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maturing family > ch 13 - skin care > Flashcards

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
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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
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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)
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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)
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5
Q

skin changes related to aging: hair (1)

A
  • diminished melanocytes, loss of hair

- other

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6
Q

skin changes related to aging: nails (1)

A

-decreased circulation (brittle)

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7
Q

common skin conditions (8)

A
  • xerosis
  • pruritis
  • scabies
  • purpura
  • skin tears
  • keratosis
  • herpes zoster
  • candidiasis
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8
Q

-Extremely dry, cracked, and itchy skin
-Most common skin problem associated with
aging

A

xerosis

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9
Q

cause of xerosis

A

decreased epidermal filaggrin

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10
Q

where is xerosis most commonly seen

A

extremities

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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
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12
Q

Itchy skin (not a disease, but a symptom)

A

pruritis

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13
Q

what can aggravate pruritis (8)

A
  • perfumed detergents
  • fabric softeners
  • heat
  • sweating
  • restrictive clothing
  • fatigue
  • exercise
  • meds
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14
Q

3 examples of disease that can cause pruritis

A
  • chronic renal failure
  • biliary disease
  • hepatic disease
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15
Q 
-Causes intense itching
• Caused by tiny mites
• Contagious, easily transmitted through 
close physical contact; intimate or 
casual
A

scabies

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16
Q

3 objects that can transmit scabies

A
  • clothing
  • linen
  • furniture
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17
Q

way to diagnose scabies

A

skin scraping

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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
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19
Q

Fragility of dermal capillaries secondary to dermal

thinning causing blood vessels to rupture; extravasation of blood into surrounding tissues

A

purpura

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20
Q

where is purpura commonly seen

A

dorsal forearm

hands

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21
Q

who is more susceptible to developing purpura

A

pts taking blood thinners

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22
Q

how to decrease risk for developing purpura (2)

A
  • pressure injury prevention

- fall prevention strategies

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23
Q
  • Occurs because skin is thin and fragile

- Painful, acute, accidental in nature

A

skin tears

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24
Q

how are skin tears categorized

A

payne-martin classification system

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25
Q

management of skin tears (6)

A
  • proper assessment
  • control of bleeding
  • cleanse with nontoxic solution
  • appropriate dressing
  • management of exudate
  • prevention of infection
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26
Q

high risk pts for skin tears (7)

A
  • old age
  • fragile skin
  • h/o skin tears/falls
  • impaired activity
  • impaired mobility
  • impaired sensation
  • impaired cognition
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27
Q

prevention tips for skin tears

A
  • 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
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28
Q

-Benign growth
-Mainly see on trunk, face,
scalp, and neck
-Waxy, raised, stuck-on
appearance
-Flesh colored or
pigmented, various sizes

A

seborrheic keratosis

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29
Q

-Precancerous
-Related to exposure to
UV light
-Rough scaly sandpaper
patches
-Pink to reddish brown
with erythematous base

A

actinic keratosis

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30
Q

2 risk factors actinic keratosis

A
  • increased age

- fair complexion

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31
Q 
• 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
A

dermatosis papulosa nigra

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32
Q

-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

A

herpes zoster (shingles)

33
Q

how long are shingles infectious

A

until crusts over

34
Q

Tx shingles (4)

A
  • analgesics
  • calamine lotion
  • antivirals
  • vaccine if >60 yo
35
Q

complications shingles (2)

A
  • postherpetic neuralgia

- eye involvement

36
Q

risk factors candidiasis (6)

A
  • obesity
  • malnourishment
  • antibiotic/steroid use
  • immunocompromised
  • chemotherapy
  • diabetes
37
Q

fungal infection Found in warm, moist areas of skin, like skinfolds, axilla, groin

A

candidiasis

38
Q

prevention candidiasis (7)

A
  • 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
Q

-Most common
-Slow growing – metastasis rare
-Triggered by extensive sun exposure, burns,
chronic irritation, or ulceration

A

basal cell

40
Q

-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

A

squamous cell

41
Q

major risk factors squamous cell skin cancer (3)

A
  • sun exposure
  • fair skin
  • immunosuppression
42
Q

-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

A

melanoma

43
Q

type of skin cancer:

  • raised mole
  • irregular borders
  • visible vasculature
A

basal cell

44
Q

type of skin cancer:

  • raised mole
  • irregular borders
  • dry crusty ulceration
A

squamous cell

45
Q

type of skin cancer:

  • multicolored
  • raised mole
  • irregular borders
A

melanoma

46
Q

tips for promoting healthy skin (6)

A
  • 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
Q

skin danger signs (ABCDE)

A 
Asymmetry
Borders irregular
Color variation
Diameter >6mm
Elevation and enlargement
48
Q

where do pressure injuries most frequently occur

A

posterior aspects of body

especially sacrum, heels, greater trochanter

49
Q

what disease puts pts at highest risk for pressure injury

A

PVD

50
Q

stage of pressure injury: nonblanchable erythema of skin

A

stage one

51
Q

stage of pressure injury: red discolored skin with exposed dermis

A

stage two

52
Q

stage of pressure injury: red and excoriated with exposed adipose tissue

A

stage three

53
Q

stage of pressure injury: visible muscle and exposed/directly palpable fascia, muscle, tendon, ligament, cartilage, or bone

A

stage four

54
Q

stage of pressure injury: black necrotic appearance, presence of slough/eschar

A

unstageable

55
Q

risk factors pressure injuries (7)

A
  • comorbid illnesses
  • malnutrition
  • frailty
  • surgical procedure
  • cognitive deficits
  • incontinence
  • reduced mobility
56
Q

mnemonic for prevention of medical device related pressure injuries (DEVICE)

A
  • 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
Q

mnemonic for pressure injury Tx (DIPAMOPI)

A
  • 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
Q

what dressing would be good for shallow dry pressure injury

A

hydrating dressing

59
Q

what dressing would be good for shallow wounds with moderate to large exudate

A

hydrocolloids
semipermeable polyurethane foam
calcium alginates
silicone-type foam

60
Q

what dressing would be good for deep wounds with moderate to large exudate

A

copolymer starch
dextranomer beads
calcium aginates
foam cavity

61
Q

nursing assessment for older adult with pressure injury (6)

A
  • thorough assessment of skin (braden scale)
  • nutritional evaluation
  • labs
  • positioning
  • incontinence care
  • wound nurse consult if needed
62
Q

what is considered high risk on braden scale

A

10-12

63
Q

what is considered severe risk on braden scale

A

9 or less

64
Q

what is considered moderate risk on braden scale

A

13-14

65
Q

what is considered mild risk on braden scale

A

15-18

66
Q

what is considered no risk on braden scale

A

19-23

67
Q

how often should nurse inspect skin in acute care setting

A
  • on admission
  • q24h
  • if pts condition changes
68
Q

how often should nurse inspect skin in long term care setting

A
  • on admission
  • weekly for 4 weeks, then quarterly
  • if pts condition changes
69
Q

how often should nurse inspect skin in home care setting

A
  • on admission

- at every home nurse visit

70
Q

payne-martin skin tear classification:

  • linear type skin tear
  • epidermis and dermis pulled apart
  • without tissue loss
A

category 1A

71
Q

payne-martin skin tear classification:

-epidermal flap completely covers dermis within 1 mm of wound margin

A

category 1B

72
Q

payne-martin skin tear classification:

-scant tissue loss (less than 25%) of epidermal flap lost)

A

category 11A

73
Q

payne-martin skin tear classification:

-greater than 25% epidermal flap lost

A

category 11B

74
Q

payne-martin skin tear classification:

-epidermal flap absent

A

category 111

75
Q

what is a “never event”

A
  • 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
Q

ability of the tissue to distribute and compensate for pressure exerted over bony prominences.

A

tissue tolerance

77
Q

factors that affect tissue tolerance (7)

A
  • moisture
  • friction
  • shear force
  • nutritional status
  • age
  • sensory perception
  • arterial pressure
78
Q

core preventative strategies for pressure injuries (5)

A
  • risk assessment
  • skin assessment
  • nutritional assessment
  • repositioning
  • appropriate support surfaces

maturing family (36 decks)

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