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Foundations Exam 2 > Ch. 30 > Flashcards

Ch. 30 Flashcards

1
Q

What are structures of the skin?

A
  • Skin layers

- Skin appendages

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2
Q

What are the skin layers?

A
  • Epidermis

- Dermis

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3
Q

What are the skin appendages?

A
  • Hair
  • Nails
  • Eccrine/apocrine sweat glands
  • Sebaceous glands
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4
Q

What are the functions of the skin?

A
  • Protection
  • Thermoregulation
  • Sensation
  • Metabolism
  • Communication
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5
Q

What are characteristics of normal skin?

A
  • Color
  • Temperature
  • Texture and thickness
  • Moisture
  • Odor
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6
Q

What are skin consideration for newborns and infants?

A

?

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7
Q

What are skin considerations for toddlers and preschoolers?

A

?

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8
Q

What are skin considerations for school-age children and adolescents?

A

?

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9
Q

What are skin considerations for adults and older adults?

A

?

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10
Q

What are factors affecting integumentary function?

A
  • Circulation
  • Nutrition
  • Condition of epidermis
  • Allergy
  • Infections
  • Abnormal growth rate
  • Systemic disease
  • Trauma
  • Burns
  • Mechanical forces
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11
Q

What are mechanical forces that affect integumentary function?

A
  • Friction
  • Shear
  • Pressure
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12
Q

Explain Friction:

A

Occurs when two surfaces rub together, causing potential for skin abrasion.
Visible

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13
Q

Explain Shearing:

A

Occurs when tissue layers move on each other, causing potential for blood vessels to stretch and tear.
Not seen on surface, under skin layers

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14
Q

Explain Pressure:

A

Intensity and duration of pressure coupled with tissue tolerance influence the potential for pressure ulcer formation.

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15
Q

What are manifestations of altered integumentary function?

A
  • Pain
  • Pruritis
  • Rash
  • Lesions
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16
Q

What things would be assessed during risk identification of the integumentary system?

A
  • 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)
17
Q

What things would be assessed during dysfunction identification of the integumentary system?

A
  • If a skin problem is present
  • If skin injury is present
  • In either of above cases: assess impact on ADLs and self-concpet
18
Q

What things would be assessed during a physical assessment of the integumentary system?

A
  • Inspection of the skin

- Wound Assessment

19
Q

What are possible integumentary nursing diagnoses?

A
  • Impaired skin integrity
  • Impaired tissue integrity
  • Risk for impaired skin integrity
  • Risk for trauma
20
Q

What things would be included in outcome identification and planning of the integumentary system?

A
  • 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
21
Q

What are types of wound healing?

A
  • Primary intention
  • Secondary intention
  • Tertiary intention

*Explain these further?

22
Q

What are phases of wound healing?

A
  • Hemostasis
  • Inflammatory phase
  • Proliferative phase
  • Maturation

*Explain these further?

23
Q

What are systemic factors affecting wound healing?

A
  • Nutrition
  • Circulation and oxygenation
  • Immune cellular function
24
Q

What are local factors affecting wound healing?

A
  • Nature of the injury
  • Infection
  • Local wound environment
25
Q

What are individual factors affecting wound healing?

A
  • Age
  • Obesity
  • Smoking
  • Medications
  • Stress
26
Q

What are complications of wound healing?

A
  • Hemorrhage and interstitial fluid loss
  • Hematomas
  • Infection
  • Dehiscence
  • Evisceration
  • Fistula
27
Q

Optimal wound healing occurs within what type of environment?

A

Consistently moist.

28
Q

What should be included in health promotion and disease prevention of the integumentary system?

A

Patient teaching or the following:

  • Proper hygiene
  • Adequate skin hydration
  • Adequate skin circulation
  • Adequate nutrition
  • Protection from the sun
  • Pressure ulcer prevention
29
Q

What are nursing interventions for skin impairment?

A
  • First aid forming wounds and burns
  • Treatment for moisture-associated skin damage
  • Wound support
  • Drainage management
30
Q

When should cold therapy application be done?

A

Immediately after injury

31
Q

What does applying cold therapy immediately after injury do?

A

Controls hemorrhage, edema, pain

32
Q

Cold therapy controls bleeding by causing what?

A

vasoconstriction

33
Q

What does local heat therapy cause?

A

vasodilation

34
Q

Vasodilation when using heat therapy does what?

A

Increases supply of oxygen, nutrients, leukocytes, and antibodies to the tissues

35
Q

Local heat therapy promotes what?

A
  • Removal of metabolic waste and dissipation of heat

- Muscular relaxation

36
Q

Local heat therapy allows what to consolidate?

A

Pus in infected areas

37
Q

Local heat therapy relieves what?

A
  • Muscle tension
  • Spasms
  • Joint stiffness
38
Q

What are examples of local applications of heat and cold?

A
  • Cold/hot packs and ice bags
  • Cold/warm compresses
  • Warm soaks
  • Sitz bath
  • Aquathermia pads
39
Q

What is included in wound management?

A
  • 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

Foundations Exam 2 (5 decks)

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