Ch 19 Test 1 Flashcards
Functions of the skin
Protection
Sensation
Temp regulation
Excretion and secretion
What changes occur in skin with aging
- Lost elastic fibers/adipose tissue sub q, causes to be thinner, wrinkle/sag
- loss collagen, more fragile slow heal
- Decreased sebaceous gland dry itchy skin
- Temp control altered. Cold intolerance
- Hair thins, grow slowly decrease number follicles,loses color- loss melanocytes
- Nail growth decreases nails thicken
What is reactive hyperemia?
Process by which blood rushes into a place where there was a decrease in cicruclation.
Within how many minutes should redness subside from skin before it is working its way to a stage 1 pressure ulcer?
45 minutes
Major contributing factors for pressure injury
Immobility Inactivity Moisture Malnutrition Advanced age Altered sensory perception Lowered mental awareness Friction and shear
Minor contributing factors for pressure injury
Dehydration
obesity
Edema
When should you first do a skin exam?
Upon admission( or at least within 8 hours) perform a detailed skin exam noting appearance.use braden scale . Pay attention to skin over bony prominences. Reassess every shift.
The braden scale for predicting pressure sore risk from 1 bei mb very poor to 4 being no impairment
Asseses point based 9n sensory perception Moisture Activity Mobility Nutrition Friction and shear
An area of skin is red, deep pink, mottled does not BLANCH with fingertip pressure. Darker skin may have a discolorationnof surrounding tissue. Warmth, edema, and induration ( area feels hard)
Stage 1 pressure injury
Partial thickness skin loss exposed dermis, wound is pink or red. Looks like a ruptured blister
Stage 2 pressure injury
Full thickness skin loss looks like CRATER. extends to fascia. SUBQ skin damaged NECROTIC. fat is visible.UNDERMINING / TUNNELING present. May be damage to surrounding tissue.
Stage 3 C.U.T
Full thickness skin loss,extensive NECROSIS DRY BLACK NECROTIC ESCHAR. wet and oozing
Stage 4 pressure injury
Loss full thickness . BASE OF INJURY COMPLETELY BLACK OR BROWN. COVERED BY ESCHAR
Unstageable.
Purple deep tissue, broken MAROON OR PURPLEblood filled damage to underlying soft tissue from pressure or shearing.
deep tissue pressure injury
AKA DEEP PURPLE
How often should ot be repositioned in a wheelchair or chair?
1 hour
How often shoukd ot be repisitioned in bed
Every 2 hours
Should you massage redened ski
NO! it has already been damaged. Avoid massage over bony prominences.
Why isnt a full bath needed wvery day?
Decreased sweat and sebaceous gland activity
Personal preference
Thinner skin/decreased sub q fat, pts can have chilling. How can we prevent.
Pre warm bath
Give adequate draping.
Type of bath that replaces tub ir shower and can be given in a bath shower or bed
Cleansing bath
Type bath that healing or medicinal. Whirlpool, oatmeal
Therapeutic
Type moist heat clean anal perineal area. Needs order
Sitz bath
Type bath that cleanses ooen wounds aplied medicine solutionsfeet arms soaked
Body soak
Tyoe bathneeds order to bring down fever
Sponge bath
Do older pts need a full bath every day?
No, pre warm the water, draoe pt, mild soao pat dry, prevent slios falks
Benefits of back massage
Communicates caring Fosters trust Opportunity to assess skin Stimulates circulation to area Reduces tension promotes relaxation
Perineal care
Ensure proper draping
Mouth care times unconscious
At least ince every 4 hours with moist swabbing every 2 hours
Check gag reflex
Make sure dont aspirate communicatemcan turn to side
Mouth care times concius
Raise bed 45-90 every 4 hours
Shaving
No shave before surgery
May not shave beard or mustache withiut order
Nail care
Straight across cuts
Ve aware of diabetic circukation issues
So dont cut on diabetic pts withiut order
Ear care
Not with q tios can push wax in
Be careful w hearing aids
