E3 Integumentary System Flashcards
What is the largest organ in the body?
Skin
What is the basal layer?
The innermost layer of the epidermis, continuously divides and proliferates.
Pushes old cells to surfacae to shed or slough off
What is the job of the Dermis?
Strength, Support, Protection
Contains capillaries, sweat glands, hair follicles, and nerve endings
What is the Primary purpose of the skin?
Protection & Sensory perception
A lesion is any
usual findings (wounds, rash, moles)
Turgor is a sign of
fluid status
(changes with age)
What does indurated mean?
hardness in the skin
Nonpitting vs Pitting Edema
Pitting- excess fluid build-up
Nonpitting- Usually injury related
Standing: legs, ankles, fett
Laying: really anywhere, even genitalia
What are good questions to ask for skin assessment?
Any changes? Color? Moisture? Texture?
History of skin issues?
Skin cancer risk factors
Is the swelling all the time or intermittent?
How much time do you spend in sun? Do you wear sunscreen?
Define Pallor & its Indications
Loss of color, in black skin tones can change to a grey color
-look particularly in mucous membranes
-Indication: Anemia (Low RBC), shock, lack of blood flow
Define Cyanosis & its indications
Bluish discoloration, in brown skin tones turn yellow-brown or grey
-Nail beds, lips, mucousa
-Indications: hypoxia, impaired venous return
Define Jaundice & Indications
Yellow discoloration
-Sclera, skin, mucous membrane
-Indication: liver dysfunction (RBC destruction)
Define Erythema & Indications
Redness, difficult to see in darker skin tones, palpate skin as well to look for warmth and texture changes
-Face, skin pressure prone areaas
-Indication: Inflammation, vasodilation, sun exposure, elevated temp
-Start of skin breakdown
Risk factors for impaired skin integrity
-Impaired sensory perception
-Impaired mobility
-Altered LOC
-Shear
-Friction
-Moisture
What types of pts are at risk for impaired sensory perception?
Spinal cord, injury
Anesthesia
Head Injury
Medications
They don’t notice skin is breaking down
What types of pts are at risk for impaired mobility?
Paralysis
Medications
Weakness
What types of patients are at risk for Altered LOC?
Anesthesia
Medications
Head injury
Define Shear
Stretch and damage capillaries: Ischemia
-Sliding movement of skin and subcutaneous tissue when muscle and bone are not moving (Dermal layers)
Define Friction
Two surfaces moving across one another (Outer layer)
Define Moisture
Duration and amount of moisture determine risk
-Moisture softens skin making it more susceptible to damage
-Incontinence, wound drainage, diaphoretic
What specific patients are at risk for impaired skin integrity?
- Older adults who have experienced a trauma =
- Spinal-cord injuries
- Nutritional deficits
- Those in long-term homes
- Acutely ill or those in hospice
- Individuals with diabetes
- Patients in ICU/critical care
- Incontinent
Define pressure Injury
Describes impaired skin integrity relate to unrealized, prolonged pressure
Define Localized injury
to area of prolonger pressure, can be related to a medical device (NC, Brace, cast, NG tube)
Define ischemia
Pressure applied over a capillary (in the skin) exceeds normal capillary pressure
What are the 3 major factors involved in pressure injury development?
- Pressure intensity
- Pressure duration
- Tissue tolerance
What is pressure intensity?
How hard surface is that the skin is against
What is pressure duration?
How long w/o repositioning
What is Tissue intolerance?
Related to integrity of the tissue & supporting structures
-Low blood pressure, poor nutrition, aging, hydration status, all affect tolerance
Define Deep Tissue Injury
Persistent non-blanchable deep red, maroon, or purple discoloration
-from intense prolonged pressure & shear forces at the bone/ muscle
-Can’t tell what layers are involved
-Deep tissue is NOT vascular or traumatic
Define Unstageable pressure injury
Unable to tell stage of pressure injury due to it being obscured by infection or dying skin (Slough/eschar)
Blanchable vs nonblanchable
Blanchable: turns lighter when pressed and then erythema returns (overcoming ischemia)
Nonblanchable: does not turn lighter in color when pressed; remains erythematous
What is MASD?
Moisture associated skin damage
-incontinence related: r/t prolonged exposure to urine or stool
Intertriginous dermatitis MASD?
inflammatory dermatitis r/t moist skin rubbing against each other (armpits, breast, fat folds, panace)
–> can crack and develop yeast
Periwound/peristoma MASD
associated with wound or stomas and enzyme breakdown associated with the exudate
–> make sure to have a well fitting stoma appliance and keep skin dry around stoma
Define wound
Disruption of the integrity and function of the tissuesA
Acute wounds
-Proceeds through normal/timely repair process
-Results in return to normal/sustained function and anatomical integrity
-Ex. trauma/ surgical incision
Chronic Wounds
-Wound that fails to proceed through normal healing process
-Does not return to normal function/ anatomical integrity
-Ex: Pressure ulcer, vascular insufficiency wound
What are the factors that affect skin and wound healing?
- Nutrition
- Tissue perfusion
- Infection
- Age
How does nutrition affect skin and wound healing?
-Deficiencies result in delayed healing
-Proteins, vitamin A, C, Zinc, & copper, are critical for wound healing
-Adequate calorie intake necessary
-Labs associated: serum albumin & prealbumin
How does tissue profusion affect skin and wound healing?
-Ability to perfuse tissues with oxygenated blood crucial to wound healing
-Diabetes/ peripheral vascular disease are at risk for poor tissue perfusion
How does infection affect skin and wound healing?
-Infection prolongs the inflammation and delays healing
-Indications that a wound is infected: purulent drainage, changes in color/volume/redness around the tissue, fever, or pain
-Low WBCs also can delay healing bc inability to fight
How does age affect skin and wound healing?
-Aging affects all aspects of wound healing
-Delayed inflammatory responses, delayed collagen synthesis, and slower epithelization
What does the braden risk assessment measure? What is the range
Lower score puts pts at higher risk for skin impairment
Range 6-23, Every shift is scored
<18 is staring risk
What scale is used to determine skin integrity for critical care patients?
Jackson-Cubbin Scale
What are interventions to prevent impaired skin integrity?
- Adequate nutrition
- Incontinence moisture management
- Positioning (Turn and mobilize)
What should the HOB be elevated to to decrease friction and shear?
Less than 30 degrees if medically appropriate
