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Fundamentals II > Wk 3 Integument > Flashcards

Wk 3 Integument Flashcards

1
Q

Where epidermis and dermis meet

A

Dermal-epidermal junction

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2
Q

The hypodermic has __ tissue woven through it

A

Connective

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3
Q

Layer of the epidermis that divides and proliferates

A

basal layer

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4
Q

Provides strength and support for higher layers and protects underlying bones and muscles

A

Dermis

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5
Q

Largest organ in the body

A

Skin

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6
Q

Primary purpose of skin is

A

Protection and sensory perception

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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

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8
Q

Pallor

A

Pale or white

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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

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10
Q

Good indication of circulation abnormalities

A

Color

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11
Q

Mucous membranes are an indicator of

A

nutritional status, shouldn’t be dry

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12
Q

Temperature changes are often an early sign of

A

Infection or circulation issues

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13
Q

Indurated

A

Thickening of the skin resulting from swelling, edema, inflammation

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14
Q

Patient should not be sweating

A

just laying in bed

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15
Q

Supple skin

A

Soft to touch and radiant

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16
Q

Elasticity of the skin, indication of fluid balance

A

Turgor

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17
Q

Turgor naturally __ with age

A

decreases

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18
Q

Color around vascular areas of the skin, that can be red, pink, or pale

A

Vascularity

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19
Q

Pinpoint, round spots that indicate small hemorrhages

A

petechiae

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20
Q

Grade 1+ pitting edema

A

2mm depression, barely detectable. Immediate rebound

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21
Q

Grade 2+ pitting edema

A

4mm deep pit, a few seconds to rebound

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22
Q

Grade 3+ pitting edema

A

6mm deep pit, 10-12 seconds to rebound

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23
Q

Grade 4+ pitting edema

A

8mm very deep pit, over 20 seconds to rebound

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24
Q

Pitting edema is most common in the

A

legs, ankles, or feet

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25
Q

Rebounding edema upon palpation

A

Pitting

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26
Q

Edema doesn’t rebound, it’s hard

A

Non-pitting edema, usually related to injury

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27
Q

Import to ask about changes in skin

A

Color, moisture, texture?

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28
Q

Questions to ask about skin

A

Do you have any history of skin issues? Any swelling? Any skin cancer risk factors?

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29
Q

Where to look to assess pallor

A

Mucous membranes

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30
Q

What does pallor (white/grey) indicate?

A

Anemia, shock, lack of blood flow

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31
Q

In dark skin tones, cyanosis can look

A

yellow-brown, or gray

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32
Q

What does cyanosis indicate?

A

Hypoxia, impaired venous return

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33
Q

Where to look for cyanosis

A

Nail beds, lips, mucousa

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34
Q

Circumoral cyanosis

A

Around the mouth

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35
Q

Cyanotic areas that are black will end up

A

dead, necrotic, because they don’t have oxygen flow to those areas

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36
Q

Where do you look for jaundice?

A

sclera of the eyes, skin, and mucous membranes

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37
Q

What does jaundice indicated?

A

Liver dysfunction, yellow caused by RBC destruction

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38
Q

Slightly yellow sclera in darker skin tones

A

Does NOT indicated jaundice

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39
Q

In a dark colored person compare yellow sclera of eyes to

A

palms of hands or feet

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40
Q

Erythema

A

Redness

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41
Q

Erythema difficult to see in darker skin tones as well

A

Need to assess warmth, texture changes, and ask the patient

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42
Q

Erythema indicates

A

Inflammation, vasodilation, sun exposure, elevated body temperature

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43
Q

If you see areas of redness or concern you can…

A

mark it and see if it continues to grow

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44
Q

Who might have impaired sensory perception

A

Immobile patients, patients in a lot of pain in other areas, or those under anesthesia

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45
Q

Risks for impaired skin integrity

A

Impaired sensory perception, impaired mobility, altered level of consciousness

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46
Q

Shear

A

Sliding movement of skin and subcutaneous tissue when muscle and bone are not working

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47
Q

With shearing, the underlying capillaries become

A

stretched and damage and leads to ischemia

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48
Q

Shearing is associated with

A

deeper tissues, such as the dermis

49
Q

Two surfaces moving across each other

A

Friction

50
Q

With shearing the outer layer of skin stays fixed

A

and the lower layer (dermis) moves down

51
Q

With friction, which layer of skin is affected?

A

Epidermis

52
Q

Moisture can impair skin integrity because

A

it softens the skin and makes it more susceptible to damage

53
Q

Moisture causes damage with

A

duration and amount of moisture

54
Q

What causes moisture for a patient?

A

Incontinence, sweating, wound exudate

55
Q

Why are older adults who have experienced a trauma (such as a hip fracture) particularly at risk for impaired skin integrity?

A

They are immobile, impaired sensory perception, inadequate nutrition

56
Q

Other patients at risk for impaired skin integrity

A

Spinal cord injuries, nutritional deficits, those in long-term care homes, acutely ill or in hospice, diabetic, in ICU or critical care, incontinent

57
Q

Why are patients with diabetes at risk for skin integrity?

A

They are higher risk for infection so their skin is likely to breakdown quicker

58
Q

Other names for pressure injuries

A

pressure ulcer, decubitus ulcer, bedsore

59
Q

area of prolonged pressure, localized injury

A

Pressure injury

60
Q

Areas at risk for pressure injury

A

back of the head, shoulders, coccyx, back of the heels

61
Q

People also get pressure injuries under the nose or behind their ears

A

due to a nasal cannula that doesn’t move

62
Q

What causes a pressure injury?

A

Pressure applied over a capillary that excessed normal capillary pressure and leads to tissue ischemia

63
Q

Three majored factors involved in pressure injury development

A

Pressure intensity, duration, tissue tolerance

64
Q

Example of pressure intensity

A

Obese patient

65
Q

Ability of our tissues to endure pressure

A

Tissue tolerance

66
Q

Things that affect tissue tolerance

A

Low blood pressure, poor nutrition, aging, hydration status

67
Q

How are pressure injuries stages?

A

Stage 1-4, depends on skin/tissue layer involvement

68
Q

Persistent non-blanch able deep red, maroon, or purple discoloration

A

Deep tissue injury

69
Q

With a deep tissue injury

A

You don’t know what layers are involved

70
Q

Turns red when pressure relieved

A

Blanchable

71
Q

Nonblanchable skin is the result of

A

Poor tissue perfusion and blood flow

72
Q

In nonblanchable skin the redness

A

doesn’t go away if you apply pressure

73
Q

Unstageable pressure injury

A

obscured by infection or dying skin, cannot determine involvement

74
Q

Slough

A

Yellow/white material in the wound bed. It’s necrotic tissue that can impeded the healing process

75
Q

Eschar

A

Dry dark scab or peeling away dead skin

76
Q

Moisture associated skin damage (MASD) types

A

incontinence associated, intertriginous dermatitis, periwound, peristomal

77
Q

Skin damage related to exposure to urine or stool

A

Incontinence related MASD

78
Q

Other names for incontinence related MASD

A

Diaper rash, perineal dermatitis

79
Q

Incontinence related MASD is usually related to

A

Liquid stool or diarrhea

80
Q

With incontinence related MASD you may need to use a

A

urinary catheter or tube to prevent the urine or stool from coming into contact with the patient’s skin

81
Q

Inflammatory dermatitis related to moist skin rubbing against each other

A

Intertriginous dermatitis related MASD

82
Q

Intertriginous dermatitis is common in

A

geriatric populations, those on bedrest

83
Q

Intertriginous dermatitis common in places like

A

under the breasts, axillary areas, perineal areas

84
Q

Intertriginous dermatitis will grow

A

yeast, you may see erythema, it will be itchy and it will ooze

85
Q

When bathing patient, make sure you check the skin folds to assess for

A

intertriginous dermatitis

86
Q

How to prevent intertriginous dermatitis

A

Keep skin folds dry! Can use pillows, powder, medications

87
Q

Associated with wounds or stomas and enzyme breakdown associated with exudate

A

peristomal/periwound MASD

88
Q

Disruption of the integrity and function of the tissues around the skin

A

Wound

89
Q

Proceeds through normal repair process and results in return to normal function and integrity

A

Actue wound

90
Q

Example of an acute wound

A

Trauma or surgery

91
Q

Wound that fails to heal and doesn’t return to normal function

A

Chronic wound

92
Q

Examples of chronic wounds

A

pressure ulcer, vascular insufficiency wound

93
Q

Chronic wounds may result in

A

permanent damage to the area (loss of sensation) and the likelihood that they will get another chronic wound there again

94
Q

What is important in regards to nutrition for wound healing?

A

Protein, Vit A, C, zinc, copper are critical, adequate caloric intake

95
Q

What labs are associated with nutrition status for wound healing?

A

Serum albumin and pre-albumin

96
Q

Protein needs are __ for those who have needs

A

increased

97
Q

May give…

A

vitamin and protein supplements to those who have wounds ex: beneprotein

98
Q

Why are diabetics or those with peripheral vascular disease at risk for poor wound healing?

A

Poor tissue perfusion

99
Q

Infections prolongs the…

A

inflammation process and delays healing

100
Q

Indications that a wound is infected

A

purulent drainage, changes in color/volume/redness around the tissue, fever or pain

101
Q

What can contribute to infection development?

A

low WBC count

102
Q

__ affects all aspects of wound healing

A

Aging

103
Q

Examples of aging and how it can affect healing

A

Delaying inflammatory response, delayed collagen synthesis, slower epithelialization

104
Q

Braden is a

A

skin assessment scale

105
Q

6 areas the Braden scale assesses

A

Sensory/mental, moisture, activity, mobility, nutrition, friction/shear

106
Q

15-16 branden score

A

Mild risk

107
Q

12-14 braden score

A

moderate risk

108
Q

Below 12 Braden score

A

high risk

109
Q

For those 75 years or older, a score of 15-18 is considered

A

mild risk

110
Q

With Braden scale, the lower the score

A

the higher the risk of skin breakdown

111
Q

Braden scales are not great for

A

Critical care or intensive care units

112
Q

To help prevent MASD, use products that

A

wick away moisture away from the patient ex: like Destine for a child

113
Q

One of the biggest things to prevent pressure injuries

A

TURN THE PATIENTS! In bed every 2 hours

114
Q

If patient is in a chair, should turn every

A

1 hour

115
Q

Try to limit how long a patient sits in a chair to less than

A

2 hours

116
Q

Don’t drag patients because it can cause

A

friction injuries. Use lift devices instead

117
Q

Padded dressing that you put on coccyx

A

Allyven or mepilex

118
Q

Nutritional supplement that helps with wound healing that has vitamins and protein in it

A

Juven

119
Q

Looks tan, will conform to patient, helps to position

A

Z flo positioner (fluidized)

Fundamentals II (2 decks)

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