Integumentary System (Exam 3) Flashcards
Two layers of skin
Epidermis: Exposed to the outside (Basal push olde cells to surface)
Dermis: Inner layer (strength support protecting) (Sweat glands nerves)
Primary Purpose of Skin
-Protection
-Sensory Perception
Pitting Edema
Know the scale
Pallor
-Loss of color, in black skin tones can change to grey
-Look in mucous membranes
Pallor: Indications
-Anemia, shock, lack of blood flow.
Cyanosis
Bluish discoloration, in brown skin tones can turn yellow-brown-grey
Nails bed, lips, mucousa
Cyanosis: Indications
Hypoxia or impaired venous return (blue feet)
Jaundice:
Yellow discoloration
Sclera, skin, mucous membranes
Jaundice: Indication
Liver dysfunction (RBC destruction)
Palms of hands best way. Sometimes eyes can have a little tent to them
Erythema:
Redness, difficult to see in darker skin tones, palpate skin as well to look for warmth and texture changes
Face, skin, pressure prone areas
Erythema: Indications
Inflammation, vasodilations, sun exposure, elevated body temp
Shear
-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
Friciton
-Two surfaces moving across one another
-Outer layer so we can see the damage
Moisture
Duration and amount of moisture determine risk
Patients at Risk for Impaired Skin Integrity
PP slide
Pressure Injuries
-Describes impaired skin integrity related to unrelieved prolonged pressure
Pressure applied over capillary in the skin–> capillary can not deliver blood
Tissue Ischemia
Tissue death from not having enough blood
Three major factors involved in pressure injury development:
- Pressure intensity
- Pressure duration
- Tissue tolerance
-low blood pressure, poor nutrition, aging, hydration status all affect tissue tolerance
Pressure Injury Classification
-Stage 1 - Stage 4
Deep tissue injury
-Persistent non blanchable deep red, maroon, or purple discoloration
-Cannot tell what layers are involved
Unstageable Pressure Injuries
-Obscured by infection or dying skin (slough/eschar), cannot determine involvement
Blanchable
-Turns lighter when pressed and then erythema
-Still hope for the skin
Non-blanchable
Does not turn lighter in color when pressed; remains erythematous
-No hope for the skin (Deep tissue damage is probably)
MASD
-Moisture associated skin damage
-Incontinence related (Urine or stool)
Intertriginous
-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
Periwound/Peristomal
-Associated with wound or stomas and enzyme breakdown associated with exudate
-Keep the skin dry
Wound
-Disruption of the integrity and function of the tissues (not just pressure injuries)
Acute Wounds
-Proceeds through normal/timely repair process
-Results in return to normal/sustained function and anatomical integrity
-Trauma / surgical incsions
Chronic Wounds
-Wound that fails to proceed through normal healing process
-Does not return to normal function/anatomical integrity
-Pressure ulcer, vascular insufficiency wound
Nutrition: Vitamins
-Deficiencies result in delayed healing
-Protein, vitamins A-C-Zinc- copper for wound healing
Tissue perfusion
-Ability to perfuse tissues with oxygenated blood crucial to wound healing
-Diabetes/peripheral vascular disease are at risk for poor tissue perfusion
Infection
-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
Age
-Aging affects all aspects of wound healing
-Delayed inflammatory responses, delayed collagen synthesis, and slower epithelization
Risk Assessment: Braden Scale
Review Table 48.5 in potter and Perry
Lower score put patient at higher risk
Interventions: Nutrition
Patients may need extra protein, calories, and nutrients
Interventions: Incontinence/Moisture management
-Keep patient dry
-Apply moisture barrier for incontient patient
-Use products that wick moisture away from the patient
Interventions: Positioning
-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
Pressure injury Prevention Algorithm
READ THE SS
Intervention: Bottom Line
-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
Diaphoretic
Just laying in bed is not normal
Injury edema
Non-pitting
-Labs associated with nutrition
Serum albumin and pre-albumin
Prevention Algo: Sensory Perception, Activity and Mobility
- Turn Q 2 h
-Static Air cushion
-Up to chair every hour
-Early and often ambulation
Prevention Algo: Friction and Shear
-Lift sheet to move patient
-Use overhead lift
-Keep patient pulled up in bed
-Float heals
-HOB 30 degrees
-Moisturize the skin
Prevention Algo: Moisture
-Perineal care
-Barrier ointment
-No briefs in bed
Prevention Algo: Nutrition
Weekly weight or as ordered
Ensure consult has been started
Feeding assistance
Chewing and swallowing problems
Good hydration
