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FOUNDATIONS EXAM 3 > Skin Integrity > Flashcards

Skin Integrity Flashcards

(63 cards)

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1
Q

What are the layers of the skin?

A

Epidermis, Dermis, Subcutaneous Tissue

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2
Q

What are the functions of the integumentary?

A

Protection, metabolism, thermoregulation, elimination, sensation, psychosocial, absorption

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3
Q

How does the integumentary protect?

A

-from physical and chemical injury
USING sebum and normal flora

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4
Q

How does the integumentary metabolize

A

Vitamin D

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5
Q

How does integumentary thermoregulate

A

The dilation and constriction of blood vessels

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6
Q

How does the integumentary eliminate?

A

Water, electrolytes, and wastes

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7
Q

How does the integumentary control sensation?

A

Nerve endings

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8
Q

How does the integumentary relate to psychosocial

A

Facial expressions and hair distribution

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9
Q

How does the integumentary control absorption

A

Substances can be absorbed from vascularity

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10
Q

What factors affect the integumentary

A

Circulation, nutrition, skin condition (wet dry), allergy, infection, abnormal growth rate, systemic diseases

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11
Q

Signs of altered integumentary function

A

Pain, pruritus, rash, lesions

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12
Q

What is pruritus

A

Itching

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13
Q

List alterations to the integumentary

A

Intentional/unintentional
Open/closed
Acute/chronic

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14
Q

Integumentary concerns with children under 2

A

-skin is thinner and weaker
-does not have good adhesion between skin layers
-skin/mucous membranes are easily injured and subject to infection
-will become increasingly resistant

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15
Q

Integumentary concerns of elderly

A

-maturation of epidermal cells is prolonged, causing thin and easily damaged skin
-circulation and collagen formation are impaired, causing decreased elasticity and increased risk for pressure injury

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16
Q

What is the largest organ that provides sensory and a regulatory process

A

Skin/integumentary

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17
Q

Key points of the epidermis

A

-replaced monthly
-outer skin layer
-no blood vessels

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18
Q

Facts about the dermis

A

-cares for the epidermis
-has blood vessels, nerves, lymph and connective tissues

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19
Q

How does circulation effect the skin

A

The skin needs oxygen, waste removal and nutrition. If the body has impaired circulation resources will be given elsewhere

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20
Q

What nutrients affects the skin

A

Vitamin C, protein, carbs

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21
Q

Key point about skin and allergies

A

Skin will be the first response to allergy

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22
Q

Most common infections to the skin, and what do viruses and fungi cause?

A

Strep and Staph
-Virus=Warts
-Fungus=Yeast

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23
Q

Systemic diseases that affect the skin

A

PVD, HF, kidney failure (toxins), liver failure, peripheral neuropathy, diabetes

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24
Q

Symptoms of psoriasis and aggregators

A

-skin will regenerate every 3-4 days
-chronic condition
-red scaly plaques (scalp, elbows, knees, feet)
Effected by stress and environment

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25
Concern with unintentional wound
More prone to infection, with longer healing time
26
What makes something an intentional wound
Created under ideal conditions for therapeutic conditions
27
What makes a wound open/closed
Open=skin is broken Closed=trauma is under the surface
28
Difference between acute/chronic wounds
Acute=predictable pattern Chronic=inflamed, stuck in the inflammatory stage and will heal slowly
29
Define Laceration, puncture, abrasion, and exposure wound
L=tearing of skin, normally loose skin P= increased infection risk, contaminated object enters skin A= rubbing/scraping E= temperature, pH, chemicals, electricity (causing skin cell death)
30
What is the primary intervention for pressure injuries
Prevention
31
What is the difference between pressure injuries, decubitus ulcers and bed sores
Nothing, they are all the same
32
What is a pressure injury
Death of tissue, caused by external pressure over a bone
33
Common causes and risk factors to pressure injuries
C= pressure intensity and duration R= impaired tissue tolerance, nutrition, moisture, age, friction, shear, Braden score less than 18 comorbid conditions: quadriplegic, unaware, dementia, ICU pts. Stroke, anything effecting consciousness, sensory, mobility
34
What is shear
Epidermal and dermal layer moving in opposite direction
35
What is a stage 1 pressure injury
Non blanchable erythema of intact skin
36
What is a stage 1 pressure injury
Non blanchable erythema of intact skin
37
What is a stage 2 pressure injury
Partial thickness skin loss Looks like abrasion or blister
38
What is a stage 3 pressure injury
Full thickness skin loss with damage or necrosis of SQ tissue Presents as a deep crater
39
What is a stage 4 pressure injury
Full thickness skin loss with extensive destruction, necrosis, damage to muscle, bone or tendons
40
What is slough
Non viable tissue -yellow, tan, gray, green, brown WOUND WILL NOT HEAL WITH IT
41
What is Escher
Dark brown or black -crust like, non viable tissue WOUND WILL NOT HEAL WITH IT
42
What is an unstageable pressure injury
Full thickness tissue damage, base of the wound is covered with slough or Escher -will be a 3-4 once dead tissue is removed and depth can be determined
43
What is a suspected deep tissue injury SDTI
Purple or maroon localized area of intact skin -can be confused to be stage one, but is 3-4
44
What is autolytic debridement
Used of hydrocolloid or foam dressings Body’s enzymes and defense mechanisms will remove necrotic tissue -dressings stay on for 3-7 days
45
What is enzymatic debridement
Application of prepared enzymes -most common treatment
46
What is sharp/surgical debridement
Use of a scalpel, done by physicians or advance practice can be done bedside or OR
47
What is mechanical debridement
Use of physical force, painful and old fashioned style -pressure wash, wet/dry dressing Can have pain meds or surgery to perform -ex. hydrogen peroxide
48
What is bio-surgical debridement
Use of surgical grade larvae, secretes enzyme that eats necrotic tissue -can be last option before amputation -can also be non therapeutic
49
List types of debridement in order of least to most severe
Autolytic, enzymatic, sharp, mechanical, bio-surgical
50
Define hemostasis healing
Controls bleeding and lasts 48 hours -vasoconstriction -exudate production -clot formation
51
Define hemostasis healing
Controls bleeding and lasts 48 hours -vasoconstriction -exudate production -clot formation
52
What is exudate
Plasma/clear fluid
53
What is exudate
Plasma/clear fluid
54
What is inflammatory response in terms of wound healing
WBC are working (with temporary increase) lasting 4-6 days -vasodilation -phagocytosis (digestion of foreign substances) -localized response — redness/heat
55
What is proliferative in terms of wound healing
New tissue is being formed, lasts 3-24 days -fibroblasts and growth factor create collagen and blood vessels -granulation formation —small/fragile skin cells
56
What is maturation in terms of wound healing
Can take 2 years -collagen matures and scar tissue is created -A vascular and less elastic -10-12 weeks to reach 70-80% strength
57
Describe primary intention wound healing
Most common process and the goal -think surgical wound
58
Describe secondary intention wound healing
What pressure injury would be
59
Describe tertiary intention wound healing
Delayed closure intentionally Least common healing process
60
Systemic factors effecting wound healing
Age, nutrition (protein/albumin, vitamin A/C, zinc) Circulation/oxygenation Health status- diabetes, shock, obesity, suppressed immune system (neutropenic)
61
What are some local factors effecting wound healing
Moisture -desiccation—DRY -maceration —MOIST Trauma (injury that got injured) Edema (impaired blood flow) Infection (competition) Bleeding Necrosis Biofilm (thick, slimy, sugar proteins of bacteria, resistant and tricky to manage)
62
Common complications of wound healing
Hemorrhage -bleeding in or out -hematoma (inside, collecting blood, watch for pressing on nerve or vessel) Dehiscence (caused by infection, bleeding, strength) Evisceration Infection Fistula - passage between surfaces dont connect (Wound healing, trauma, cancer)
63
Signs of localized infection
Redness — cant happen in late healing Heat Edema Pain Altered function Drainage and dehiscence

FOUNDATIONS EXAM 3 (6 decks)

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