Tissue Integrity Flashcards
1
Q
Epidermis
A
- surface or outermost part of the skin
- consists of epithelial cells
- 4 or 5 layers, depending on location
- -5 layers over the palms of the hands and soles of the feet
- -4 layers over the rest of the body
2
Q
Dermis
A
- second, deeper layer of skin
- flexible connective tissue
- richly supplied with blood cells, nerve fibers, and lymphatic vessels
- most hair follicles, sebaceous glands, and sweat glands are located in the dermis
- papillary and reticular layer
3
Q
SubQ tissue
A
aka hypodermis
- lies below the dermis
- loose connective tissue
- stores roughly half the fat cells of the body
- serves as insulator and cushion for the body
- stores energy from the fat
4
Q
Keratin
A
- fibrous, water-repellent protein
- gives epidermis its tough, protective quality
5
Q
Melanin
A
- forms a shield that protects the keratinocytes and the nerve endings in the dermis from the damaging effects of ultraviolet light
- accounts for the difference in skin color
6
Q
Sebum
A
an oily secretion of the sebaceous glands.
7
Q
Vernix caseosa
A
a greasy deposit covering the skin of a baby at birth.
-cheese like protectant
8
Q
Pruritis
A
severe itching of the skin, as a symptom of various ailments.
9
Q
functions of skin
A
- protection
- sensation
- temp regulation
- secretion
- excretion
10
Q
Newborn
A
- thin skin
- less subQ fat
- increased absorption of topical meds
- decreased ability to shiver
11
Q
Eldery
A
- decreased thickness and collagen
- decreased elasticity
- decreased subQ
- decreased sensation
- decreased thermoregulation
- increased healing time
- increased skin tearing
- decreased melanin
12
Q
Dark skin
A
- increased susceptibility to inflammatory processes and keloids
- post-inflammatory hypo- or hyperpigment action
- increased sebum production and sweat due to larger pores
- prone to scarring after acne
- age slower
- produces more melanin than light skin
13
Q
Asians
A
- less protective
- more sensitive
14
Q
culturally and ethnically diverse patients may…
A
use home remedies for hair and skin
15
Q
intact skin
A
normal skin and skin layers uninterrupted by wounds
16
Q
3 types of skin disorders
A
infectious
Inflammatory
neoplastic
17
Q
infectious skin disorder
A
caused by microorganisms
-bacteria, virus, fungi, or parasite
18
Q
inflammatory skin disorder
A
caused by pathologies
-acne, burns, eczema
19
Q
neoplastic skin disorder
A
caused by skin cancers
20
Q
primary lesions
A
arise from healthy skin (papules, macules, vesicles)
21
Q
secondary lesions
A
result from a change in a primary lesion (scar, keloid)
22
Q
Skin Assessment
A
- inspect for color, lesions, scars, tattoos
- inspect for alterations in integrity (redness, tears)
- inspect skin surrounding tubes, pins, caths, stomas
- note any odors
- palpate for temp, turgor, edema
23
Q
turgor
A
checking for hydration status
good/brisk: if it is elastic and returns quickly
24
Q
Risk factors for compromised skin integrity
A
- immobilization
- reduced sensation
- poor nutrition and/or hydration
- secretions/excretions
- altered cognition
25
Hair/scalp assessment
- inspect for hair distribution
- inspect for hair texture
- inspect for lesions
26
Nail assessment
- nail curvature
- nail color even
- not too thick
27
90% of African Americans have
pigmented bands
28
yellow nail
fungal; psoriasis
29
trauma to nail
turns dark color
30
normal nail curvature
160 degrees
31
clubbing
180 degrees
- CHD in children
- lack of oxygen or long term smoking in adults
32
tinea unguium
yellow, thick nail
- fungal, hard to treat
- oral antifungal
33
melanonychia
dark pigmented band in nail
common in His/Afr.Amer./Asians
Whites: could be melanoma, get checked immediately
34
Types of diagnostic tests for skin integrity
1. biopsy
2. culture
3. wood lamp
4. patch/scratch
35
biopsy
pathology
36
culture
infection; not prevention
| -what is growing??
37
wood lamp
fungal skin infections
38
patch/scratch test
allergies
39
Wounds can be...
- intentional or unintentional
| - open or closed
40
intentional
surgical incision
41
unintentional
road rash
42
open
papercut
43
closed
hematoma
44
clean
closed wounds
45
clean contaminated
surgical wounds
46
contaminated
fresh, accidental wounds
47
dirty or infected
dead tissue, w/ evidence of infection
48
incision
scapel, knife
49
contusion
bruise, sharp blow
50
abrasion
surface scrape
51
puncture
penetration of skin and underlying tissues, sharp instrument
| -can be intentional or unintentional
52
laceration
tissues torn apart; often accidents
53
penetrating
penetration of skin and underlying tissues
| usually unintentional
54
Untreated wounds
- control bleeding
- prevent infection
- control swelling and pain
- assess for signs of shock related to bleeding
55
signs of shock related to bleeding
- rapid, thready pulse
- cold and pale skin
- low BP
56
Treated wounds
- observe healing
- observe for signs of infection
- document
-if covered; assess dressing and document
57
C/D/I
clean/dry/intact
58
Types of wound drainage
serous
sanguineous
sero-sanguineous
purulent
59
serous
thin, watery, clear
60
sanguineous
thin, bright red (bloody)
61
sero-sanguineous
thin, watery, pale red to pink
| bloody and serous fluid
62
purulent
thick or think, color may be tan to yellow or green; may have offensive odor
-infectious looking
63
Wounds by depth
partial thickness
full thickness
64
partial thickness
heals on its own by regeneration
-contained in epidermis and dermis
65
full thickness
needs help healing through connective tissue repair
-involves, epidermis, dermis, subQ (hypodermis), muscle and bone possibly
66
dehiscence
see tissue underneath; partial or total rupture of sutured wound; usually involves abdominal wound
67
evisceration
protrusion of internal viscera through an incision
-usually abdominal contents showing or coming out
68
Pressure Ulcers
- develop over bony prominences
- external pressure impairs blood flow and lymph
- worsens with friction and shearing
69
event timeline of PU
ischemia-->necrosis-->pressure ulcer
70
ischemia
inadequate blood supply to an organ or part of the body
71
shearing
when moving patient in bed and bones move opposite of skin or skin stays put; skin tears
72
Risk of factors for pressure ulcers
- immobility
- poor nutrition
- incontinence
- decreased mental status
- decreased sensation
- increased temp of skin
- increased age
73
______ is key for PU
prevention
74
Prevention of Pressure Ulcers
- assess the skin!!!!!
- relieve pressure on body areas
- Q 2hr turning
- airflow beds
- provide nutrition
- maintain skin hygiene
- promote ROM/OOB/Mobility
75
Nutrition
- supplemental nutrition to increase calories, protein, vitamins, and iron
- monitor hemoglobin, albumin
- monitor weight
- monitor intake and output (I&Os)
76
Stage 1 Pressure Ulcer
non-blanchable
erythema of intact skin
can be painful, soft, firm, warm or cool
77
Stage 2 Pressure Ulcer
partial thickness skin loss (abrasion, blister, shallow crater)
involves epidermis and possibly dermis
Skin NOT intact
78
Stage 3 Pressure Ulcer
full thickness skin loss involving subQ tissue (deep crater)
| -may have undermining or tunneling
79
Stage 4 Pressure Ulcer
full thickness skin loss, tissue necrosis or damage to muscle, bone, or supporting structures (tendon or joint capsule)
-typically wheelchair bound patients
80
Unstageable Pressure Ulcer
full thickness tissue loss where the base of the ulcer cannot be seen
- covered by yellow, tan, brown, or black tissue
- not sure how deep the ulcer goes
81
Deep tissue injury
pressure-related deep tissue injury under intact skin
-purple or maroon localized area of discolored intact skin or blood-filled blister
82
Pressure Ulcer Treatment
- collaborative/interdisciplinary
- depends on stage
- wound management
- debridement, dressing
- surgical flap
- wound vacs
- drains, irrigation
- nutrition
- antibiotics
- maggots
83
Topical Corticosteroids
relieves inflammation and pruritus
- apply thin layer to avoid toxicity
- No more than 7 to 14 days
- assess for atrophy and hypo-/hyperpigmentation
84
Antiacne
gets worse before gets better
| minimize sun exposure
85
antibacterials/antibiotics
monitor for signs of allergic rxn
86
antifungals
monitor for allergic rxn
87
antivirals
may take several weeks
herpes not cured
teach standard precautions
88
anesthetics
avoid applying in large areas
| avoid eyes
89
antihistamines
avoid taking both oral and topical simultaneously
| avoid applying over large areas or broken skin
90
topicals are applied as...
creams
lotions
ointments
91
Braden scale
assess risk for pressure ulcer
| -most commonly used assessment tool in US for predicting pressure sore risk
92
6 categories of Braden scale
```
sensory perception
moisture
activity
mobility
nutrition
friction and shear
```
total of 23 pts possible
