Objective 2 (1)

Question 1

Largest organ system of the body
Consists of skin, hair, nails, and glands
Forms a barrier between the internal organs and external env
Participates in vital body functions

Answer 1

integumentary system

Question 2

what are the functions of the integumentary system?

Answer 2

Protection: against bacteria, foreign matter, water loss
Sensation: pain, temp, touch
Fluid balance: absorbs water, prevents excessive loss
Temp regulation: heat dissipation, evaporation
Vitamin production: vitamin D
Immune response functio: dermatitis, asthma. Cells in skin are diff inppl with allergies than those who are healthy

Question 3

bruising

Answer 3

ecchymosis

Question 4

red, pinpoint spots from blood leakage

Answer 4

petechiae

Question 5

itchy skin

Answer 5

pruitis

Question 6

redness

Answer 6

erythema

Question 7

bluish skin

Answer 7

cyanosis

Question 8

pale skin

Answer 8

pallor

Question 9

yellowing of the skin

Answer 9

jaundice

Question 10

ease of rising of skin

Answer 10

tugor

Question 11

ability of the skin to return to place

Answer 11

mobility

Question 12

moles

Answer 12

nevus

Question 13

what are the factors that affect the skin integrity?

Answer 13

physical, emotional and lifestyle
medical management
environment, socio-economic, care setting, potential for self-management
systems; health care support and communication

Question 14

Detailed history of general health
Diabetes, age, peripheral artery disease, collagen vascular disease cancer, chemo, among others

Answer 14

physical, emotional and lifestyle

Question 15

Overall health, OTC meds/creams, allergies, hydration, and nutrition, psychological factors
Pain assessment: painscales, one of the worst aspects of chronic wounds, lead to anx
Quality of life: mental and physical well being

Answer 15

medical management (listen)

Question 16

Overall impressionL body language, effect, interaction, clothing, assistive devices
Skin assessment: skin and mucous membranes, mobility/tugor, maceration, bruising, red shiny lower legs, edema, nail thickness, hair distribution

Answer 16

medical management (look)

Question 17

Skin temp, pitting edema, nutritional status, hemoglobin

Answer 17

medical management (touch)

Question 18

Income
Working conditions, food, housing/env\
Early childhood development
edu/literacy
Social supports
Health behaviours/access to healthcare
Lower income negatively impacts health, lack of resources and social supports can lead to smoking, alcohol/substance abuse

Answer 18

environment, socio-economic, care setting, potential for self-management

Question 19

Access to funding, access to services and wound-related products
Diagnostic services, service delivery personnel

Answer 19

systems; health care support and communication

Question 20

what are the changes related to aging?

Answer 20

Skin dryness, wrinkling, thinning, decreased tugor, increased skin fragility
Loss of subcut tissue
Decreased blood supply
Thinning hair
Photoaging

Question 21

what are the goals of care?

Answer 21

Should aim goals to SMART principle:
Specific – what needs to be accomplished (how, when, where
Measurable – how much, how many, how often
Attainable – realistically achievable
Rewarding –all should feel good when goal is achieved
Timely – realistic timeframe (short, intermediate and long

Question 22

what are the factors associated with increased wound infection?

Answer 22

Characteristics of the Individual
Poorly controlled diabetes
Prior surgery
Radiation or chemo
Hypoxia, anemia, arterial/vascular disease, rheumatoid arthritis,shock)
Immune system disorders (AIDS, malignancy)
Malnutrition, alcohol, smoking, drug abuse

Question 23

Contaminated wounds, trauma from delayed treatment
Pre-existing infection / sepsis
Penetrating wounds over 4 hours

Answer 23

acute wound

Question 24

Duration of wound, large wound area, deep wound
Located near a site of potential contamination (perineum, sacrum)

Answer 24

chronic wound

Question 25

what are the S&S associated with bacterial burden?

Answer 25

contamination colonization local infection

Question 26

wound acquires microorganisms, if not successful in invading host they will not multiply or persist

Answer 26

contamination

Question 27

microbial species grow and divide but does not cause damage or infection

Answer 27

colonization

Question 28

bleeding, wound breakdown and enlargement, delayed healing, pain, odour

Answer 28

covert (subtle)

Question 29

erythema, local swelling, purulent discharge, delayed healing, pain, odour

Answer 29

overt (classic)

Question 30

what are the S&S of spreading infection?

Answer 30

Extending induration, erythema Lymphagitis Wound breakdown with dehiscence (wound rupture along surgical incision) Malaise, nonspecific deterioration Loss of appetite Swelling of lymph glands

Question 31

what are the S&S associated with systemic infection?

Answer 31

Severe sepsis Septic shock Organ failure Death

Question 32

identify and implement an evidence-informed plan to correct the causes that affect skin integrity...

Answer 32

Physical activity – beneficial effects physically and mentally Nutrition – vital role in prevention and management of wounds Moisture control – keep skin dry, avoid irritants, treat secondary infection (manage incontinence) Pain management Smoking cessation, weight management, stress management, mental health programs

Question 33

normal saline, sterile water, tap water and antiseptics

Answer 33

wound cleansing

Question 34

antimicrobial or antiseptics (povidone-iodine)

Answer 34

infected wounds

Question 35

maggots liquify necrotic tissue and secrete substances that destroy bacteria

Answer 35

biological debridement

Question 36

applying moistened gauze and periodically removing it (wet to dry dressing); non-traumatic irrigation systems (syringe and needle) 19 gauge needle gives 15 pounds of pressure; ultrasound (sound waves through saline)

Answer 36

mechanical debridement

Question 37

specialized, powered surgical tool

Answer 37

hydrosurgical debridement

Question 38

sodium hypochlorite

Answer 38

chemical debridement

Question 39

self-digestion of enzymes naturally present in the wound

Answer 39

autolytic debridement

Question 40

application of proteolytic substances to breakdown tissue

Answer 40

enzymatic debridement

Question 41

fastest way to remove devitalized (slough), contaminated or infected tissue

Answer 41

surgical debridement

Question 42

removal of only devitalized tissue with scalpel or scissors

Answer 42

conservative sharp wound debridement

Question 43

how do we manage bacterial balance>

Answer 43

Optimize host response and wound environment Reduce the number of microorganisms Antibiotics – agents that kill selectively and require metabolic activity for action

Question 44

non-selective agents that does not require metabolic action

Answer 44

antiseptics

Question 45

umbrella term used to group antibiotics and antiseptics

Answer 45

antimicrobial

Question 46

Greyish-blue tone, especially in nail beds, earlobes, lips, mucous membranes, and palms and soles of feet Ashen or greyish colour most easily seen in the conjunctiva of the eye, mucous membranes, and nail beds

Answer 46

cyanosis

Question 47

Dark red, purple, yellow, or green colour, depending on age of bruise. Purple to brownish-black; difficult to see unless occurring in an area of light pigmentation

Answer 47

ecchymosis

Question 48

Reddish tone, possibly accompanied by increased skin temperature secondary to localized inflammation Deeper brown or purple skin tone with evidence of increased skin temperature secondary to inflammation

Answer 48

erythema

Question 49

Yellowish colour of skin, sclera, fingernails, palms of hands, and oral mucosa Yellowish-green colour most obviously seen in sclera of eye, palms, and soles

Answer 49

jaundice

Question 50

Pale skin colour that may appear white or ashen; also evident on lips, nail beds, and mucous membranes May appear yellowish, ashen, or grey

Answer 50

pallor

Question 51

Lesions appear as small, reddish purple pinpoints, best observed on abdomen and buttocks Difficult to see; may be evident in the buccal mucosa of the mouth or the conjunctiva of the eye

Answer 51

petechiae

Question 52

May be visualized as well as felt with light palpation. Not easily visualized, but may be felt with light palpation

Answer 52

rash

Question 53

Narrow scar line, usually white or pink. Higher incidence of keloid development, resulting in a thickened, raised scar

Answer 53

scar

Question 54

collect subjective data about overall health, family history, medications, skin disorders, allergies

Answer 54

health history

Question 55

assessment of all skin areas, mucous membranes, scalp, hair and nails

Answer 55

physical exam

Question 56

color, vascularity, temperature, mobility, turgor, texture and edema

Answer 56

inspection and palpation

Question 57

how do we assess lesions?

Answer 57

Type of lesion – primary or secondary (e.g. macule, papule, pustule, vesicle) Color of lesion Associated pain, redness, heat or swelling Size and location Configuration (pattern) of eruption

Question 58

what does documentation include for skin lesions?

Answer 58

Wound bed – necrotic or granulation tissue, exudate, color and odor Wound edges and margins – observe for extension of the wound under the skin surface Wound size – measure in mm or cm to determine diameter and depth Surrounding skin – color, suppleness and moisture and irritation

Question 59

what is the ABCDE method for screening moles

Answer 59

A : Asymmetry – one half is not like the other half B : Borders – irregular edges, ragged, notched and not well defined C : Color – variation or change D : Diameter – growth in size larger than a pencil E : Evolution – change in size, shape, symptoms, surface elevation, bleeding, color

Question 60

tissue obtained from nodules, plaques, blisters and other lesions for microscopic examination. Used to rule out malignancies or other disease

Answer 60

skin biopsy

Question 61

identifies site of immunologic reaction using dye

Answer 61

immunofluorescence

Question 62

applying suspected allergens to healthy skin

Answer 62

patch testing

Question 63

tissue samples and scraped from suspected fungal lesions and examined under microscope (scabies)

Answer 63

skin scrapings