ch 13 - skin care Flashcards
functions of the skin (7)
- protect underlying structures
- regulate body temp
- sensory input
- stores fat
- metabolism of fat and water
- gas exchange
- production of vit d
skin changes related to aging: epidermis (5)
- decreased melanocytes (lightened skin, decreased protection against sun)
- keratinocytes smaller (slowed wound healing)
- enlarged pigmented spots
- “liver spots”
- dermatosis papulosa nigra
skin changes related to aging: dermis (5)
- 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)
skin changes related to aging: hypodermis (4)
- 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)
skin changes related to aging: hair (1)
- diminished melanocytes, loss of hair
- other
skin changes related to aging: nails (1)
-decreased circulation (brittle)
common skin conditions (8)
- xerosis
- pruritis
- scabies
- purpura
- skin tears
- keratosis
- herpes zoster
- candidiasis
-Extremely dry, cracked, and itchy skin
-Most common skin problem associated with
aging
xerosis
cause of xerosis
decreased epidermal filaggrin
where is xerosis most commonly seen
extremities
interventions for xerosis (7)
- 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
Itchy skin (not a disease, but a symptom)
pruritis
what can aggravate pruritis (8)
- perfumed detergents
- fabric softeners
- heat
- sweating
- restrictive clothing
- fatigue
- exercise
- meds
3 examples of disease that can cause pruritis
- chronic renal failure
- biliary disease
- hepatic disease
-Causes intense itching • Caused by tiny mites • Contagious, easily transmitted through close physical contact; intimate or casual
scabies
3 objects that can transmit scabies
- clothing
- linen
- furniture
way to diagnose scabies
skin scraping
Tx scabies (3)
- prescribed lotion and creams
- wash clothes and linens in hot soapy water and dry with high heat
- clean and vacuum rooms
Fragility of dermal capillaries secondary to dermal
thinning causing blood vessels to rupture; extravasation of blood into surrounding tissues
purpura
where is purpura commonly seen
dorsal forearm
hands
who is more susceptible to developing purpura
pts taking blood thinners
how to decrease risk for developing purpura (2)
- pressure injury prevention
- fall prevention strategies
- Occurs because skin is thin and fragile
- Painful, acute, accidental in nature
skin tears
how are skin tears categorized
payne-martin classification system
management of skin tears (6)
- proper assessment
- control of bleeding
- cleanse with nontoxic solution
- appropriate dressing
- management of exudate
- prevention of infection
high risk pts for skin tears (7)
- old age
- fragile skin
- h/o skin tears/falls
- impaired activity
- impaired mobility
- impaired sensation
- impaired cognition
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
-Benign growth
-Mainly see on trunk, face,
scalp, and neck
-Waxy, raised, stuck-on
appearance
-Flesh colored or
pigmented, various sizes
seborrheic keratosis
-Precancerous
-Related to exposure to
UV light
-Rough scaly sandpaper
patches
-Pink to reddish brown
with erythematous base
actinic keratosis
2 risk factors actinic keratosis
- increased age
- fair complexion
• 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
-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)
how long are shingles infectious
until crusts over
Tx shingles (4)
- analgesics
- calamine lotion
- antivirals
- vaccine if >60 yo
complications shingles (2)
- postherpetic neuralgia
- eye involvement
risk factors candidiasis (6)
- obesity
- malnourishment
- antibiotic/steroid use
- immunocompromised
- chemotherapy
- diabetes
fungal infection Found in warm, moist areas of skin, like skinfolds, axilla, groin
candidiasis
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
-Most common
-Slow growing – metastasis rare
-Triggered by extensive sun exposure, burns,
chronic irritation, or ulceration
basal cell
-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
major risk factors squamous cell skin cancer (3)
- sun exposure
- fair skin
- immunosuppression
-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
type of skin cancer:
- raised mole
- irregular borders
- visible vasculature
basal cell
type of skin cancer:
- raised mole
- irregular borders
- dry crusty ulceration
squamous cell
type of skin cancer:
- multicolored
- raised mole
- irregular borders
melanoma
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
skin danger signs (ABCDE)
Asymmetry Borders irregular Color variation Diameter >6mm Elevation and enlargement
where do pressure injuries most frequently occur
posterior aspects of body
especially sacrum, heels, greater trochanter
what disease puts pts at highest risk for pressure injury
PVD
stage of pressure injury: nonblanchable erythema of skin
stage one
stage of pressure injury: red discolored skin with exposed dermis
stage two
stage of pressure injury: red and excoriated with exposed adipose tissue
stage three
stage of pressure injury: visible muscle and exposed/directly palpable fascia, muscle, tendon, ligament, cartilage, or bone
stage four
stage of pressure injury: black necrotic appearance, presence of slough/eschar
unstageable
risk factors pressure injuries (7)
- comorbid illnesses
- malnutrition
- frailty
- surgical procedure
- cognitive deficits
- incontinence
- reduced mobility
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
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
what dressing would be good for shallow dry pressure injury
hydrating dressing
what dressing would be good for shallow wounds with moderate to large exudate
hydrocolloids
semipermeable polyurethane foam
calcium alginates
silicone-type foam
what dressing would be good for deep wounds with moderate to large exudate
copolymer starch
dextranomer beads
calcium aginates
foam cavity
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
what is considered high risk on braden scale
10-12
what is considered severe risk on braden scale
9 or less
what is considered moderate risk on braden scale
13-14
what is considered mild risk on braden scale
15-18
what is considered no risk on braden scale
19-23
how often should nurse inspect skin in acute care setting
- on admission
- q24h
- if pts condition changes
how often should nurse inspect skin in long term care setting
- on admission
- weekly for 4 weeks, then quarterly
- if pts condition changes
how often should nurse inspect skin in home care setting
- on admission
- at every home nurse visit
payne-martin skin tear classification:
- linear type skin tear
- epidermis and dermis pulled apart
- without tissue loss
category 1A
payne-martin skin tear classification:
-epidermal flap completely covers dermis within 1 mm of wound margin
category 1B
payne-martin skin tear classification:
-scant tissue loss (less than 25%) of epidermal flap lost)
category 11A
payne-martin skin tear classification:
-greater than 25% epidermal flap lost
category 11B
payne-martin skin tear classification:
-epidermal flap absent
category 111
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
ability of the tissue to distribute and compensate for pressure exerted over bony prominences.
tissue tolerance
factors that affect tissue tolerance (7)
- moisture
- friction
- shear force
- nutritional status
- age
- sensory perception
- arterial pressure
core preventative strategies for pressure injuries (5)
- risk assessment
- skin assessment
- nutritional assessment
- repositioning
- appropriate support surfaces
