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Nurse Aide 1 > MODULE H - INTEGUMENTARY SYSTEM > Flashcards

MODULE H - INTEGUMENTARY SYSTEM Flashcards

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1
Q

AVOIDABLE PRESSURE INJURY

A

one that develops from improper use of the nursing process

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2
Q

BEDFAST

A

Confined to bed

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3
Q

BONY PROMINENCES

A

Areas of the body where the bone is close to the skin,
e.g. elbows, shoulder blades, sacrum

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4
Q

DEEP TISSUE PRESSURE INJURY

A

Purple or deep red localized area of discolored INTACT skin or blood fill blister
. usually due to damage of underlying soft tissue from pressure and /or shear

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5
Q

DERMATITIS

A

inflammation of the skin

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6
Q

DERMIS

A

The layer of skin under the epidermis

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7
Q

ECZEMA

A

RED, ITCHY AREA ON THE SURFACE OF THE SKIN

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8
Q

EPIDERMIS

A

The outer layer of the skin

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9
Q

FRICTION

A

rubbing of one surface against another;
skin is dragged across a surface

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10
Q

INTEGUMENTARY SYSTEM

A

.the skin
. the largest organ in the body
. the largest system in the body
. provides a protective covering for the body

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11
Q

PRESSURE INJURY (PRESSURE ULCER)

A

any lesion caused by unrelieved pressure that results in damage to underlying tissues

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12
Q

PRESSURE INJURY (STAGE 1)

A

.INTACT SKIN
.redness over a bony prominence

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13
Q

pressure injury ( stage 2)

A

. skin loss ( partial-thickness)
may see a blister
or shallow reddish pink ulcer
blister may be intact or open

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14
Q

PRESSURE INJURY STAGE 3

A

.SKIN LOSS ( full thickness)
.skin gone
.may see subcutaneous fat
.slough( dead soft tissue, often moist and varies in color- white yellow green or tan)
could be attached or stringy loose

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15
Q

Pressure injury stage 4

A

.full-thickness skin and tissue loss
.with muscle, tendon,and bone exposure;
.slough and eschar (thick, leathery dead tissue that may be
loose or attached to skin); often black or brown

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16
Q

Shear ( skin on skin)

A

.when layers of skin rub up against each other;
.or it could be when skin remains in place, but tissues underneath move and stretch causing damage to
capillaries and blood vessels

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17
Q

Shingles (or Herpes Zoster)

A

.a disease caused by a virus,
.most common in people over 50,
.with signs that include a rash or blisters on one side of the body,
.burning pain, numbness, and itching

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18
Q

Stasis Dermatitis

A

a skin condition affecting lower legs and ankles that occurs from
a buildup of fluid under the skin and causes problems with circulation

19
Q

The 30-degree lateral position

A

. position of a resident when the bed is not raised more
than 30 degrees
. pillows are placed under the head, shoulder, and leg to lift the hip at about a 30-degree angle to avoid pressure on the hip

20
Q

Unavoidable pressure injury

A

a pressure injury occurs despite efforts to
prevent one through proper use of the nursing process

21
Q

Unstageable pressure injury

A

full-thickness tissue loss with injury covered by slough and/or eschar

22
Q

3 layers of the skin

A
  1. epidermis
  2. dermis
  3. subcutaneous fat
23
Q

EPIDERMIS

A

.the outer layer;
.has living and dead cells;
.living cells push dead cells up as they divide and
dead cells flake off;
. living cells contain pigment that
give the skin its color;
.*does not have blood vessels
.and only few nerve cells

24
Q

DERMIS

A

.inner layer;
.made up of connective tissue;blood vessels, nerves, sweat glands, oil glands, and
hair roots located there

25
Q

Subcutaneous (fatty) tissue

A
  1. thick layer of fat
  2. connective tissue
26
Q

Integumentary System – Function

A
  1. Protects the body from injury and pathogens
    2* Regulates body temperature
    3* Eliminates waste through perspiration
    4* Contains nerve endings for cold, heat, pain, pressure and
    pleasure
    5* Stores fat and vitamins
27
Q

Integumentary System – Normal Findings

A

Warm, dry
Absence of breaks, rash, discoloration, swelling

28
Q

Integumentary System – Changes Due to Aging

A

1* Skin is thinner, drier, more fragile
2* Skin loses elasticity
3* Fatty layer decreases so the person feels colder
4* Hair thins and may gray
5* Folds, lines, wrinkles, and brown spots may appear
6* Nails harden and become more brittle
7* Reduced circulation to the skin, leading to dryness and
itching
8* Development of skin tags, warts and moles

29
Q

Integumentary System – Variation of Normal

A
  • Breaks in skin
  • Pale, white or reddened areas
  • Black and blue areas
  • Changes in scalp or hair
  • Rash, itching or skin discoloration
  • Abnormal temperature
  • Swelling
  • Ulcers, sores, or lesions
  • Dry or flaking skin
  • Fluid or bloody drainage
30
Q

Shingles (Herpes Zoster)

A

.Caused by a virus;
.Same virus that causes chickenpox;
.virus is inactive in nerve tissue and can become active
years later;
.Most common in people over 50
* Signs – rash or blisters on one side of the body, burning
pain, numbness, and itching;

.lasts about 3 to 5 weeks;

  • Infectious until lesions are crusty
  • Nurse aide’s role – per the directive of care plan, keep rash
    covered until crusty, remind the resident to wash hands often
    and avoid scratching or touching rash; the vaccine
    recommended for people 60 years or older who have had
    chicken pox
31
Q

HOW LONG DOES SHINGLES LAST

A

3 to 5 weeks

32
Q

Stasis Dermatitis

A
  • Skin condition affecting lower legs and ankles
  • Occurs from buildup of fluid under skin
  • Problems with circulation resulting in fragile skin
  • Can lead to open ulcers and wounds
  • Early signs – scaly, red, itchy areas;
    .later signs –swelling of legs, ankles, or other areas; thin skin;
    darkening skin, leg pain
  • Nurse aide’s role – report signs; note too tight stockings
    and shoes and report to nurse; follow directives of care
    plan which may include anti-embolism stockings and
    elevation of feet
33
Q

The Pressure Injury

A
  1. as “any lesion caused by unrelieved pressure that results in damage to underlying tissues;
  2. friction and shear are factors
  3. Many pressure ulcers occur within first 4 weeks of
    admission to the facility
34
Q

BONY PROMINENCE

A
  1. an area where bone sticks out or
    projects from flat surface of the body;
  2. back of head,
  3. shoulder blades, elbows, hips, spine, sacrum, knees,
    ankles, heels, and toes
35
Q

MAJOR FACTORS TO PRESSURE INJURY

A
  1. PRESSURE
  2. SHEARING
  3. FRICTION
36
Q

Pressure Injury – At Risk Factors

A

immobility,
breaks in skin,
poor circulation to area,
moisture,
dry skin, and
urine and feces irritation

  • Older residents and disabled residents are at risk due to
    skin changes due to age, chronic disease, and frailty
37
Q

Pressure Injury – Residents at Risk

A
  • Bedfast (confined to bed) residents
  • Requires some or total help moving (coma, paralysis, hip
    fracture)
  • Agitated or have involuntary muscle movement
  • Urinary or fecal incontinence
  • Exposed to moisture
  • Poor nutrition; poor fluid balance
  • Lowered mental awareness
  • Problems sensing pain or pressure
  • Have circulatory problems
  • Are older
  • Are obese or very thin
  • Refuse care
  • History of pressure injuries
    *Older residents and disabled residents are
    at risk due to skin changes
38
Q

STAGES OF PRESSURE INJURY

A
  1. Stage 1 – intact skin; redness over bony prominence

2* Stage 2 – Skin loss (partial-thickness); may see a blister
or shallow reddish-pink ulcer; the blister may be intact or
open

3* Stage 3 – Skin loss (full-thickness); skin gone; may see
subcutaneous fat; slough (dead soft tissue, often moist
and varies in color – white, yellow, green, or tan) may be
present; could be attached or stringy loose

4* Stage 4 – Full-thickness skin and tissue loss with muscle,
tendon, and bone exposure; slough and eschar (thick,
leathery dead tissue that may be loose or attached to
skin); often black or brown

5* Unstageable – Full-thickness tissue loss with injury
covered by slough and/or eschar

6* Deep tissue injury – purple or deep red localized area of
discolored intact skin or blood-filled blister; usually due to
damage of underlying soft tissue from pressure and/or
shear

39
Q

Pressure Injury – Pressure Points

A

Occur over bony areas, called pressure points and
include back of head, ears, shoulder blades, elbows,
hips, spine, sacrum, knees, ankles, heels, and toes;

sacrum being the most common site

40
Q

MOST COMMON PRESSURE POINT SITE

A

the sacrum

41
Q

Pressure injury PREVENTION

A
  • Use assistive devices (pillows, foam wedges); support
    feet properly
  • Do not position on red area, pressure injury, on tubes or
    other medical devices
  • Prevent bed friction (powdered sheets are an example)

Prevent shearing (do not raise the head more than 30 degrees)

  • Keep feet and heels off the bed
42
Q

The 30 degree Lateral Position

A
  • Bed is not raised more than 30 DEGREES
  • Pillows are placed under head, shoulder, and leg
  • Position lifts up the hip to avoid pressure on the hip at
    about a 30o angle
  • Person does not lie on hip as with the side-lying position
43
Q

PREVENTION OF PRESSURE INJURIES

A

Measures directed at
1) handling, moving,
and positioning of the resident and

2)providing skincare

Nurse Aide 1 (11 decks)

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