Wk 3 Integument Flashcards
1
Q
Where epidermis and dermis meet
A
Dermal-epidermal junction
2
Q
The hypodermic has __ tissue woven through it
A
Connective
3
Q
Layer of the epidermis that divides and proliferates
A
basal layer
4
Q
Provides strength and support for higher layers and protects underlying bones and muscles
A
Dermis
5
Q
Largest organ in the body
A
Skin
6
Q
Primary purpose of skin is
A
Protection and sensory perception
7
Q
When looking at color look for
A
uniformity, areas of discolor, pay attention to palms and bottom of feet, especially in diabetic patients
8
Q
Pallor
A
Pale or white
9
Q
In patients with dark skin tones, to assess pallor look at
A
mucous membranes or areas of lighter skin such as the palms of hands, lips
10
Q
Good indication of circulation abnormalities
A
Color
11
Q
Mucous membranes are an indicator of
A
nutritional status, shouldn’t be dry
12
Q
Temperature changes are often an early sign of
A
Infection or circulation issues
13
Q
Indurated
A
Thickening of the skin resulting from swelling, edema, inflammation
14
Q
Patient should not be sweating
A
just laying in bed
15
Q
Supple skin
A
Soft to touch and radiant
16
Q
Elasticity of the skin, indication of fluid balance
A
Turgor
17
Q
Turgor naturally __ with age
A
decreases
18
Q
Color around vascular areas of the skin, that can be red, pink, or pale
A
Vascularity
19
Q
Pinpoint, round spots that indicate small hemorrhages
A
petechiae
20
Q
Grade 1+ pitting edema
A
2mm depression, barely detectable. Immediate rebound
21
Q
Grade 2+ pitting edema
A
4mm deep pit, a few seconds to rebound
22
Q
Grade 3+ pitting edema
A
6mm deep pit, 10-12 seconds to rebound
23
Q
Grade 4+ pitting edema
A
8mm very deep pit, over 20 seconds to rebound
24
Q
Pitting edema is most common in the
A
legs, ankles, or feet
25
Rebounding edema upon palpation
Pitting
26
Edema doesn't rebound, it's hard
Non-pitting edema, usually related to injury
27
Import to ask about changes in skin
Color, moisture, texture?
28
Questions to ask about skin
Do you have any history of skin issues? Any swelling? Any skin cancer risk factors?
29
Where to look to assess pallor
Mucous membranes
30
What does pallor (white/grey) indicate?
Anemia, shock, lack of blood flow
31
In dark skin tones, cyanosis can look
yellow-brown, or gray
32
What does cyanosis indicate?
Hypoxia, impaired venous return
33
Where to look for cyanosis
Nail beds, lips, mucousa
34
Circumoral cyanosis
Around the mouth
35
Cyanotic areas that are black will end up
dead, necrotic, because they don't have oxygen flow to those areas
36
Where do you look for jaundice?
sclera of the eyes, skin, and mucous membranes
37
What does jaundice indicated?
Liver dysfunction, yellow caused by RBC destruction
38
Slightly yellow sclera in darker skin tones
Does NOT indicated jaundice
39
In a dark colored person compare yellow sclera of eyes to
palms of hands or feet
40
Erythema
Redness
41
Erythema difficult to see in darker skin tones as well
Need to assess warmth, texture changes, and ask the patient
42
Erythema indicates
Inflammation, vasodilation, sun exposure, elevated body temperature
43
If you see areas of redness or concern you can...
mark it and see if it continues to grow
44
Who might have impaired sensory perception
Immobile patients, patients in a lot of pain in other areas, or those under anesthesia
45
Risks for impaired skin integrity
Impaired sensory perception, impaired mobility, altered level of consciousness
46
Shear
Sliding movement of skin and subcutaneous tissue when muscle and bone are not working
47
With shearing, the underlying capillaries become
stretched and damage and leads to ischemia
48
Shearing is associated with
deeper tissues, such as the dermis
49
Two surfaces moving across each other
Friction
50
With shearing the outer layer of skin stays fixed
and the lower layer (dermis) moves down
51
With friction, which layer of skin is affected?
Epidermis
52
Moisture can impair skin integrity because
it softens the skin and makes it more susceptible to damage
53
Moisture causes damage with
duration and amount of moisture
54
What causes moisture for a patient?
Incontinence, sweating, wound exudate
55
Why are older adults who have experienced a trauma (such as a hip fracture) particularly at risk for impaired skin integrity?
They are immobile, impaired sensory perception, inadequate nutrition
56
Other patients at risk for impaired skin integrity
Spinal cord injuries, nutritional deficits, those in long-term care homes, acutely ill or in hospice, diabetic, in ICU or critical care, incontinent
57
Why are patients with diabetes at risk for skin integrity?
They are higher risk for infection so their skin is likely to breakdown quicker
58
Other names for pressure injuries
pressure ulcer, decubitus ulcer, bedsore
59
area of prolonged pressure, localized injury
Pressure injury
60
Areas at risk for pressure injury
back of the head, shoulders, coccyx, back of the heels
61
People also get pressure injuries under the nose or behind their ears
due to a nasal cannula that doesn't move
62
What causes a pressure injury?
Pressure applied over a capillary that excessed normal capillary pressure and leads to tissue ischemia
63
Three majored factors involved in pressure injury development
Pressure intensity, duration, tissue tolerance
64
Example of pressure intensity
Obese patient
65
Ability of our tissues to endure pressure
Tissue tolerance
66
Things that affect tissue tolerance
Low blood pressure, poor nutrition, aging, hydration status
67
How are pressure injuries stages?
Stage 1-4, depends on skin/tissue layer involvement
68
Persistent non-blanch able deep red, maroon, or purple discoloration
Deep tissue injury
69
With a deep tissue injury
You don't know what layers are involved
70
Turns red when pressure relieved
Blanchable
71
Nonblanchable skin is the result of
Poor tissue perfusion and blood flow
72
In nonblanchable skin the redness
doesn't go away if you apply pressure
73
Unstageable pressure injury
obscured by infection or dying skin, cannot determine involvement
74
Slough
Yellow/white material in the wound bed. It's necrotic tissue that can impeded the healing process
75
Eschar
Dry dark scab or peeling away dead skin
76
Moisture associated skin damage (MASD) types
incontinence associated, intertriginous dermatitis, periwound, peristomal
77
Skin damage related to exposure to urine or stool
Incontinence related MASD
78
Other names for incontinence related MASD
Diaper rash, perineal dermatitis
79
Incontinence related MASD is usually related to
Liquid stool or diarrhea
80
With incontinence related MASD you may need to use a
urinary catheter or tube to prevent the urine or stool from coming into contact with the patient's skin
81
Inflammatory dermatitis related to moist skin rubbing against each other
Intertriginous dermatitis related MASD
82
Intertriginous dermatitis is common in
geriatric populations, those on bedrest
83
Intertriginous dermatitis common in places like
under the breasts, axillary areas, perineal areas
84
Intertriginous dermatitis will grow
yeast, you may see erythema, it will be itchy and it will ooze
85
When bathing patient, make sure you check the skin folds to assess for
intertriginous dermatitis
86
How to prevent intertriginous dermatitis
Keep skin folds dry! Can use pillows, powder, medications
87
Associated with wounds or stomas and enzyme breakdown associated with exudate
peristomal/periwound MASD
88
Disruption of the integrity and function of the tissues around the skin
Wound
89
Proceeds through normal repair process and results in return to normal function and integrity
Actue wound
90
Example of an acute wound
Trauma or surgery
91
Wound that fails to heal and doesn't return to normal function
Chronic wound
92
Examples of chronic wounds
pressure ulcer, vascular insufficiency wound
93
Chronic wounds may result in
permanent damage to the area (loss of sensation) and the likelihood that they will get another chronic wound there again
94
What is important in regards to nutrition for wound healing?
Protein, Vit A, C, zinc, copper are critical, adequate caloric intake
95
What labs are associated with nutrition status for wound healing?
Serum albumin and pre-albumin
96
Protein needs are __ for those who have needs
increased
97
May give...
vitamin and protein supplements to those who have wounds ex: beneprotein
98
Why are diabetics or those with peripheral vascular disease at risk for poor wound healing?
Poor tissue perfusion
99
Infections prolongs the...
inflammation process and delays healing
100
Indications that a wound is infected
purulent drainage, changes in color/volume/redness around the tissue, fever or pain
101
What can contribute to infection development?
low WBC count
102
__ affects all aspects of wound healing
Aging
103
Examples of aging and how it can affect healing
Delaying inflammatory response, delayed collagen synthesis, slower epithelialization
104
Braden is a
skin assessment scale
105
6 areas the Braden scale assesses
Sensory/mental, moisture, activity, mobility, nutrition, friction/shear
106
15-16 branden score
Mild risk
107
12-14 braden score
moderate risk
108
Below 12 Braden score
high risk
109
For those 75 years or older, a score of 15-18 is considered
mild risk
110
With Braden scale, the lower the score
the higher the risk of skin breakdown
111
Braden scales are not great for
Critical care or intensive care units
112
To help prevent MASD, use products that
wick away moisture away from the patient ex: like Destine for a child
113
One of the biggest things to prevent pressure injuries
TURN THE PATIENTS! In bed every 2 hours
114
If patient is in a chair, should turn every
1 hour
115
Try to limit how long a patient sits in a chair to less than
2 hours
116
Don't drag patients because it can cause
friction injuries. Use lift devices instead
117
Padded dressing that you put on coccyx
Allyven or mepilex
118
Nutritional supplement that helps with wound healing that has vitamins and protein in it
Juven
119
Looks tan, will conform to patient, helps to position
Z flo positioner (fluidized)
