Ch. 30 Flashcards
(39 cards)
What are structures of the skin?
- Skin layers
- Skin appendages
What are the skin layers?
- Epidermis
- Dermis
What are the skin appendages?
- Hair
- Nails
- Eccrine/apocrine sweat glands
- Sebaceous glands
What are the functions of the skin?
- Protection
- Thermoregulation
- Sensation
- Metabolism
- Communication
What are characteristics of normal skin?
- Color
- Temperature
- Texture and thickness
- Moisture
- Odor
What are skin consideration for newborns and infants?
?
What are skin considerations for toddlers and preschoolers?
?
What are skin considerations for school-age children and adolescents?
?
What are skin considerations for adults and older adults?
?
What are factors affecting integumentary function?
- Circulation
- Nutrition
- Condition of epidermis
- Allergy
- Infections
- Abnormal growth rate
- Systemic disease
- Trauma
- Burns
- Mechanical forces
What are mechanical forces that affect integumentary function?
- Friction
- Shear
- Pressure
Explain Friction:
Occurs when two surfaces rub together, causing potential for skin abrasion.
Visible
Explain Shearing:
Occurs when tissue layers move on each other, causing potential for blood vessels to stretch and tear.
Not seen on surface, under skin layers
Explain Pressure:
Intensity and duration of pressure coupled with tissue tolerance influence the potential for pressure ulcer formation.
What are manifestations of altered integumentary function?
- Pain
- Pruritis
- Rash
- Lesions
What things would be assessed during risk identification of the integumentary system?
- Allergy history
- History of past conditions
- Recent exposure to factors that can cause skin trauma, rash, or lesions
- Factors that may delay wound healing
- Risk for pressure ulcer formation (Braden or Norton scales)
What things would be assessed during dysfunction identification of the integumentary system?
- If a skin problem is present
- If skin injury is present
- In either of above cases: assess impact on ADLs and self-concpet
What things would be assessed during a physical assessment of the integumentary system?
- Inspection of the skin
- Wound Assessment
What are possible integumentary nursing diagnoses?
- Impaired skin integrity
- Impaired tissue integrity
- Risk for impaired skin integrity
- Risk for trauma
What things would be included in outcome identification and planning of the integumentary system?
- Skin will remain intact
- Wounds will demonstrate evidence of healing
- Patient will verbalize understanding of preventative skin care
- Patient or family will demonstrate appropriate wound management techniques
What are types of wound healing?
- Primary intention
- Secondary intention
- Tertiary intention
*Explain these further?
What are phases of wound healing?
- Hemostasis
- Inflammatory phase
- Proliferative phase
- Maturation
*Explain these further?
What are systemic factors affecting wound healing?
- Nutrition
- Circulation and oxygenation
- Immune cellular function
What are local factors affecting wound healing?
- Nature of the injury
- Infection
- Local wound environment
