Integumentary System Flashcards
Top layer of skin
Epidermis
Second layer of skin that contains connective tissue and appendages such as hair follicles, sweat glands, and sebaceous glands
Dermis
Layer of skin beneath the dermis that contains adipose or fat tissue
Hypodermis
Wound healing
Primary intention: wound is closed or approximated using sutures, staples, or glue
Secondary intention: wound is left open to heal through granulation, contraction, and epithelialization
Tertiary intention: intentionally leave wound open to debride necrotic tissue or wait for inflammation to subside, then close it at a later time
Factors that can delay wound healing
Older age, decreased immune function, impaired nutrition (protein), impaired circulation, smoking, diabetes
Inflammatory phase of wound healing
Hemostasis — vasoconstriction, platelet aggregation, formation of clot
Proliferate phase of wound healing
Consists of epithelialization, granulation, contraction — open wound will fill with granulation tissue consisting of collagen, wound edges will contract or get smaller, resurfacing of wound with new skin cells
Maturation/remodeling phase of wound healing
Collagen produced during proliferative phase is replaced with new, stronger collagen (may take over 1 year)
Pressure injury risk factors
Impaired nutrition, reduced sensation, excess, moisture, immobility, impaired oxygenation, and friction and shear forces
Scales used for assessment of increased risk of skin breakdown
Norton and Braden
Patients with a score less than or equal to ___ with the Norton scale, or a score less than or equal to ___ with the Braden scale at increased risk for skin breakdown
14; 18
Stage I pressure injury
- Damage to the epidermis
- skin intact non-blanchable erythema
Stage II pressure injury
- damage to the epidermis and dermis
- wound with partial thickness, skin loss, base of wound is usually red and moist
- May also present as serous-filled blister
Stage III pressure injury
- damage extends to the subcutaneous tissue
- full-thickness skin loss with visible adipose tissue
- undermining or tunneling may be present
Stage IV pressure injury
- Full-thickness skin loss with exposure of bone, tendon, or muscle
- may have undermining or tunneling present
Unstageable pressure injury
Necrotic tissue that covers wound base (slough or eschar) preventing staging
Deep tissue injury
- damage that occurs at the bone-muscle interface
- intact or non-intact skin with a deep purple or maroon discoloration
- may also present as blood-filled blister
Nursing care for pressure injuries
Ensure patient is on specialty mattress that provides pressure redistribution, turn and reposition frequently (q2h), keep HOB under 30 degrees, NEVER massage bony prominences, ensure patient is receiving adequate nutrition (protein intake)
Wound culture nursing care
Obtain prior to administration of antibiotics, clean wound with NS, swab and area of viable tissue in wound bed for about 5 sec, do NOT touch skin surface when placing swab in tube
Inflammation of a hair follicle that presents as a small, erythematous pustule
Folliculitis
Infection of multiple hair follicles as well as the adjacent tissue presenting as large, erythematous pus-filled nodule
Furuncle
Bacterial infection of deep tissue that can’t be life-threatening if left untreated
Cellulitis
Symptoms of cellulitis
Erythema, warmth, pain, and swelling in the affected area, fever, malaise
Cellulitis treatment
Systemic antibiotics, IV antibiotics
Tinea infections
- ringworm
- tinea capitus (on head)
- tinea corporis (on body)
- tinea cruris (jock itch)
- tinea pedis (athletes foot)
S/S of tinea infection
Pruritis, red scaly cracked skin, ring-shaped rash, hair loss
Tinea infection diagnosis and treatment
Dx: clinical examination, KOH test
Tx: oral or topical antifungals agents, selenium sulfate shampoo w/ oral antifungal for tinea capitus
Tinea infection patient education
Keep skin clean and dry, avoid sharing personal items, avoid walking barefoot through locker rooms or public showers
Candidiasis risk factors
Antibiotic therapy, immunosuppression, corticosteroids, diabetes, pregnancy
S/S of candidiasis
Red, irritated skin with burning and itching, oral — white patches in mouth and throat
Candidiasis patient education
Keep skin clean and dry, vaginal candidiasis — wear cotton underwear, avoid tight clothing, inhaled corticosteroids — rinse mouth after administration
What type of fungal infection is spread through contact with people, pets, or contaminated objects?
Dermatophytosis (tinea infections)