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NUR 333: > Skin > Flashcards

Skin Flashcards

(70 cards)

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1
Q

Largest organ in body

A

Skin

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2
Q

Layers of skin

A

Dermis
Epidermis

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3
Q

What separates the two layers of skin

A

Dermal epidermal junction

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4
Q

Role of epidermis

A

Divides and proliferates, sloughs off dead cells

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5
Q

Role of dermis

A

Provides strength and support or upper layers, protects underlying layers (muscles, bones)

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6
Q

Primary purpose of skin

A
  • protection
  • sensory protection
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7
Q

Main assessments of skin

A
  • color
  • moisture
  • temperature
  • texture
  • turgor
  • vascularity
  • edema
  • lesions
  • have you noticed any changes or issues?
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8
Q

Pitting edema

A

1+ 2 mm deep, barely detected
2+ few seconds to rebound
3+ 10 -12 secs to rebound
4+ more than 20 secs to rebound

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9
Q

Pallor

A

Loss of color, in black skin tones it can be gray
- mucous membranes
- indications: anemia, shock, lack of blood flow

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10
Q

Cyanosis

A

Bluish discoloration, brown/dark skin can turn yellow-brown, gray
- nail beds, lips, mucous membranes
- indications: hypoxia, impaired venous return

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11
Q

Jaundice

A

Yellow discoloration
- sclera, skin, mucous membranes, can do palms of hands
- indication: liver dysfunction (RBC break down causing yellow)

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12
Q

Risk factors for impaired skin integrity

A
  • impaired senseroy perception
  • impaired mobility
  • altered LOC
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13
Q

Shear

A

Sliding movement of skin and subq tissue when muscle and bone are not moving
- more dermal layer
- affects capillary, stretch and damage, cause ischemia

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14
Q

friction

A

Two surfaces moving across one another
-most common, easy to identify
- occurs when pulling up pt in bed
- outer layer of skin

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15
Q

Moisture

A

Duration and amount of moisture determine risk, softens your skin making it susceptible to damage (incontinence, sweating, wound exudate)

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16
Q

who’s at risk for skin integrity

A
  • older adults: trauma
  • spinal cord injuries
  • nutritional deficiencies
  • long term homes
  • acutely ill, hospice
  • diabetes
  • ICU, critical care
  • incontinence
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17
Q

Pressure injuries

A

Impaired skin related to prolonged, unrelieved pressure
- localized
- can be caused by medical device
* pressure applied over a capillary (weak) exceeds normal capillary pressure then it can lead to ischemia *

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18
Q

Major factors of pi

A

Pressure intensity (can be affected by heavier wt)
Pressure duration
Tissue tolerance

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19
Q

Deep tissue injury

A

Persistent non-blanchable deep red, maroon, purple discoloration
- can’t tell what layers are involved

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20
Q

Unstageable

A

Obscured by infection or dying skin, cannot determine involvement

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21
Q

Blanchable

A

Skin turns red when pressure relieved

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22
Q

Non blanchable

A

Redness does not occur

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23
Q

MASD

A

Moisture associated skin damage
- incontinence related
- intertriginous: inflammatory dermatitis, moist skin or rubbing together
- periwound/peristoma: wounds or stoma related, enzyme in exudate associated w breakdown

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24
Q

Wound

A

Disruption of the integrity and function of the tissue

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25
Acute wounds
- proceeds through normal and timely repair - results in return to normal and sustained function and anatomical integrity - ex: trauma/surgical incisions
26
Chronic wounds
- wound that fails to proceed through normal healing process - does not return to normal function/anatomical integrity - ex: pi, vascular insufficiency wound
27
Nutrition for wounds
- def result in delayed healing - protein, vitamin a,c, since, copper - adequate calories - labs: serum albumin, pre albumin
28
Tissue perfusion
Ability to perfume tissues w oxygenated blood crucial to wound healing - diabetes and peripheral vascular at risk
29
Infection and wounds
- prolongs inflammation and delays healing - will have purulent drainage, changes in color, fever, pain - low WBC can delay healing, dec ability to fight
30
Age and wounds
- affects healing - delayed inflammatory responses - delayed collagen synthesis, - slower epitheliation
31
Braden Risk Assessment
*table 48.3, 1244* - 6-23 - lower the score, the increased risk of impairment - not great for ICU so use a diff one
32
Interventions to prevent impaired skin
- nutrition: extra supplements, protein, calories, nutrients - incontinence/moisture management: moisture barrier, products that wick moisture away - positioning: q2, move to chair, use assist device to prevent drag, specialized equipment *slide 78*
33
Factors that affect wound healing
- age, loss of skin turgor, skin fragility, dec collagen - dec circulation and oxygenation - slower tissue regeneration - dec absorption of nutrients - impaired immune function - dehydration
34
Factors affecting wound healing pt 2
- overall wellness - dec WBC - infection - medications - low HgB levels - obesity, smoking, chronic disease - malnutrition
35
Inflammation
Localized protective response to injury to destruction of tissue
36
3 components of management
- assessment —> thorough and document - cleansing - protection
37
Wound assessment
- Appearance: red, yellow, black - length, depth, width - closed: well approximated? - drains, tubes? - pain
38
Wound assessment: appearance
- red: signs of inflammation, good thing is localized - yellow: likely indication of infection - black: eschar that requires surgical debridement
39
Wound assessment: length, width, depth
Sinus tracks, tunnels, redness/swelling - common in the vaginal, sacral, anal areas - mark and measure areas around too that are not normal
40
Wound assessment: closed wound
Edges are well approximated (clean and closed) - staples, sutures, tissue adhesive - can break open bc too much movement, swelling, etc - always consider how long the staples should be there
41
Wound assessment: drains/tubes
- where are the drains located - what is the color of drainage - how much drainage is present - making sure the drains are not clogged
42
Wound assessment: pain
- pain is typically good bc its a indicator that something is wrong and we can solve that problem - control it w meds - understand if the pain is appropriate for the wound
43
Wound drainage
- can be normal/abnormal - doc amount, odor, consistency, color - note integrity of skin surrounding - can weigh dressing for amount of drainage (1g=1ml) but most ppl just say scant moderate large copious)
44
Types of exudate
- serous - serosanguinous - sangiuneous - purulent
45
Serous exudate
Portion of blood (serum) that watery and clear or slightly yellow in appearance - think blisters
46
Serosanguinous
Contains serum and blood, more watery - looks pale pink
47
Sanguineous
Serum and red blood cells, thick and appears reddish - brighter red is indicative of actual bleeding - darker red is indicative of older bleeding
48
Purulent
Thick, contains WBC, tissue debris, and bacteria - results of an infection - yellow, tan, green, brown (any color not pink or red)
49
Nursing intervention for pt wounds
- adequate hydration and nutrition - monitor albumin and prealbumin - wound cleaning - remove sutures - admin analgesics - admin antimicrobials and monitor effectiveness - document
50
Wound dressing types
- woven gauze - non adherent material - wet to dry - self adhesive, transparent - hydrocolloid
51
Purpose of gauze sponges
Helps absorb exudate
52
Purpose of non adherent material
Don’t want dressing to stick to wound bed
53
Purpose of wet to dry
Used to mechanically debride a wound until granulation tissue starts to form - mechanically: remove damage skin off wound
54
Self adherent, transparent purpose
Allow you to watch the wound w out having to - typically superficial wounds - not really good for fragile skin
55
Hydrocolloid
Occlusive dressing that swells in the presence of exudate - forms seal abound wound surface preventing evaporation from the skin - helps maintain granulating wound bed *some can last 3-5 days, but if the dressing is filled w exudate then change it*
56
Hydrogels
Mostly water, gels after contact w exudate - promoted autolytic debridement - rehydrates and fills dead space - used for infected deep wounds or necrotic tissue - dont use if lots of drainage - provides moist wound bed and reduce pain - prevents skin breakdown in high pressure areas
57
Alginates
Non adherent dressing that conform to wounds shape and absorb exudate - provides moist wound bed - back wounds - support debridement
58
Collagen
Powders, pastes, granules, gels - helps stop bleeding, promotes wound healing
59
Vacuum assisted closure system
Use foam strips into wound bed with occlusive dressing, create negative pressure to occur once tubing is connected - helps w tissue generation, dec swelling, and enhance healing in moist protective environment - suctions wound close and brings blood supply towards wound - some can infuse antibiotics
60
Complications wound healing
- adhesions - contractions - hemorrhage - dehiscence - evisceration - fistula formation - infection - excessive granulation tissue - keloid formation
61
Hemorrhage
Blood ruptures from vessel - greatest risk first two days after surgery - can be caused by clot dislodgment, slipped suture, blood vessel damage - may be swelling, distinction, sanguineous drainage - subtle change in vs - can be emergency
62
Hematoma
Local are of blood collection that appears as red or blue bruise
63
Hemorrhage emergency actions
Apply pressure dressing, notify provider, monitor vs
64
Dehiscence
Partial or total rupture of a sutured wound, usually w a separation of underlying skin - inc risk if obese, move too early - will not be resutured, left to heal/close on own
65
Evisceration
A dehiscence that involved the protrusion of visceral organs through wound opening - typically traumatic incidents or occurs around vaginal/anal canals
66
Eviscerations manifestations
Significant inc in flow of serosanguinous fluid on the wound dressing - immediate history of sudden straining (coughing, vomiting, going to the bathroom) - pt reports sudden change/popping/giving way - visualize viscera
67
Risk factors for dehiscence and evisceration
- chronic disease - advanced age - obesity - invasive abdominal cancer - vomiting (other excessive strains like coughing, sneezing) - dehydration - malnutrition - ineffective suturing - abdominal surgery - infection
68
Dehiscence and evisceration, nursing management
- notify provider - stay w pt - cover wound w gauze and any organs w sterile towel/sterile dressings soaked w sterile saline - dont try to put organs back - position pt supine with hips and knees bent - calm environment - NPO
69
Infection info
- big risk always being monitored for - risk factors: age extremes, immune suppression, impaired circulation/oxygenation, wound condition, chronic disease, poor wound care - 2-11 days after injury: pain, redness, swelling, edema, purulent drainage, fever, chills, odor, inc pulse/RR/WBC
70
Infection, nursing interventions
-prevent infection by using aseptic technique w dressing changes - provide optimal nutrition - provides adequate rest - administer antibiotics therapy

NUR 333: (10 decks)

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