ch 13 - skin care Flashcards
1
Q
functions of the skin (7)
A
- protect underlying structures
- regulate body temp
- sensory input
- stores fat
- metabolism of fat and water
- gas exchange
- production of vit d
2
Q
skin changes related to aging: epidermis (5)
A
- decreased melanocytes (lightened skin, decreased protection against sun)
- keratinocytes smaller (slowed wound healing)
- enlarged pigmented spots
- “liver spots”
- dermatosis papulosa nigra
3
Q
skin changes related to aging: dermis (5)
A
- 20% thickness loss (tears/bruising more likely)
- dermal blood vessels decrease (pallor, cooler temp, increased susceptibility to skin cancer)
- decreased collagen synthesis (tears more easily)
- thickened and fragmented elastin fibers (“saggy” appearance)
- decreased sebum production (dryer skin)
4
Q
skin changes related to aging: hypodermis (4)
A
- loss of subq fat tissue (higher risk injury)
- reduced efficiency of eccrine glands (temp regulation compromised)
- fewer meissners/pacinian corpuscles (diminished tactile sensitivity, higher risk injury)
- decreased langerhans cells (reduced skin immune response)
5
Q
skin changes related to aging: hair (1)
A
- diminished melanocytes, loss of hair
- other
6
Q
skin changes related to aging: nails (1)
A
-decreased circulation (brittle)
7
Q
common skin conditions (8)
A
- xerosis
- pruritis
- scabies
- purpura
- skin tears
- keratosis
- herpes zoster
- candidiasis
8
Q
-Extremely dry, cracked, and itchy skin
-Most common skin problem associated with
aging
A
xerosis
9
Q
cause of xerosis
A
decreased epidermal filaggrin
10
Q
where is xerosis most commonly seen
A
extremities
11
Q
interventions for xerosis (7)
A
- maintain 60% humidity environment
- adequate fluid intake
- apply lotions to damp skin after bath
- mineral oil or vaseline is more effective than lotion
- tepid water for bathing, avoid long baths
- use super fatted soaps or skin cleansers
- can use petroleum jelly to affected areas before bed
12
Q
Itchy skin (not a disease, but a symptom)
A
pruritis
13
Q
what can aggravate pruritis (8)
A
- perfumed detergents
- fabric softeners
- heat
- sweating
- restrictive clothing
- fatigue
- exercise
- meds
14
Q
3 examples of disease that can cause pruritis
A
- chronic renal failure
- biliary disease
- hepatic disease
15
Q
-Causes intense itching • Caused by tiny mites • Contagious, easily transmitted through close physical contact; intimate or casual
A
scabies
16
Q
3 objects that can transmit scabies
A
- clothing
- linen
- furniture
17
Q
way to diagnose scabies
A
skin scraping
18
Q
Tx scabies (3)
A
- prescribed lotion and creams
- wash clothes and linens in hot soapy water and dry with high heat
- clean and vacuum rooms
19
Q
Fragility of dermal capillaries secondary to dermal
thinning causing blood vessels to rupture; extravasation of blood into surrounding tissues
A
purpura
20
Q
where is purpura commonly seen
A
dorsal forearm
hands
21
Q
who is more susceptible to developing purpura
A
pts taking blood thinners
22
Q
how to decrease risk for developing purpura (2)
A
- pressure injury prevention
- fall prevention strategies
23
Q
- Occurs because skin is thin and fragile
- Painful, acute, accidental in nature
A
skin tears
24
Q
how are skin tears categorized
A
payne-martin classification system
25
management of skin tears (6)
- proper assessment
- control of bleeding
- cleanse with nontoxic solution
- appropriate dressing
- management of exudate
- prevention of infection
26
high risk pts for skin tears (7)
- old age
- fragile skin
- h/o skin tears/falls
- impaired activity
- impaired mobility
- impaired sensation
- impaired cognition
27
prevention tips for skin tears
- wear long sleeves/pants
- ensure adequate hydration and nutrition
- moisturize 2x daily
- careful transfers
- pad bed rails, wheelchairs arms, leg supports
- avoid adhesive products
- tepid water for bathing, soapless bathing products
- caregivers keep nails short and minimal jewelry
- fall preventions
28
-Benign growth
-Mainly see on trunk, face,
scalp, and neck
-Waxy, raised, stuck-on
appearance
-Flesh colored or
pigmented, various sizes
seborrheic keratosis
29
-Precancerous
-Related to exposure to
UV light
-Rough scaly sandpaper
patches
-Pink to reddish brown
with erythematous base
actinic keratosis
30
2 risk factors actinic keratosis
- increased age
| - fair complexion
31
```
• a benign epidermal
growth that presents as
hyperpigmented or skin-
colored papules
• develop on the face and
neck beginning in
adolescence.
-most commonly affects people of african/asian descent
```
dermatosis papulosa nigra
32
-Viral infection caused by reactivation of the varicella-
zoster (chicken pox) virus
-Preceded by itching, tingling, rash along the dermatome
prior to outbreak of vesicular lesions
-Lesions rupture, crust over, and heal
herpes zoster (shingles)
33
how long are shingles infectious
until crusts over
34
Tx shingles (4)
- analgesics
- calamine lotion
- antivirals
- vaccine if >60 yo
35
complications shingles (2)
- postherpetic neuralgia
| - eye involvement
36
risk factors candidiasis (6)
- obesity
- malnourishment
- antibiotic/steroid use
- immunocompromised
- chemotherapy
- diabetes
37
fungal infection Found in warm, moist areas of skin, like skinfolds, axilla, groin
candidiasis
38
prevention candidiasis (7)
- adequate drying of skin after baths
- prompt care after incontinence
- dry washcloth between skin folds
- loose fitting clothing and underwear
- avoid incontinent products that are tight or have plastic that touches skin
- avoid use of cornstarch
- optimize nutrition and glycemic control
39
-Most common
-Slow growing – metastasis rare
-Triggered by extensive sun exposure, burns,
chronic irritation, or ulceration
basal cell
40
-Second most common
-Aggressive – high risk for metastasis
-Major risk factors are sun exposure,
fair skin, immunosuppression
-Slightly different clinical presentations and may be overlooked
-Treatment depends on size, histology, and patient
preference
squamous cell
41
major risk factors squamous cell skin cancer (3)
- sun exposure
- fair skin
- immunosuppression
42
-Accounts for less than 2% of all skin cancers
-Neoplasm of the melanocytes
-Multicolored, raised, asymmetrical, irregular borders
-More common in men than women
-Risk factors: more than 50 moles, sun sensitivity, history excessive sun exposure, severe sunburns, tanning
beds
melanoma
43
type of skin cancer:
- raised mole
- irregular borders
- visible vasculature
basal cell
44
type of skin cancer:
- raised mole
- irregular borders
- dry crusty ulceration
squamous cell
45
type of skin cancer:
- multicolored
- raised mole
- irregular borders
melanoma
46
tips for promoting healthy skin (6)
- avoid indoor tanning
- wear protective clothing, hat, sunglasses
- sunscreen atleast 30 SPF
- apply sunscreen 30 mins before going outside, reapply q2h
- examine skin head to toe every month
- yearly dermatology skin exam
47
skin danger signs (ABCDE)
```
Asymmetry
Borders irregular
Color variation
Diameter >6mm
Elevation and enlargement
```
48
where do pressure injuries most frequently occur
posterior aspects of body
| especially sacrum, heels, greater trochanter
49
what disease puts pts at highest risk for pressure injury
PVD
50
stage of pressure injury: nonblanchable erythema of skin
stage one
51
stage of pressure injury: red discolored skin with exposed dermis
stage two
52
stage of pressure injury: red and excoriated with exposed adipose tissue
stage three
53
stage of pressure injury: visible muscle and exposed/directly palpable fascia, muscle, tendon, ligament, cartilage, or bone
stage four
54
stage of pressure injury: black necrotic appearance, presence of slough/eschar
unstageable
55
risk factors pressure injuries (7)
- comorbid illnesses
- malnutrition
- frailty
- surgical procedure
- cognitive deficits
- incontinence
- reduced mobility
56
mnemonic for prevention of medical device related pressure injuries (DEVICE)
- Determine all med devices are commercially manufactured and not placed over existing injury
- Evaluate skin and devices atleast bid
- Verify all nursing staff know how to correctly use and secure medical devices
- Identify all medical devices on pt
- Consider: does pt still need, is fit right, and can dressing be used underneath
- Educate all staff to look for objects under pt
57
mnemonic for pressure injury Tx (DIPAMOPI)
- Debride
- Identify and treat infection
- Pack dead space lightly
- Absorb excess exudate
- Maintain moist wound surface
- Open or excise closed wound edges
- Protect healing wound from infection/trauma
- Insulate to maintain normal temp
58
what dressing would be good for shallow dry pressure injury
hydrating dressing
59
what dressing would be good for shallow wounds with moderate to large exudate
hydrocolloids
semipermeable polyurethane foam
calcium alginates
silicone-type foam
60
what dressing would be good for deep wounds with moderate to large exudate
copolymer starch
dextranomer beads
calcium aginates
foam cavity
61
nursing assessment for older adult with pressure injury (6)
- thorough assessment of skin (braden scale)
- nutritional evaluation
- labs
- positioning
- incontinence care
- wound nurse consult if needed
62
what is considered high risk on braden scale
10-12
63
what is considered severe risk on braden scale
9 or less
64
what is considered moderate risk on braden scale
13-14
65
what is considered mild risk on braden scale
15-18
66
what is considered no risk on braden scale
19-23
67
how often should nurse inspect skin in acute care setting
- on admission
- q24h
- if pts condition changes
68
how often should nurse inspect skin in long term care setting
- on admission
- weekly for 4 weeks, then quarterly
- if pts condition changes
69
how often should nurse inspect skin in home care setting
- on admission
| - at every home nurse visit
70
payne-martin skin tear classification:
- linear type skin tear
- epidermis and dermis pulled apart
- without tissue loss
category 1A
71
payne-martin skin tear classification:
| -epidermal flap completely covers dermis within 1 mm of wound margin
category 1B
72
payne-martin skin tear classification:
| -scant tissue loss (less than 25%) of epidermal flap lost)
category 11A
73
payne-martin skin tear classification:
| -greater than 25% epidermal flap lost
category 11B
74
payne-martin skin tear classification:
| -epidermal flap absent
category 111
75
what is a "never event"
- event deemed by the CMS to be a hospital-acquired condition or preventable event
- hospital doesn't receive additional reimbursement to care for pt
76
ability of the tissue to distribute and compensate for pressure exerted over bony prominences.
tissue tolerance
77
factors that affect tissue tolerance (7)
- moisture
- friction
- shear force
- nutritional status
- age
- sensory perception
- arterial pressure
78
core preventative strategies for pressure injuries (5)
- risk assessment
- skin assessment
- nutritional assessment
- repositioning
- appropriate support surfaces
