Integumentary System

Question 1

Skin function

Answer 1

Protection, insulation, holds organs together, sensation, fluid balance, temperature control, absorb UV, metabolize vitamin D, synthesize epidermal lipids

15-20% body weight

Question 2

Components of epidermis

Answer 2

Most superficial layer

keratinocytes, melanocytes, langerhans cells, basal cells

Question 3

Components of dermis

Answer 3

Middle layer

collagen, reticulum, fibroblasts, macrophages, lymphatic glands, blood vessels, nerve fibers

Question 4

Skin receptor function: meissner’s corpuscles

Answer 4

detect light touch and texture

dermis

Question 5

Skin receptor function: merkel disks

Answer 5

detect light touch, texture, pressure

dermis

Question 6

Skin receptor function: pacinian corpuscles

Answer 6

detect deep pressure and vibration

hypodermis

Question 7

Skin receptor function: ruffini endings

Answer 7

detect warmth, stretch, deformation within joints

hypodermis

Question 8

Skin receptor function: free nerve endings

Answer 8

detect pain, temperature, touch, pressure, tickle and itch

epidermis and dermis

Question 9

Skin receptor function: krause end bulbs

Answer 9

detect cold

dermis

Question 10

Herpes zoster

Answer 10

Shingles

Initial sxs of pain and paraesthesia localized to affected dermatome

Painful rash w/ clusters of fluid filled vesicles
Mostly unilateral
Raised to palpation <2 mm height
Pink with silvery white appearance

Question 11

Which CNs are affected by herpes zoster

Answer 11

CN 5 - trigeminal most common

CN 7 - facial
CN 8 - vestibulocochlear

Question 12

Precautions for herpes zoster

Answer 12

Airborne, contagious
Wear gloves and mask

Question 13

Herpes simplex virus type 1 vs type 2

Answer 13

HSV-1 = anything above waist
HSV-2 = anything below waist

Question 14

Venous insufficiency

Answer 14

inadequate drainage of venous blood from a body part, usually resulting in edema and/or skin abnormalities and ulcerations

blood accumulates in LE
wet skin

Question 15

Arterial insufficiency

Answer 15

refers to lack of adequate blood flow to a region of a body

decreased blood to limb, pale/dry skin

Question 16

Venous insufficiency clinical presentation

Answer 16

Location: proximal to medial malleolus

Appearance:
irregular, shallow
flaking/brownish discoloration
hemosiderin staining
wet wound

Mild to mod pain
Elevation to decrease pain

Question 17

Arterial insufficiency clinical presentation

Answer 17

Location: lower 1/3 of leg, toe, dorsum of foot, lateral malleolus

Appearance:
smooth edges, well defined, deep
thin, shiny
hair loss, yellow nails, dry skin

Severe pain
Intermittent claudication
Elevation increases pain

Question 18

Intermittent claudication scale

Answer 18

Question 19

Stage 1 pressure ulcer

Answer 19

Intact skin with non-blanchable redness

Question 20

Stage 2 pressure ulcer

Answer 20

Partial thickness wound
Superficial w/ pink/red wound bed
Shallow crater

Question 21

Stage 3 pressure ulcer

Answer 21

Full thickness wound
Subcutaneous fat visible
No visible bone
Tendon/muscle may be exposed
Deep crater
Slough/eschar present
Undermining/tunneling may occur

FAT = 3 letter word = stage 3

Question 22

Stage 4 pressure ulcer

Answer 22

Full thickness w/ exposed bone, tendon, or muscle.
Slough/eschar present
Undermining/tunneling often occur

BONE = 4 letter word = stage 4

Question 23

Unstageable pressure ulcer

Answer 23

Wound bed covered with slough/eschar (unable to identify depth)

Question 24

Deep tissue injury

Answer 24

Intact skin
Purple maroon appearance

Question 25

Wound examination

Answer 25

Location and size: length x width x depth using a disposable ruler q-tip for depth characteristics: granulation tissue = viable necrotic tissue = non-viable drainage and color edges: thick or thin = indurated rolled = epibole periwound = area surrounding wound

Question 26

Transudate drainage

Answer 26

clear thin, watery

Question 27

Serosanguineous drainage

Answer 27

clear or tinge of red/brown thin, watery normal and indicates healing

Question 28

serous drainage

Answer 28

clear, amber thin, watery

Question 29

sanguineous drainage

Answer 29

bloody, bright red indicates inflamed wound

Question 30

pus drainage

Answer 30

yellow, brown mod to very thick

Question 31

infected pus drainage

Answer 31

hues of yellow, blue, green thick, usually indicates infection foul smelling

Question 32

Maceration

Answer 32

Moist wound, edges and periwound are wet white, friable, overhydrated, wrinkled skin cause: inappropriate wound care, uncontrolled wound drainage, perspiration, incontinence

Question 33

Dessication

Answer 33

Wound lacks moisture cracked, dry/flaky edges, tissue within wound bed hard or crusty causes: inappropriate wound care, inadequate moisture, infection, dehydration

Question 34

Most appropriate initial cleaning application for wound

Answer 34

sterile normal saline

Question 35

Selective debridement

Answer 35

Removal of only nonviable tissue from a wound (<50% necrotic tissue) Sharp debridement - scalpel, scissors, forceps Enzymatic debridement - topical application of enzymes autolytic debridement - use of body's own mechanism to remove nonviable tissue *brief intense TENS

Question 36

Nonselective debridement

Answer 36

Removal of both nonviable and viable tissues from a wound (>50% necrosis) Wet to dry dressings - application of moistened gauze over area of necrotic tissue to be completely dried and removed Wound irrigation - moves necrotic tissue from wound bed using pressurized fluid hydrotherapy - whirlpool with agitation directed toward a wound requiring debridement

Question 37

Dressings

Answer 37

Exudate: Very mild exudate: Transparent films Minimal exudate: Hydrogel dressing, Hydrocolloid Moderate exudate: Foams Heavy exudate: Calcium alginates, Hydrofiber (max capacity) Infected wounds: Hydrofiber, Hydrogels, Calcium alginates, and Gauze

Question 38

Superficial burn

Answer 38

Epidermis Dry, red skin, no open areas Heals in 5 days w/o scarring

Question 39

Superficial partial thickness burn

Answer 39

Epidermis, some dermis Mottled red Intact, weeping blisters Blanches to pressure with quick capillary refill Extremely painful Heals in 10-14 days Minimal scarring

Question 40

Deep partial thickness burn

Answer 40

Epidermis, dermis Mixed red and white areas Blanches to pressure with slow capillary refill Decreased pinprick sensation Can take up to 3 weeks Large wounds can be managed surgically

Question 41

Full thickness burn

Answer 41

Epidermis, dermis, some subcutaneous tissue Dry, rigid, leathery eschar Lack of pain, pressure, temperature sensation Requires more than 3 weeks Will require surgical closure, may have contractures

Question 42

Subdermal burn

Answer 42

Epidermis, dermis, subcutaneous tissue Charred, dry and exposed deep tissue Requires surgical interventions Amputation and paralysis possible

Question 43

Rule of 9s Adult

Answer 43

*LOOK UP Head 4.5% Chest 18% Back 18% Each side of each arm 4.5% Each side of each leg 9% Perineum 1%

Question 44

Rule of 9s children

Answer 44

Head 8.5% Chest 18% Back 18% Each side of each arm 4.5% Each side of each leg 6.5% Perineum 1%

Question 45

Normal scar

Answer 45

Flat and similar to skin color

Question 46

Hypertrophic scar

Answer 46

Healed wound w/ thick fibrous tissue that remains w/in original wound border

Question 47

Keloid scar

Answer 47

Excessive scar tissue grows outside of original margins of wound