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Foundations 1 > immobility and integumentary > Flashcards

immobility and integumentary Flashcards

1
Q

subcutaneous layer

A
  • deepest layer
  • protective cushion
  • capillary beds/blood supply
  • oil glands
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2
Q

dermis layer

A
  • middle layer
  • first defense between body and environment (infection)
  • no blood supply
  • keratinized
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3
Q

skin changes in older adults

A
  • loss of heat (subQ thins)
  • less cushion to protect
  • easily torn (loss of elasticity)
  • dry skin (sebaceous glands decrease)
  • brusising (subq thins)
  • higher risk for infection (decrease immune function)
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4
Q

interventions for skin care

A
  • reposition Q 2 hrs
  • use draw sheet/board to move
  • assess incontinence/keep bedding dry
  • assess skin Q shift or more
  • water temp 90-115 F
  • limit showers and baths
  • avoid alcohol based products
  • increase fluids
  • avoid powders
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5
Q

pressure intensity

A

amount of pressure exerted on body

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6
Q

pressure duration

A

how long that pressure is there

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7
Q

non-blanching hyperemia

A
  • NOT GOOD
  • blood moves out (white) and doesn’t return (stays white)
  • stage 1 pressure injury
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8
Q

blanching hyperemia

A
  • GOOD

- Blood moves out of capillary bed (white) then returns (red)

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9
Q

assessments that indicate ischemia

A
  • change in color (red or white)
  • reduced sensation (numbness, pain)
  • warm or cool skin
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10
Q

ischemia

A

pressure constricts blood vessels causing decrease perfusion and nutrients and build up of waste. cells starve and die leading to necrosis

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11
Q

tissue tolerance

A

how well tissues can stand pressure and how well it recovers

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12
Q

stage 1 pressure injury

A
  • skin intact
  • non-blanching
  • warmth
  • redness
  • edema
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13
Q

stage 2 pressure injury

A
  • shallow opening
  • intact
  • blister
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14
Q

stage 3 pressure injury

A
  • full thickness tissue lost
  • slough
  • edges cant heal
  • tunneling
  • fat showing
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15
Q

stage 4 pressure injury

A
  • full thickness tissue lost
  • exposed tendon or bone
  • slough
  • tunneling
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16
Q

unstageable pressure injury

A
  • too much slough to see edges
  • cant get accurate measurement
  • need to debree first
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17
Q

Friction VS Shearing

What are some interventions?

A

friction
skin against surface

shearing

  • deep tissue damage
  • boney prominences
  • pressure moving one way, body moving the other-
Interventions 
HOB 30 or less
-use draw sheet
-mechanical lifts
-wrinkle-free sheets
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18
Q

granulation tissue

A
  • red
  • moist
  • scar tissue
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19
Q

maturation wound healing stage

A

collagen scar continues to reorganize and regain strength (1 month-1 yr)

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20
Q

proliferation wound healing stage

A

filling of the wound with granulation tissue, necessary for healing and formation of scar tissue

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21
Q

inflammatory wound healing stage

A

histamine secreted causing inflammation/vasodilation then WBC move into tissues to prevent and fight infection

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22
Q

hemostasis wound healing stage

A

-injured blood vessels constrict and platelets gather to stop bleeding

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23
Q

tertiary intention healing

A
  • intentionally left open

- high infection risk

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24
Q

secondary intention healing

A
  • granulation tissue

- longer to heal

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25
Q

primary intention healing

A
  • edges are together
  • quick healing
  • scar tissue
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26
Q

chronic wound

A
  • takes longer to heal
  • higher infection risk
  • not healing correctly
27
Q

acute wound

A
  • surgical incision

- going to get better

28
Q

slough

A
  • soft yellow or white
  • has to be removed before it can heal
  • dead tissue
  • creamy
29
Q

eschar

A
  • black or brown

- necrotic

30
Q

risk factors for impaired skin

A
  1. altered sensory perception
  2. poor nutrition
  3. impaired mobility
  4. shearing
  5. incontinence
  6. casts
  7. age
  8. chronic illness
  9. medications
31
Q

nutrition for impaired skin

A
  • high calories
  • high protein
  • increase fluids

-chicken, fruits, cheese, PB

32
Q

lab values for tissue healing

A
  • O2 level for adequate tissue perfusion
  • wound culture
  • albumin (3.5-5 g/dL)
  • hemoglobin
  • RBC
  • total protein (6.4-8.3 g/dL)
33
Q

nursing interventions to prevent pressure injuries

A
  • assistive devices for repositioning and transfers
  • asses incontinence
  • braden scale
  • clean skin w pH balance cleanser
  • inspect skin Q shift
  • assess boney prominences
  • encourage activity
  • nutrition
  • increase fluids
  • moisture barrier
  • reposition
34
Q

isotonic exercise

A

active movement, muscle shortening and lengthens-ROM

Benefits-muscle tone, strength, cardiac and muscle function, increase bone building

Push-ups, pull-ups, crunches, sit ups

35
Q

isometric exercise

A

muscle contractions without moving the joint or the length of the muscle

Plank

36
Q

isokinetic exercise

A

muscle contractions with restrictions or resistance

Lifting weights

37
Q

aerobic exercise

A

increase heart and blood flow, by using oxygen

Walking, jogging, etc

38
Q

Effects of Exercise on musculoskeletal

A

Decreases risk of falls

Improves overall strength, muscle mass, improves gait, coordination, bone density

39
Q

Effects of Exercise on Cardiovascular

A

Increases stroke volume, resting heart rate decreases

Strengthens muscle tissue

Perfusion, circulation

40
Q

Effects of Exercise on Respiratory

A

Respiratory rate increases

More toxins are being released

More gas exchange occurs

Better stamina

41
Q

Effects of Exercise on Gastrointestinal

A

Increases blood flow to the GI tract

Increase peristalsis

decrease acid reflex

42
Q

Effects of Exercise on Metabolic/Endocrine

A

Increase BMR(metabolism)

Uses more glucose

43
Q

Effects of Exercise on Urinary

A

Limits the blood flow to the kidney, lower your BP

Increasing the muscle tone of the bladder wall

  • Making it easier to release the urine
  • Don’t urinate-UTI
44
Q

Effects of Exercise on Immune

A

Boost your immune system
-More likely to respond to the issue

Decrease inflammation

  • Through the lymphatic system
  • -Works through muscle contractions to move the lymph throughout the body
45
Q

Effects of Exercise on Psycho-neurologic

A

Release of positive good endorphins

  • serotonin
  • Positive mood overall

Reduce stress

Improves sleep quality

46
Q

Effects of Exercise on Cognitive

A

Increases ability to remember things

Helps with problem solving, paying attention

Builds nuero connections

Improves brain density

47
Q

Effects of Exercise on Spiritual Health

A

Helps clear stress, gives purpose

Bodys response to that particular time and whats going on in that moment

48
Q

Maslows hierarchy of needs

A

(level 1) Physiological Needs(breathing, food, water, sex, sleep, homeostasis, excretion)

(level 2) Safety and Security(security of body, employment, resources, morality, family, health, home)

(level 3) Relationships/love and belonging(friendship, family, intimacy)

(level 4) Self Esteem(self-esteem, confidence, achievement, respect of others, respect by others)

(level 5) Self Actualization(morality, creativity, spontaneity, problem solving, lack of prejudice, acceptance of facts)

49
Q

effects of immobility on Cardiovascular system

A

Fluid impact-edema
Skeletal muscle pump-becomes weaker, but has to work harder and increase HR to equal out for SV decrease
Stroke Volume-decreases bc less BV, all in tissues
Cardiac deconditioning
Postural Hypotension

50
Q

effects of immobility on Respiratory system

A

Decrease in depth and rate of respirations-decreased TV

Atelectasis (collapsed alveoli)-decreased gas exchange

Poor exchange of O2 and CO2 = acid base imbalance

Movement of secretions in the respiratory tract is decreased, causing secretions to pool leading to respiratory congestion-cilia dont work as well, decrease ability to expel

Hypostatic pneumonia

51
Q

effects of immobility on hematological system

A

Blood Viscosity: thickness and stickiness of the blood, will be high bc all the fluid is in the tissues
Erythropoiesis: the formation of new RBC
-Stimulated by low O2, or a low amount of RBC, wont be stimulated bc no great need for O2

Oxygen transport: moving oxygen usually via hemoglobin

Virchow’s Triad

52
Q

virchow’s triad

A

describes the three broad categories of factors that are thought to contribute to thrombosis(the formation of the blood clot)

Venous stasis: slow blood flow

Hypercoagulability: easily forming a blood clot

Blood vessel damage-causing inflammation

53
Q

effects of immobility on musculoskeletal

A

Muscles-atrophy

Connective tissue
Contractures: limitation in the passive range of motion, caused by the stiffness of connective tissue within the body

Bone-osteoporosis, Ca is leaving the bone, need wt bearing exercise

54
Q

effects of immobility on endocrine system

A

Cortisol secretion
-Stress, increases, sympathetic, fight or flight

Metabolic changes
Glucose intolerance: results in higher blood glucose levels- less muscle mass to take in the glucose with the insulin receptor sites

Mineral/electrolyte

55
Q

effects of immobility on integumentary system

A

Capillary pressure

Ischemia: restriction in blood supply to tissues, causing a shortage of oxygen that is needed for cellular metabolism (to keep tissue alive)

Nutrition

56
Q

effects of immobility on immune system

A

inflammation: heat, redness, pain
- increases risk

-decrease in lymphatic flow

57
Q

Effects of immobility gastrointestinal

A

lowers Appetite

Peristalsis: movement of food/chyme through the GI tract
-lowers

Motility: capable of movement
-lessens

58
Q

Effects of immobility renal

A

Retention
-less likely to release urine

Calculi(kidney stones)
-more likely to have kidney stones, have more Ca in blood

59
Q

Effects of immobility psychological

A

depression, mental illnesses

60
Q

hydrogel dressing

A

moisture dressing

autolytic debridement

61
Q

hydrocolloid dressing (duoderm)

A

prevents friction and shear

62
Q

alginate (sorbsan)

A

absorbs drainage

63
Q

foam (mepliex)

A

thermal
protects against exudate
most likely used on bottom

64
Q

transparent adherent dressing

A

skin tear on arm

Foundations 1 (8 decks)

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