Integumentary System Flashcards
What is the largest organ?
The skin
What are the 4 techniques used by nurses in physical assessment?
Inspection, Percussion, Palpation, and Auscultation.
What kind of information can the skin provide us with?
Changes in oxygenation, circulation, tissue damage, hydration, mental issues. Ect
What kind of information can the skin provide us with?
Systemic problems, and self-care abilities.
What are some examples of systemic skin problems?
Impaired circulation, respiratory disorders, endocrine imbalance, and allergies.
What are some examples of self care abilities related to skin?
Hygiene, excercise, and maintenance could be related to mental health.
What is the biggest endocrine system in the human body?
The pancreas
What can nails help us with?
Assessing a persons mental and physical health.
When do we assess the skin?
During comprehensive assessments, when a concern is present, an injury, during hygiene cares, beginning of shift, and when assessing health status.
What is cyanosis?
A bluish discoloration of the skin due to poor circulation or inadequate oxygenation of the blood.
Which nursing techniques are most important when assessing skin, hair, and nails?
Inspection and pal-station.
When do we wear sterile gloves?
Only during important procedures such as surgery or inserting catheters ect
What are some examples of subjective data when assessing skin? (6)
Problems/conditions, current symptoms (past family history), lifestyle, practices.
What does COLDSPA stand for?
COLDSPA. Definition. Character, Onset, Location, Duration, Severity, Pattern, Associated Factors / How it Affects the client.
What is Parkinson’s disease?
Nerve cell damage in the brain causes dopamine levels to drop, leading to the symptoms of Parkinson’s.
Parkinson’s often starts with a tremor in one hand. Other symptoms are slow movement, stiffness and loss of balance.
What is subjective data?
Subjective data are information from the client’s point of view (“symptoms”)
Define short term memory loss?
Short-term memory loss is when you forget things you heard, saw, or did recently.
True or False? Family are apart of the patient
True
What’s important when preforming a physical examination?
Preparing the patient - aka getting informed consent, positioning, privacy, protection, and equipment.
What’s involved in positioning of a patient?
Ensuring they are in a position that helps for an examination but that is comfortable and warm for the patient.
What equipment should you have when preforming a skin assessment?
Gloves, and alcohol based hand rub (or you are frequently washing your hands), an examination light / penlight, a centimetre ruler, and an examination gown and drape.
What are the key assessment points of skin assessment?
Skin colour, temp, moisture, and texture. Skin integrity. Skin lesions. Hair condition. And nail condition (capillary refill)
What’s involved in a basic skin inspection?
Distinctive odour, colour variations, skin breakdown, primary, secondary or vascular lesions, and level of moisture.
What is skin integrity?
Overall skin health
What is involved in a colour variation skin inspection?
General colour and pigmentation, general appearance, smooth - moles - acne - hair growth, consistent with genetic backround, lips and conjunctivia- sclera (jaundice), increased areas of pigmentation.
What is normal pigmentation?
Light pink to brown or olive
What is involved in a lesions skin inspection?
ABCDE. Asymmetry (pattern), Border irregularity, Colour variation, Diameter, Elevation.
Why do we use a ruler?
To assess the size of abnormalities on the skin.
What do we look at when inspecting for skin integrity?
Nutrition, tissue perfusion, infection, and age.
What do we look at when inspecting for skin integrity?
Nutrition, tissue perfusion, infection, and age, signs of pressure injury.
What risk assessment scales may we use when inspecting skin integrity?
Braden or water low scale.
What are pressure ulcer risk factors?
Perception, Mobility, moisture, nutrition, friction or shear, and decreased tissue tolerance.
What are the common pressure injury sites of someone in the posterior position? (10)
Occipital prominence (neck), Spinous process (upper spine), scapula, elbow, iliac crest (lower left back), sacrum (just above anus), lschium (butt) Achilles’ tendon, heel, and sole.
What is the posterior position?
Standing
What is the lateral position?
Laying on side
What is the prone position?
Laying tummy down
What are nursing interventions for pressure injury’s?
Ensure dry clear moisturised skin, 2 hourly position changes, 2 hourly skin checkups (at pp), relief aids, avoid friction during transferring, and insure healthy diet/fluid intake.
What do we look at in terms of texture and thickness of the skin?
Whether the ski is rough/smooth, thin/thick/fragile, or scaliness.
How do you determine skin texture?
Stroke the skin lightly with fingertips.
What should normal skin texture feel like?
Smooth, soft, and flexible.
True or false, texture is different in parts of the body.
True it can be for example comparing thickness of feet to hands.
How should you assess temperature differences?
Using the back of your hand assessing changes of upper / lower limbs and opposing limbs.
What may localised heat indicate?
Inflamination or infection
What may coldness indicate?
Decreased blood flow
How do you palpate for turgor/elasticity?
You gently pinch the skin under the clavicle or sternum and then release. (In elderly use skin on back near clavicle)
What is a normal result when palpating for turgor/elasticity?
You will see the skin easily move back to its place
If the skin is dehydrating what will happen during a turgor/elasticity palpate?
It will not return so easily and it will usually tent
How do you palpate for oedema?
Press firmly for 5 seconds with the thumb and release?
What is pitting oedema?
Pitting edema is when a swollen part of your body has a dimple (or pit) after you press it for a few seconds. It can be a sign of a serious health issue.
What is non pitting oedema?
accumulation of excess fluid in soft tissues, causing swelling
How do you palpate for tenderness?
Palpate lightly and watch for facial expressions.
The accumulation of fluid in intercellular space is what?
Not normal.
What is oedema?
a condition characterized by an excess of watery fluid collecting in the cavities or tissues of the body.
What does the palpating of capillary refill test for?
The circulation of the periphery
When palpating capillary refill what are you looking for?
Colour returning in the nail bed
How quick should your nail return to pink in a good capillary refill?
1-2 seconds
