Hair, Skin, Nails- Ch. 12

Question 1

Structure of skin

Answer 1

Epidermis
Dermis
Subcutaneous layer

Question 2

Fxn of skin

Answer 2

First line of defense 
Largest Organ 
Supports tissue and blood vessel 
Fluid balance 
Sensory fxn 
Absorbs and excretes

Question 3

Importance of skin

Answer 3

Immune system
Vit D synthesis
Thermoregulation
Wound repair

Question 4

Nursing interventions for age related skin changes

Answer 4

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

Question 5

Health status and skin condition that increase a risk for breakdown

Answer 5

Thin
Obese
Fluid loss
Excessive sweating 
Skin disease 
Friction
Pressure 
Bad nutrition-elderly

Question 6

Things that affect skin condition

Answer 6

Diabetes 
GI-diarrhea 
Bed rest 
Casts
Meds 
Lifestyle 
Piercings

Question 7

Steroids-prednisone

Answer 7

Lower skin integrity

Make paper thin

Question 8

Pressure ulcer development

Answer 8

External pressure that compresses blood vessels
Friction and shear tear injure blood vessels and tear top layer of skin
Bony prominences

Question 9

Braden scale categories

Answer 9

Sensory perception 
Moisture 
Activity 
Mobility 
Nutrition 
Friction and shear

Question 10

Pressure ulcer staging

Answer 10

Stage 1-4

Question 11

Stage 1

Answer 11

Skin intact with non-blanchable redness

Rx- turning/reposition
Relive pressure
Use pillow

Question 12

Stage 2

Answer 12

Partial thickness loss of dermis, presents as abrasion or blister

Rx- saline, occlusive dressing

Question 13

Stage 3

Answer 13

Full thickness loss, subcutaneous tissue may be visible, presents as deep crater

Rx- wet to dry, surgical, meds to debride

Question 14

Stage 4

Answer 14

Full thickness skin loss, tissue necrosis, damage to bone, muscle, tissue or supporting structure

Rx- surgical intervention, medications/enzymes for debridment

Question 15

RYB classification

Red, yellow, black

Answer 15

Classification by color universal use
Easy to use
Practical method

Question 16

Braden scale scores

Answer 16

9 or less indicates high risk

19-23 generally not at risk

Question 17

R= Red= Protect

Answer 17

Wound is in the proliferative stage of healing
Healthy granulation tissue is present
*protect

Question 18

Y=Yellow=Cleanse

Answer 18

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)

Question 19

B=Black=Debride

Answer 19

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

Question 20

Stages of healing

Answer 20

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

Question 21

Treatment for R Y B wounds

Answer 21

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)

Question 22

Annular or circular lesions

Answer 22

Look like circles 🔴

Question 23

Gyrate lesions

Answer 23

Twisted or worm like 〰➰

Question 24

Linear lesions

Answer 24

Scratch, streak, line ➖