Skin integrity: Power Point Flashcards by jennifer ortega

Purpose of Integumentary System

Protection against infection
Major organ of sense
Temperature regulation
Prevents fluid loss
Elimination of wastes
Storage and synthesis
Absorption
Psychosocial wellness

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Puritius

Itching

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PQRSTU

provoke, quality, radiate, severity, time, u

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presently altering skin integrity

Demographics: age, gender, race
PQRSTU for skin!
Exposure to chemicals or irritants
Description of injury (if applicable)
Changes from baseline
Pain
Puritis
Exudate or drainage

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health of…

Rash history
Allergy history
Scarring history
Tanning/burning history
Smoking history
Chronic illnesses (especially autoimmune)
History is usually problem based

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Jaundice

yellow color of the skin and whites of the eyes caused by excess bilirubin in the blood

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Bilirubin produced by

normal breakdown of red blood cells

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bilirubin is excreted through

the liver and excreted by bile from a result of hemolysis

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influences on the skin… there are a ton!!!

Illness
Extremes in weight
Fluid loss
Perspiration
Skin diseases
Jaundice
Decreased self care
Immobility
Poor nutrition
Dehydration
Decreased sensation
Vascular problems
Exposure to irritants
Chronic disease

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Psychosocial factors

Culture
Socioeconomic status
Access to running water
Emotional health
Personal preferences

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Age related changes: infancy

Infancy
Skin is delicate
More prone to infections

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Age related changes: childhood

Childhood

Increased resistance to injury

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Age related changes: adolescence

Adolescence
Increased secretion of sebum
Increased incidence of acne

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age related changes: Mid to late adulthood

Skin becomes thinner
Decreases in elasticity
Less subq fat
Slower wound healing
Decreased insulating quality
Changes in pigmentation
Senile Lentigines

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benign, localized brownish patch on the skin, often occurring in old age and usually in fair-skinned people with sun-damaged skin

age spot…Senile Lentigines

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senile lentigines

age spots

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a common, inflammatory skin condition that causes flaky, white to yellowish scales to form on oily areas

seborrheic ddermatitis

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always look first

Inspection

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skin inspection

Inspect in adequate light
Overall color
Localized variations
Presence of open areas or sores

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Thick, leathery skin, usually the result of constant scratching and rubbing

lichenification

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shapes of lesions

Round/Oval
Annular
Iris
Gyrate

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patterns of lesions

Singular/discrete
Grouped/clustered
Polycyclic
Confluent
Linear
Zosteriform
Generalized

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while palpitating notice for…. (5)

Texture
Temperature
Moisture
Skin turgor
Thickness
Callus

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no need to…. while assessing

percussion, auscultation

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lab/diagnostics

culture, biopsy

if purulent, considered...

infected

skin teaching/health promotion (6)

``` Cleanliness Adequate hydration Adequate nutrition Use sunscreen Don’t pick, lance, squeeze, or otherwise manipulate lesions Keep open wounds covered ```

Acute Wounds (3 types)

trauma, surgery, "healing chronic wounds"

Traumatic Wounds: acute (5)

``` Contusions Abrasions Avulsions Lacerations Punctures ```

avulsions

is an injury in which a body structure is forcibly detached from its normal point of insertion by either trauma or surgery

chronic wounds

Ulcers and wounds that take > 3 months to heal

types of chronic ulcers

diabetic, pressure, and circulatory Pressure ulcers Venous ulcerations Arterial ulcerations Diabetic ulcerations

the healing process

inflammation, proliferation, maturation

1st step of the healing process

inflammation 24 hour period endothelial cells release cytokines Inflammatory Cascade

2nd step of the healing process

``` Proliferation Phase 2 days-3 weeks Granulation edges pull together Epithelialization ```

3rd step of the healing process

Maturation, Remodeling Phase 3 weeks-2 years New Collagen

scar tissue is only...

80% as strong as original tissue

types of healing

primary, secondary, and tertiary

Primary intention healing

Surgical closure of a wound | Closure is complete

benefits of primary intention healing

Minimal tissue loss | Scarring is minimal

Secondary intention of healing

Gap exists between tissue margins | Granulation tissue must fill gaps

causes of secondary intention of healing wounds

too large, delayed wound closure

tertiary intention is also called

delayed surgical closure

reasons for tertiary intention of healing

dehiscence, infection, debridement needed

wide scars are a result of what healing type....

tertiary intention

the healing process is slow in what healing type...

secondary intention

role of healing: protein

Fibroplasia, angiogenesis, collagen formation | and wound remodeling, immune function

role of healing: zinc

Collagen formation, protein synthesis, cell | membrane and host defenses, Epithelialization

zinc caution

large doses can be toxic

role of Vitamin C

Collagen synthesis, capillary wall integrity, fibroblast function, immunological function, antioxidant

role of Vitamin A

Epithelialization, wound closure, inflammatory | response, angiogenesis, collagen formation

Vitamin A caution

Can reverse steroid effects on skin and delayed healig

role of `Vitamin E

No known role in wound healing, antioxidant

Vitamin E caution

blood thinner

sources of vitamin E

fish, oysters, liver, dark meat, eggs, legumes

important to wound healing...

Tissue Perfusion

infection or contamination of a wound...

stops the wound from healing, increased costs, must be eradicated so healing can occur

how does the infection stop a wound from healing...(4)

Prolongs inflammatory phase Disrupts normal clotting mechanisms Promotes disordered white cell response Disrupts or prevents development of new blood vessels and granulation tissue

wound assessment (7)

``` Location Size Surrounding skin color Drainage Wound surface Induration Granulation tissue ```

measuring a wound....

diameter, depth in cm or mm

saline, water, hydrogen peroxide, iodine, cotton gauze and swabs

cleaning wounds

rule of thumb when cleaning wounds

"if you can't put it in your eye, it doesn't belong in a wound"

things to look for in a good dressing.... (bunch)

Will remove excessive exudate but won’t let the wound dry out. Will allow gas exchange. Will be thermally insulating. Will be impermeable to micro-organisms. Will be free from particulate or toxic contamination. Will be non-traumatic and will not adhere to the wound. Will use minimal tape.

Skin integrity: Power Point Flashcards

(63 cards)