaccine recommended for people 60 years or older who have had chicken pox

Question 31

HOW LONG DOES SHINGLES LAST

Answer 31

3 to 5 weeks

Question 32

Stasis Dermatitis

Answer 32

* Skin condition affecting lower legs and ankles * Occurs from buildup of fluid under skin * Problems with circulation resulting in fragile skin * Can lead to open ulcers and wounds * Early signs – scaly, red, itchy areas; .later signs –swelling of legs, ankles, or other areas; thin skin; darkening skin, leg pain * Nurse aide’s role – report signs; note too tight stockings and shoes and report to nurse; follow directives of care plan which may include anti-embolism stockings and elevation of feet

Question 33

The Pressure Injury

Answer 33

1. as “any lesion caused by unrelieved pressure that results in damage to underlying tissues; 2. friction and shear are factors 3. Many pressure ulcers occur within first 4 weeks of admission to the facility

Question 34

BONY PROMINENCE

Answer 34

1. an area where bone sticks out or projects from flat surface of the body; 2. back of head, 3. shoulder blades, elbows, hips, spine, sacrum, knees, ankles, heels, and toes

Question 35

MAJOR FACTORS TO PRESSURE INJURY

Answer 35

1. PRESSURE 2. SHEARING 3. FRICTION

Question 36

Pressure Injury – At Risk Factors

Answer 36

immobility, breaks in skin, poor circulation to area, moisture, dry skin, and urine and feces irritation * Older residents and disabled residents are at risk due to skin changes due to age, chronic disease, and frailty

Question 37

Pressure Injury – Residents at Risk

Answer 37

* Bedfast (confined to bed) residents * Requires some or total help moving (coma, paralysis, hip fracture) * Agitated or have involuntary muscle movement * Urinary or fecal incontinence * Exposed to moisture * Poor nutrition; poor fluid balance * Lowered mental awareness * Problems sensing pain or pressure * Have circulatory problems * Are older * Are obese or very thin * Refuse care * History of pressure injuries *Older residents and disabled residents are at risk due to skin changes

Question 38

STAGES OF PRESSURE INJURY

Answer 38

1. Stage 1 – intact skin; redness over bony prominence 2* Stage 2 – Skin loss (partial-thickness); may see a blister or shallow reddish-pink ulcer; the blister may be intact or open 3* Stage 3 – Skin loss (full-thickness); skin gone; may see subcutaneous fat; slough (dead soft tissue, often moist and varies in color – white, yellow, green, or tan) may be present; could be attached or stringy loose 4* Stage 4 – Full-thickness skin and tissue loss with muscle, tendon, and bone exposure; slough and eschar (thick, leathery dead tissue that may be loose or attached to skin); often black or brown 5* Unstageable – Full-thickness tissue loss with injury covered by slough and/or eschar 6* Deep tissue injury – purple or deep red localized area of discolored intact skin or blood-filled blister; usually due to damage of underlying soft tissue from pressure and/or shear

Question 39

Pressure Injury – Pressure Points

Answer 39

Occur over bony areas, called pressure points and include back of head, ears, shoulder blades, elbows, hips, spine, sacrum, knees, ankles, heels, and toes; **sacrum being the most common site**

Question 40

MOST COMMON PRESSURE POINT SITE

Answer 40

the sacrum

Question 41

Pressure injury PREVENTION

Answer 41

* Use assistive devices (pillows, foam wedges); support feet properly * Do not position on red area, pressure injury, on tubes or other medical devices * Prevent bed friction (powdered sheets are an example) ****Prevent shearing (do not raise the head more than 30 degrees)**** * Keep feet and heels off the bed

Question 42

The 30 degree Lateral Position

Answer 42

* Bed is not raised more than 30 DEGREES * Pillows are placed under head, shoulder, and leg * Position lifts up the hip to avoid pressure on the hip at about a 30o angle * Person does not lie on hip as with the side-lying position

Question 43

PREVENTION OF PRESSURE INJURIES

Answer 43

Measures directed at 1) handling, moving, and positioning of the resident and 2)providing skincare