EXAM 2 Flashcards
Structures of the skin
Epidermis Dermis Subcutaneous tissue Hair Nails Sebaceous, sweat, and mammary glands
layers of skin from superficial to deep
stratum corneum stratum lucidum stratum granulosum stratum spinosum stratum basale
the state of structurally intact and physiologically functioning epithelial tissues such as integument (including the skin and subcutaneous tissue) and mucous membranes
tissue integreity
antecedents of tissue integrity
good nutrition
lack of external trauma
adequate perfusion
limited pressure on site
attributes of tissue integrity
structurally intact and functioning integument
skin integrity risk factors
prolonged pressure poor hygiene poor nutrition incontinence break in the skin
Categories of impaired tissue integrity
trauma or injury loss of perfusion immunological reaction infections and infestations thermal or radiation injury lesions
Primary prevention of skin integrity
patient education identifying risk factors the importance of nutrition mobility keeping skin clean and dry hygiene and skin care discuss safety behaviors to prevent trauma
second prevention of skin integrity
providing pain management
repositioning
using barrier creams
checking incontinent patients frequently to keep skin clean and dry
manage hygiene
provide appropriate nutrients to promote health skin or for wound healing
administer medications
prevent spread of infections or infestations
tertiary prevention of skin integrity
teach patient and care giver about home care pressure relief wound care hygiene incontinence care pruritus relief safety behaviors to prevent trauma general skin care
thinner more permeable skin
infants
less subcutaneous fat than older adults and children puts infants at greater potential for what?
fluid loss
less effective temperature regulation
what is the texture of skin for young children
smooth and dry
when do the apocrine glands become functional
after puberty
increased apocrine sweat gland and sebaceous acctivity
adolescents
oily skin acne
adolescents
Changes occurring in the skin as a person ages
skin becomes more fragile delayed wound healing decreased Vitamin D production susceptible to dry skin decrease in sensory perception greater risk of hypothermia or hyperthermia elasticity decreases decreased perspiration
pharmacotherapy for tissue integrity
pain medications topical antibiotics topical antifungals topical steroids medicated lotions or powders bleach solutions topical agents to promote healing topical emollients hydrocolloidal agents
positive outcomes of skin integrity
protection from infection adaptation to the environment maintenance of fluid and electrolyte balance regulation of acid-base balance Vitamin D production
physical and physiological clinical manifestations of impaired skin integrity
itching burning pain excessively dry, peeling skin draining wound Stage 1-4 pressure ulcer tear in skin, abrasion, laceration depression, low self-esteem change in skin color, skin temperature fluid and electrolyte imbalance
Diagnostic tests for impaired skin integrity
wound culture tissue biopsy black light or immunofluorescence lab work such as chemistry and CBC doppler if suspected perfusion issue MRI and CT scans to detect deep tissue
largest organ of the body
skin
serves as a barrier or protective coating and protects us from infections, keeps us from losing fluid, and helps us manage temperature
skin
help us detect pain, temperature, and touch
nerves of the skin
why is it important for nurses to understand tissue integrity and the importance of the skin?
the nurse’s job is to maintain optimal skin integrity/tissue integrity and work individually and with others to manage care when that integrity is disrupted
4 types of tissue
muscle
neural
connective
epithelial
most important of the tissues related to tissue integrity?
epithelial
impaired skin integrity can affect?
epidermis and dermis skin layers, but if it gets deep enough, it can damage underlying structures such as bones, joints, and muscles
the ability of the body tissues to regenerate and/or repair to maintain normal physiological processes
tissue integrity
negative consequences associated with tissue integrity
pain infection altered body image loss of fluid and electrolytes decubiti amputation
positive outcomes associated with skin integrity
protection from infection adaptation to environment (sweating) maintenance of fluid and electrolytes regulation of acid-base balance Vitamin D production (the sun) protection from injury/trauma
the scope of tissue integrity ranges from
intact skin and tissue to partial thickness injury to full thickness injury
the process by which oxygen is transported to the cells and carbon dioxide is transported from the cells
gas exchange
where does diffusion of respiratory gases occur?
at the alveolar capillary membrane
the process of inhaling oxygen and exhaling carbon dioxide
ventilation
disparities of ventilation
unavailability of oxygen
narrowed bronchi
obstruction of bronchi
inflammation of bronchi and alveoli
obtainability and capability of hemoglobin to carry oxygen
transport
disparities of transportation
anemia
blood loss - acute or chronic
destruction of red blood cells
ability of blood to transport oxygen to cells and return carbon dioxide to alveoli
perfusion
disparities of perfusion
decreased cardiac output
thrombi, emboli, vessel narrowing
vasoconstriction
blood loss
occurs when the diffusion of gases becomes impaired
impairment of gas exchange
gas exchange becomes impaired as a result of:
ineffective ventilation
reduced capacity for gas transportation
inadequate perfusion
examples of gas exchange imbalance and impairment processes
asthma pneumonia: aspiration pneumonia RSV/bronchiolitis tracheoesophageal fistula COPD
risk factors for impaired gas exchange
age smoking immunosuppression reduced state of cognition brain injury prolonged immobility presence of prolonged medical conditions such as CF, HTN, COPD, CHF, CHD
elements of respiratory assessment
past medical history family history current medications lifestyle behaviors occupation social environment problem based history
