Late adult III Flashcards
(26 cards)
What are the three layers of the skin and their function?
EPIDERMIS: keeps moisture in, microorganisms out
DERMIS: str and protection
SUBCUTATNEOUS: structural support and E storage
What are the age related changes to the skin?
colour/pigmentation
texture (skin tags)
vascularity and lesions
ex. senile pupura, cherry angioma, seborrheic keratosis
dec turgor
reduced thickness, inc wrinkles, sags, and dec subcutaneous fat
dec moisture and perspiration
What are factors affecting structure and function of skin?
mental status
general health
moisture
mobility and activity
nutrition
circulation
sensory perception
What is pressure ulcer?
an impairment of the skin as a result of prolonged ischemia (dec blood supply) in tissues
resulting from pressure
What are the 5 forces that contribute to destruction of skin?
mechanical
immunological
bacterial
chemical
What are the 4 stages in development of a pressure ulcer?
pressure
tissue compression
vascular obstruction
interference with cell metabolism
pressure x time = ischemia = cell death -> pressure sore
what is the mathematical formula for pressure?
pressure = force/area
What is erythema?
reddened skin, localized vasodilation
normal reaction to hyperemia (compensatory response to lack of blood flow in underlying tissue
What is abnormal reactive hyperemia?
when redness remains long after pressure is removed
> 1 hr
precursor for pressure ulcer
What are the 4 stages in pressure ulcer formation?
1) epidermis and dermis are damaged, but not destroyed
2) epidermis and dermis are destroyed, dmg reaches subcutaneous layer
3) subcutaneous layers destroyed, decaying cells produce cavity
4) muscle and bone tissue damage occurs
What is the most common assessment tool for the development of pressure ulcers?
the Braden scale
What does the Braden scale assess?
1) sensory perception
2) moisture
3) activity
4) mobility
5) nutrition
6) friction and sheer
If you get a high score on the Braden skill, what risk level are you?
high risk
Explain the difference between friction and shear
FRICTION: force occurs in a direction opposite of movement. Rubbing of surfaces
SHEAR: bones and soft tissues above them move in opposite directions (occurs when sliding pt in bed with raised head)
What are 8 interventions that can prevent pressure ulcers?
1) risk assessment (braden scale)
2) identify high risk areas
3) maintain mobility and activity
4) massage and exercise
5) pressure relieving devices
6) REPOSITIONING
7) adequate nutrition and fluids
What are the strategies for management of pressure ulcers?
- team approach
- reduce pressure
- manage friction and shear
- protect bony prominences
- avoid unnecessary pads, sheets, clothing
- dec moisture
What is the ideal position for HOB to reduce pressure ulcer risk?
30-45 degrees not 90
What are the three factors influencing aging?
family hx
environment
lifestyle
What are some indications of underlying health problems in the aging adult?
- change in mental status
- falls
- dehydration
- dec appetite
- pain
- loss of functional ability
- dizziness
- incontinence
- infection
- alterations in gastrointestinal status
- cardiac disease
How does infection present in aging adults?
factors influencing:
decreased immune system,
higher risk for infection,
response is slower and less effective
doesn’t present the same way (ex delirium)
What is the alteration in GI?
decreased peristalsis
How does cardiac disease present in the aging adult?
less crushing pain, more of an aching pain
congestive heart failure is harder to notice b/c it simply causes fatigue in older adults
How does type 2 diabetes present in the older adult?
more gradual onset
dehydration, confusion, weight loss are more prevalent
How does thyroid disease present in the older adult?
harder to detect
fatigue, tremors
