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NUR5111 > Integumentary > Flashcards

Integumentary Flashcards

1
Q

What are the three layers of the skin?

A
  1. Epidermis
  2. Dermis
  3. Subcutaneous tissue
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2
Q

Nosocomial infection:

A

Acquired within a hospital (eg. nosocomial pneumonia)

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3
Q

Latrogenic infection:

A

Result from a treatment or diagnostic procedure (eg. bacteraemia from peripheral or central venous cannulation)

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4
Q

Chain of infection:

A
  1. Etiological agent (virus, bacteria)
  2. Reservoir (humans)
  3. Portal of exit (coughing, sneezing, wounds)
  4. Method of transmission (via healthcare worker hands)
  5. Portal of entry
  6. Susceptible host
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5
Q

Standard precautions examples:

A
  • hand hygiene (5 moments)
  • PPE
  • sharps use and disposal
  • environmental cleaning
  • cough etiquette
  • aseptic non-touch technique
  • waste management
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6
Q

Additional precautions examples:

A

May be required where patient has highly transmissible infection:

  • patient-dedicated equipment
  • single rooms
  • air handling
  • enhanced cleaning
  • specific PPE
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7
Q

Functions of skin:

A
  • protection of underlying tissues and organs
  • excretion of salts, water and organic wastes (glands)
  • maintenance of body temperature
  • production of melanin and keratin
  • synthesis of vitamin D
  • storage of lipids
  • detection of touch, pressure, pain and temperature
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8
Q

Integumentary objective assessment:

A
  1. Inspect and palpate
    - colour (eg. jaundice, pallor, erythema, cyanosis)
    - cap refill (normal <3secs)
    - temperature (dorsum)
    - moisture
    - turgor (from dehydration) & oedema
    - nails (clubbing, cigarette stains)
    - colour and texture of hair, balding pattern
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9
Q

Risk factors for delayed wound healing or chronic wounds:

A
  • diabetes
  • excess alcohol intake
  • inadequate nutrition
  • inflammatory disease
  • polypharmacy
  • renal failure
  • smoking
  • vascular disease
  • poor circulation
  • older age
  • location of wound
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10
Q

Minimising patient harm in pressure ulcers (SSKIN)

A
  • Skin assessment: skin touch test
  • Surface: mattresses, pillows, lifting heels off bed (soft surfaces)
  • Keep moving
  • Incontinence
  • Nutrition and hydration
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11
Q

Pressure ulcer risk factors:

A
  • immobility
  • older age
  • lack of sensory perception
  • poor nutrition or hydration
  • excess moisture or dryness
  • poor skin integrity
  • reduced blood flow
  • incontinence
  • friction and shearing
  • incorrect positioning
  • hard support surfaces
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12
Q

Primary intention healing:

A
  • tissue surfaces are closed and there is minimal tissue loss
  • eg. surgical incision
  • wound edges are easily opened
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13
Q

Secondary intention healing

A
  • extensive wound and considerable tissue loss
  • eg. pressure ulcers
  • wound heals through process of granulation
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14
Q

Tertiary intention healing

A
  • wounds left open for 3-5 days
  • eg. traumatic wounds and abscess drainage
  • primary intention is then attempted
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15
Q

Three type of exudate:

A
  1. Serous
  2. Purulent
  3. Sanguineous (hemorrhagic)
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16
Q

Serous exudate:

A
  • Mostly serum
  • looks watery and has few cells
  • eg. blister from a burn
17
Q

Purulent exudate:

A
  • thicker
  • presence of pus (consists of leukocytes, liquefied dead tissue debris, bacteria)
  • colour varies with organisms
18
Q

Sanguineous (hemorrhagic) exudate

A
  • large amounts of RBCs
  • indicates severe damage to capillaries
  • seen in open wounds
  • serosanguineous exudate = consists of clear and blood-tinged drainage
  • purosanguineous exudate = consists of pus and blood
19
Q

Local factors affecting wound healing:

A
  • pressure
  • desiccation
  • maceration
  • trauma
  • oedema
  • infection
  • foreign bodies
  • necrosis
  • dead space
20
Q

Systemic factors affecting wound healing

A
  • age
  • circulation and oxygenation
  • nutritional status
  • medication and health status
  • glucose control
  • immunosuppression
21
Q

Define pressure ulcer:

A

Any lesion caused by unrelieved pressure, including shearing and friction forces
- due to a deficiency in the blood supply to the tissue (localised ischaemia)

22
Q

Risk assessment tools for pressure ulcers:

A
  • Braden scale
  • Norton’s Scale
  • Waterloo scale
23
Q

Assessing common pressure sites:

A
  • inspect pressure areas for discolouration (brisk cap refill or blanch response when palpated)
  • inspect pressure areas for abrasions and excoriations
  • palpate temp of pressure areas (increased is abnormal and may be due to inflammation or trapped blood)
  • palpate for oedema
24
Q

Preventing pressure ulcers:

A
  • Providing nutrition
  • maintaining skin hygiene (reduces friction, moisturising lotions)
  • avoiding skin trauma (wrinkle-free surfaces, position, ambulation)
  • providing supportive devices (wedges, pillows, heel protectors, mattresses)
25
Q

Treating pressure ulcers:

A
  • Minimise direct pressure
  • schedule position changes
  • clean and dress ulcer using surgical asepsis
  • obtain sample of drainage for culture and sensitivity
  • mobilise
26
Q

Aseptic Non-Touch Technique:

A
  • patient is considered ‘dirty’
    1. appropriate and effective hand hygiene
    2. maintaining non-touch technique
    3. using new sterilised equipment
    4. cleaning existing key parts
27
Q

Wound field theory:

A
  • the patient wound is considered part of the environment
28
Q

Key nutrients for wound healing:

A
  • Vitamins A, C, E
  • Minerals zinc and iron
  • Dietary protein, amino acids
  • Energy from carbohydrates and fats
29
Q

Which two layers of the epidermis are responsible for the germination of skin cells?

A
  • stratum spinosum and straum basale

- make up the stratum germinativum

30
Q

What influence does site/location of a wound have on healing?

A
  • areas exposed to more moisture and friction will take longer to heal
  • skin depth influences ease of healing
  • easier to heal in places of more tissue and more elastic tissue
  • less protection around wounds on bony prominences
31
Q

Why is a moist wound environment advocated?

A
  • prevents dehydration
  • enhances angiogenesis and collagen synthesis
  • promotes granulation
  • reduces pain
  • helps debridement
32
Q

What clinical features should be assessed and documented in a wound assessment?

A
  • location
  • colour
  • exudate
  • pain
  • temperature
  • skin flap or intact skin
  • dressings
  • solution used to clean wound
33
Q

What is the difference between the three types of transmission precautions required?

A

Contact precautions: infectious disease spread by contact, gloves & gown, patient dedicated equipment.
Droplet precautions: infectious disease spread by respiratory droplets, surgical mask, single-patient room
Airborne precautions: infectious disease spread by airborne route, P2 respirator, negative pressure room.

NUR5111 (14 decks)

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