Ch. 30 Flashcards
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
What are individual factors affecting wound healing?
- Age
- Obesity
- Smoking
- Medications
- Stress
What are complications of wound healing?
- Hemorrhage and interstitial fluid loss
- Hematomas
- Infection
- Dehiscence
- Evisceration
- Fistula
Optimal wound healing occurs within what type of environment?
Consistently moist.
What should be included in health promotion and disease prevention of the integumentary system?
Patient teaching or the following:
- Proper hygiene
- Adequate skin hydration
- Adequate skin circulation
- Adequate nutrition
- Protection from the sun
- Pressure ulcer prevention
What are nursing interventions for skin impairment?
- First aid forming wounds and burns
- Treatment for moisture-associated skin damage
- Wound support
- Drainage management
When should cold therapy application be done?
Immediately after injury
What does applying cold therapy immediately after injury do?
Controls hemorrhage, edema, pain
Cold therapy controls bleeding by causing what?
vasoconstriction
What does local heat therapy cause?
vasodilation
Vasodilation when using heat therapy does what?
Increases supply of oxygen, nutrients, leukocytes, and antibodies to the tissues
Local heat therapy promotes what?
- Removal of metabolic waste and dissipation of heat
- Muscular relaxation
Local heat therapy allows what to consolidate?
Pus in infected areas
Local heat therapy relieves what?
- Muscle tension
- Spasms
- Joint stiffness
What are examples of local applications of heat and cold?
- Cold/hot packs and ice bags
- Cold/warm compresses
- Warm soaks
- Sitz bath
- Aquathermia pads
What is included in wound management?
- Categories of dressings
- Dressing changes
- Packing or filling
- Cleansing and disinfection
- Methods of securing dressings
- Wet wound= wound vac
- Dry wound= packing
- Would consult wound/ostomy nurse
