MODULE 8: INTEGUMENTARY HYGIENE Flashcards
WHAT IS THE INTEGUMENTARY SYSTEM? WHATS INCLUDED IN IT? DIFFERENT TYPES OF GLANDS?
- the outer layer of the body
- made up of the skin, nails, hair
- nails and hair contain keratin
- sebacous glands secrete sebum
- sweat glands can either be apocrine or eccrine
WHAT ARE SOME FUNCTIONS OF THE SKIN?
HINT: 9
- protection
- preventing penetration
- perception (SENSES)
- temp regulation
- identification (tatoo’s birthmarks)
- communication
- wound repair
- absorption and secretion
- producing vitamin D
WHAT ARE SOME IMPLICATIONS OF CARE FOR PROTECTING SKIN
- preventing too much dryness or moisture, and being careful with hygeine products like soaps, cosmetics, detergents etc
- making sure skin is clean and bath water is not too hot or cold
WHAT ARE SOME IMPLICATIONS FOR CARE FOR SENSATION
- preventing friction
- smoothing bed linen
- removing jewlery before care
WHAT ARE SOME IMPLICATIONS FOR CARE FOR TEMPERATURE REGULATION
- promoting normothermia (normal temps)
- improving circulation
WHAT ARE SOME IMPLICATIONS FOR CARE INVOLVING ABSORPTION AND SECRETION
- avoid drying and keep clean
WHAT ARE SOME AGE RELATED CHANGES IN INFANTS/KIDS
struggle with temperature regulation
think abt it: infants always needa wear that goofy cap
WHAT ARE SOME AGE RELATED CHANGES IN PREGNANT INDIVIDUALS
hyperpigmentation and strech marks
WHAT ARE SOME AGE RELATED CHANGES IN OLDER ADULTS
- dry skin
- increased risk for shedding and tearing of skin
- increased risk for pressure injuries
- impared wound healing
- altered self esteem
WHAT ARE SOME DETERMINANTS OF HEALTH RELATED TO SKIN
awareness of cultural differences and socioeconomic status/ rural areas
- melanoma is much more prominent in people with lighter skin.
- low socioeconomic status increases chances for advances diagnosis
WHAT ARE SOME EXAMPLES OF QUESTIONS TO ASK WHEN DEALING WITH
- pigmentation, moles, hormones
- excessive dryness or moisturre
- pruitus (itching) and sensation
- excessive bruising
1) changes in skin colour, moles, pregnancy?
2) skin feel different?
3) any itching or tingling?
4) any excessive bruising? where and how?
5) when? where? how long? colour? raised or flat? spread? alleviating or aggravating factors? associated symptoms?
WHAT IS SOME SUBJECTIVE DATA YOU CAN COLLECT FOR
- Hair loss
- change in nails
- previous history of skin disease
- medication
- environmental or occupation hazards
- self care behaviours
1) gradual or sudden? changes in symetry or texture?
2) change in shape? colour or brittleness?
3) any previous skin disease or problems, family history? allergies or tatoos?
4) any meds? perscription or over the counter? how long?
5) any hazards, sun exposure, insects, plants or animals?
6) current care practices? cosmetics, soaps, chemicals, do you use sunscreen? nail care? or self skin assessments?
WHATS SOME OBJECTIVE DATA WHEN YOU LOOK AT SKIN?
inspect: colour
palpate: temperature, moisture, texture, thickness, edema (4 pt scale), bruising or vascularity, lesions, mobility or turgor (strechiness)
WHATS SOME OBJECTIVE DATA YOU CAN COLLECT ABOUT HAIR
HINT: scalp
inspect: colour, texture, distribution, lessions on scalp
paplate: lumps or tenderness on scalp
WHATS SOME OBJECTIVE DATA YOU CAN COLLECT ABOUT NAILS
inspect: colour , consistency, shape and contour
palpate: nail base and capillary refill
WHAT IS THE MELANOMA SCREENING TOOL
Assymetry
Border
Colour
Diameter
Evolution
WHAT ARE THE DIFFERENT COLOURS SKIN CAN BE? USE THE PROPER NAMES
- pallor: pale
- jaundice: yellow
- erythmea: red
- cyanosis: blue, check in the eyes (pull down)
- nails: ask abt new pigmentation, note in darkskins they usually have hyperpigmentation, ask if they’ve seen new pigmentation
HOW WOULD YOU ADDRESS PLAN OF CARE AND PLANNING IN REGARDS TO SKIN. WHAT SHOULD THE TIME FRAME BE?
Plan of care: depends on if they’re at risk for damaged skin or if skin is already damaged
planning: acute or chronic wound
Time frame: days-weeks
WHAT ARE SOME HYGEINE GUIDLINES FOR SKIN
TOP PRIORITY!!
- privacy
- safety
- warmth
- independence promotion
- anticipate needs ( get ur shit together so you don’t needa go back and forth)
WHAT ARE SOME CONSIDERATIONS FOR WORKING WITH PEOPLE WITH SKIN ISSUES
- Engaging with patient (don’t be awkward)
- self esteem and health
- baseline assessment
- documentation and reporting!!!!!!!! be as objective as possibe
WHAT ARE THE TIMES FOR A HYGEINE CARE SCHEDULE
- early morning
- routine morning
- afternoon
- evening or before sleep care
WHATS THE DIFFERENCE BETWEEN PARTIAL AND COMPLETE BATHING
- partial: only parts that would cause discomfort or odour if not cleaned (face, oral, perineum, axillae)
- complete: patient is totally dependent and requires total hyegine care. its everything in partial PLUS torso, extremities, hair, nails. usually involves bed linen change
WHAT IS A PRESSURE INJURY? WHATS IT’S PATHOGENESIS
- an injury localized on the skin, usually over a bony prominence as a result of pressure, sheer, or friction
PATHOGENESIS
- duration
- intensity: exceeds normal pressure of capillaries
- tissue tolerance: depends on bp, age, nutrition, moisture, friction, etc.
WHAT ARE SOME RISK FACTORS ASSOCIATED WITH PRESSURE INJURIES
HINT: 12
- impared sensory
- impared mobility
- alteration in conciousness
- shear
- friction
- moisture
- nutrition
- tissue perfusion
- infection
- pain
- age
- psychosocial
WHAT ARE SOME CLASSIC SIGNS OF WOUND INFECTION
HINT: 9
- pain and tenderness
- edema
- erythmea
- inflammation
- purulent discharge
- warmth
- foul odour
- elevated white blood cell count
- delayed healing
WHAT ARE THE STAGES OF A PRESSURE INJURY
- stage 1: intact skin and erythmea
- stage 2: some exposed dermis, looks like blister
- stage 3: looks like a crater, exposed adipose and full loss of thickness of skin
- stage 4: can see the bone, ligaments, and muscles
WHAT ARE SOME NURSING INTERVENTIONS FOR DECREASED SENSORY PERCEPTION
- assess pressure points for non-blanching. provide pressure redistribution surface.
WHAT ARE SOME NURSING INTERVENTIONS FOR MOISTURE
- assess need for incontinence management, after that clean area and protect skin with moisture-barrier cream
WHAT ARE SOME NURSING INTERVENTIONS FOR FRICTION AND SHEAR
- reposition patient using drawsheet or trapeze
- limit head elavation to 30 degrees and do a 30 degree lateral turn
WHAT ARE SOME NURSING INTERVENTIONS FOR DECREASED ACTIVITY OR MOBILITY
- establish a turning schedule
- esure functionality of pressure loading devices for a wheelchair and bed
WHAT ARE SOME NURSING INTERVENTIONS FOR POOR NUTRITION
- assess teeth and dentures and ensure good mouth care
- provide good nutrition and fluid intake
- consult dietition for nutritional evaluation
