Hair, Skin, Nails- Ch. 12 Flashcards
Structure of skin
Epidermis
Dermis
Subcutaneous layer
Fxn of skin
First line of defense Largest Organ Supports tissue and blood vessel Fluid balance Sensory fxn Absorbs and excretes
Importance of skin
Immune system
Vit D synthesis
Thermoregulation
Wound repair
Nursing interventions for age related skin changes
Do not apply tape Maintain hydration I/O Nutritional needs Monitor lab results Hand hygiene Monitor for temperature Monitor skin for break down Administer medications on time Pad bony areas Lotion as needed
Health status and skin condition that increase a risk for breakdown
Thin Obese Fluid loss Excessive sweating Skin disease Friction Pressure Bad nutrition-elderly
Things that affect skin condition
Diabetes GI-diarrhea Bed rest Casts Meds Lifestyle Piercings
Steroids-prednisone
Lower skin integrity
Make paper thin
Pressure ulcer development
External pressure that compresses blood vessels
Friction and shear tear injure blood vessels and tear top layer of skin
Bony prominences
Braden scale categories
Sensory perception Moisture Activity Mobility Nutrition Friction and shear
Pressure ulcer staging
Stage 1-4
Stage 1
Skin intact with non-blanchable redness
Rx- turning/reposition
Relive pressure
Use pillow
Stage 2
Partial thickness loss of dermis, presents as abrasion or blister
Rx- saline, occlusive dressing
Stage 3
Full thickness loss, subcutaneous tissue may be visible, presents as deep crater
Rx- wet to dry, surgical, meds to debride
Stage 4
Full thickness skin loss, tissue necrosis, damage to bone, muscle, tissue or supporting structure
Rx- surgical intervention, medications/enzymes for debridment
RYB classification
Red, yellow, black
Classification by color universal use
Easy to use
Practical method
Braden scale scores
9 or less indicates high risk
19-23 generally not at risk
R= Red= Protect
Wound is in the proliferative stage of healing
Healthy granulation tissue is present
*protect
Y=Yellow=Cleanse
May indicate the presence of exudate, drainage or slough
Oozing from the tissue
Drainage-white, yellow, cream yellow, yellow green or beige
Cleanse the wound, drainage will be present (exudate)
B=Black=Debride
Indicates presence of eschar (necrotic tissue)-black,brown, gray
Debride the necrotic so the wound can heal, tissue with a scalpel or removal with Other tools
- mechanical Deb:scalpel
- Chemical Deb: using enzyme or autolytic dressing
Stages of healing
Homeostasis: blood vessels
Inflammatory: 4-6 days, pain, heat, redness, swelling at site of injury
Proliferative: several weeks, new tissue is being made
Maturation: remodeling
Treatment for R Y B wounds
R: gentle cleansing, moist dressing, transparent dressing
Y: irrigation, wet to moist dressing, topical anti microbial med
B: Debride either mechanical or chemical (enzymatic dressings-autolytic)
Annular or circular lesions
Look like circles 🔴
Gyrate lesions
Twisted or worm like 〰➰
Linear lesions
Scratch, streak, line ➖
