Integumentary System Flashcards
What to assess for skin?
color, moisture, temperature, texture, turgor, vascularity, edema, lesions
the Skin and its functions
biggest organ of the system; protects and does sensory perception
Where to look for color changes on dark skin?
Lips, palms, mucus membranes
How may pallor look on dark skin?
Gray color
Jaundice
yellow color in sclera and mucus membranes that may indicate liver dysfunction (and RBC death)
Where to look to assess jaundice in dark skin?
Palms
What does erythema indicate?
inflammation, vasodilation, sun exposure, warm temperature
Risk factors for impaired skin integrity
impaired sensory perception, immobility, altered LOC, LOPS, shear, friction, moisture, trauma, brace/cast/medical device, spinal cord injury, movement deficit, long term care, acutely ill or hospice, diabetes, incontinence, pt in ICU
shear
sliding movement of skin and SQ tissue when muscle/bone doesn’t move
Friction
2 surfaces sliding against each other
Pressure injuries cause
unrelenting prolonged pressure
Why does tissue ischemia occur with pressure injuries?
pressure is applied over a capillary and exceeds normal capillary pressure
3 major factors involved in pressure injuries
Pressure intensity, pressure duration, tissue tolerance
blanchable
turns light when pressed and goes back to red
nonblanchable
red skin that does not turn white when pressed
Deep tissue injury
persistent nonblanchable deep red, purple, or maroon color where you can’t tell what layers are involved
Unstageable pressure injury
obscured by slough/escar or infection, can’t determine depth
moisture associated skin damage
incontinence related prolonged exposure to urine/stool
intertriginous skin
inflammatory dermatitis related to skin rubbing (often in folds and under breasts)
Periwound/periostomal
Skin around the wound or stomach that can b/d from GI contents or moisture on it
Wound
disruption of integumentary and tissue function
acute wound
heals within normal timeline, returned to sustained function and integrity
chronic wound
abnormal healing process (pressure injury, diabetic ulcer)
Factors affecting skin and wound healing
nutrition, tissue perfusion, infection, extreme ages
What does a low Braden score mean?
high risk of skin breakdown
Interventions for wound healing and prevention
Q2 turns, Q1 if in the chair, adequate nutrition, keep pt dry, use lift to avoid friction, use special mattresses, aleve dressings, administer pain meds and anti-biotics, remove staples and sutures as ordered, DOCUMENT THOROUGHLY
Adequate nutrition for wound healing
monitor albumin and pre-albumin levels, high protein, high calorie, vitamins with moderate fat
Factors affecting healing
age, slow turgor, dec WBCs, fragile skin, dec circ and oxygen, infection, dec tissue absorption, dec collagen and immune function, mal nut, dehydration, overall wellness, dec Hgb, chronic disease
Key principles of wound management
assessment, cleaning, protection (from further damage)
yellow wound
could be slough (could indicate the wound is staying in an inflammatory stage) or purulent drainage
Black wound
might be eschar–dead skin; often needs to be removed in surgery
Beefy red wound
usually good, healing, granulation tissue
How to measure a wound
LxWxD in cm
what should a closed wound look like
well-approximated edges
what to document for drainage?
color, odor, amount, texture/consistency
Serous exudate
thin, clear, slightly yellow (like in blisters)
Sanguineous exudate
serum and RBCs, thick and reddish (bright–new, active bleed; dark–old blood)
How to chart tunneling?
Use Q tip to show depth and indicate location on the wound with a clock (ie at 7 oclock)
Serosanguinous exudate
serum and blood, watery, pale pink
Purulent
from infection; thick with WBCs, tissue debris, bacteria, creamier (yellow, tan, green, brown)
what is woven gauze used for?
exudate
when to use non-adherent material
don’t want it to stick to skin or wound
When to use wet-to-dry/damp bandage
want some mechanical debridement; dries and pulls off dead skin
Tegaderm
transparent; use with caution bc can pull off good skin
Hydracolloid
swells in presence of exudate; change MAX 3 days, pulls away excessive drainage
Hydrogel
watery bandage that meets exudate and does autolytic debridement; used for small amounts of exudate; give moist wound bed and decreases pain, prevent b/d in high pressure area; for infection, deep wound, necrotic tissue
Alginates
nonadherent dressing that conforms to wound shape and absorbs exudate
Collagen
powder, paste, granules or gels that stop bleeding and promote healing
What dressings might you need an order for?
Collagen, alginates, hydrogel
Wound vac dressing
foam with occlusive dressing connected to negative pressure and suction; brings nutrients and tissue perfusion to the area; good for large wounds and bad locations (near moisture and stool); need order for and change every 3 days
hemorrhage and sx
in surgical wounds; greatest risk 24-48 hours after surgery; can cause internal bleeding noted by swelling, distention, sanguineous exudate; can be an emergency
Fistula
abnormal or surgical opening that formed between 2 organs between organ tubes or organ and skin
adhesion
band of scar tissue that ties two places together
wound contractions
How the skin closes around the wound; abnormal contraction may results in holes under the skin
keloids
area of irregular fibrous tissue at the site of a wound; thick and raised, red or pinkish
Hematoma
local area of blood collection that appears red or blue
What to do in the case of an emergent hemorrhage
Notify HCP, apply pressure dressing, monitor VS
dehiscence
partial or total rupture or separation of a sutured wound usually with exposed layers of skin; usually found 2-11 days post-surgery; tx with wet to dry
Risk factors for dehiscence
obesity, coughing, poor surgical technique, decreased blood flow
Evisceration
intrusion of visceral organs through the wound opening; significant inc in serosanguious fluid on the dressing
Sx of evisceration
sudden pop after straining, see visceral organs, increased sanguineous exudate through the bandage
risk factors for dehiscence and evisceration
diabetes, old age, chronic disease, cancer, vomiting, strain/cough, obesity, dehydration, malnutrition, abdominal surgery, infection
Nursing care for evisceration
cover wound with sterile towel or gauze with sterile technique, DON’T try to reinsert wounds, position supine with knees bent, keep calm, keep pt NPO in case of surgery
Risk factors for infection
very young or old, chemo, malnutrition, chronic disease, poor wound care, immune suppressed, impaired oxygen
Infection prevention
good rest, use aseptic technique, nutrition, give antibiotics
s/s of infection
2-11 days post-surgery; pain, red, swell, purulent drainage, fever and chills, odor, inc pulse and RR, inc WBCs
Causes of hemorrhage
Clot dislodge, slipped suture, BV damage
