Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Nur 333 Fun 2 > Integumentary System (Exam 3) > Flashcards

Integumentary System (Exam 3) Flashcards

1
Q

Two layers of skin

A

Epidermis: Exposed to the outside (Basal push olde cells to surface)

Dermis: Inner layer (strength support protecting) (Sweat glands nerves)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Primary Purpose of Skin

A

-Protection

-Sensory Perception

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Pitting Edema

A

Know the scale

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Pallor

A

-Loss of color, in black skin tones can change to grey

-Look in mucous membranes

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Pallor: Indications

A

-Anemia, shock, lack of blood flow.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Cyanosis

A

Bluish discoloration, in brown skin tones can turn yellow-brown-grey

Nails bed, lips, mucousa

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Cyanosis: Indications

A

Hypoxia or impaired venous return (blue feet)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Jaundice:

A

Yellow discoloration

Sclera, skin, mucous membranes

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Jaundice: Indication

A

Liver dysfunction (RBC destruction)

Palms of hands best way. Sometimes eyes can have a little tent to them

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Erythema:

A

Redness, difficult to see in darker skin tones, palpate skin as well to look for warmth and texture changes

Face, skin, pressure prone areas

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Erythema: Indications

A

Inflammation, vasodilations, sun exposure, elevated body temp

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Shear

A

-Sliding movement of skin and subcutaneous tissue when muscle and bones are not moving

-Dermal layers that are under epidermis. Can not really see damage

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Friciton

A

-Two surfaces moving across one another

-Outer layer so we can see the damage

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Moisture

A

Duration and amount of moisture determine risk

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Patients at Risk for Impaired Skin Integrity

A

PP slide

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Pressure Injuries

A

-Describes impaired skin integrity related to unrelieved prolonged pressure

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Pressure applied over capillary in the skin–> capillary can not deliver blood

A

Tissue Ischemia

Tissue death from not having enough blood

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Three major factors involved in pressure injury development:

A
  1. Pressure intensity
  2. Pressure duration
  3. Tissue tolerance
    -low blood pressure, poor nutrition, aging, hydration status all affect tissue tolerance
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Pressure Injury Classification

A

-Stage 1 - Stage 4

19
Q

Deep tissue injury

A

-Persistent non blanchable deep red, maroon, or purple discoloration

-Cannot tell what layers are involved

20
Q

Unstageable Pressure Injuries

A

-Obscured by infection or dying skin (slough/eschar), cannot determine involvement

21
Q

Blanchable

A

-Turns lighter when pressed and then erythema

-Still hope for the skin

22
Q

Non-blanchable

A

Does not turn lighter in color when pressed; remains erythematous

-No hope for the skin (Deep tissue damage is probably)

23
Q

MASD

A

-Moisture associated skin damage

-Incontinence related (Urine or stool)

24
Q

Intertriginous

A

-Inflammatory dermatitis r/t moist skin on rubbing against each other

-Under breast and arm pits

-Can develop yeast and the skin can crack open

-Make sure skin is dry

25
Q

Periwound/Peristomal

A

-Associated with wound or stomas and enzyme breakdown associated with exudate

-Keep the skin dry

26
Q

Wound

A

-Disruption of the integrity and function of the tissues (not just pressure injuries)

27
Q

Acute Wounds

A

-Proceeds through normal/timely repair process

-Results in return to normal/sustained function and anatomical integrity

-Trauma / surgical incsions

28
Q

Chronic Wounds

A

-Wound that fails to proceed through normal healing process

-Does not return to normal function/anatomical integrity

-Pressure ulcer, vascular insufficiency wound

29
Q

Nutrition: Vitamins

A

-Deficiencies result in delayed healing

-Protein, vitamins A-C-Zinc- copper for wound healing

30
Q

Tissue perfusion

A

-Ability to perfuse tissues with oxygenated blood crucial to wound healing

-Diabetes/peripheral vascular disease are at risk for poor tissue perfusion

31
Q

Infection

A

-Prolong the inflammation and delay healing

-Indications that a wound is infected: purulent drainage, changes in color/volume/redness around the tissue, fever, or pain

-Low WBC also can delay healing because inablity to fight

32
Q

Age

A

-Aging affects all aspects of wound healing

-Delayed inflammatory responses, delayed collagen synthesis, and slower epithelization

33
Q

Risk Assessment: Braden Scale

A

Review Table 48.5 in potter and Perry

Lower score put patient at higher risk

34
Q

Interventions: Nutrition

A

Patients may need extra protein, calories, and nutrients

35
Q

Interventions: Incontinence/Moisture management

A

-Keep patient dry

-Apply moisture barrier for incontient patient

-Use products that wick moisture away from the patient

36
Q

Interventions: Positioning

A

-TURN TURN TURN TURN
-at least 2 hours in bed
-at least 1 hour in chair

-Use lift device rather than dragging can help prevent friction injuries

-Specialized mattresses, chair cushions, heel cushions

37
Q

Pressure injury Prevention Algorithm

A

READ THE SS

38
Q

Intervention: Bottom Line

A

-Nurses are the key to patients skin integrity

-Assessment must be thorough and consistent

-Interventions center around you —> turning, nutrition, and maintaining skin integrity is crucial

39
Q

Diaphoretic

A

Just laying in bed is not normal

40
Q

Injury edema

A

Non-pitting

41
Q

-Labs associated with nutrition

A

Serum albumin and pre-albumin

42
Q

Prevention Algo: Sensory Perception, Activity and Mobility

A
  • Turn Q 2 h

-Static Air cushion

-Up to chair every hour

-Early and often ambulation

43
Q

Prevention Algo: Friction and Shear

A

-Lift sheet to move patient

-Use overhead lift

-Keep patient pulled up in bed

-Float heals

-HOB 30 degrees

-Moisturize the skin

44
Q

Prevention Algo: Moisture

A

-Perineal care

-Barrier ointment

-No briefs in bed

45
Q

Prevention Algo: Nutrition

A

Weekly weight or as ordered

Ensure consult has been started

Feeding assistance

Chewing and swallowing problems

Good hydration

Nur 333 Fun 2 (19 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2025 Bold Learning Solutions. Terms and Conditions