Objective 2 (1) Flashcards
Largest organ system of the body
Consists of skin, hair, nails, and glands
Forms a barrier between the internal organs and external env
Participates in vital body functions
integumentary system
what are the functions of the integumentary system?
Protection: against bacteria, foreign matter, water loss
Sensation: pain, temp, touch
Fluid balance: absorbs water, prevents excessive loss
Temp regulation: heat dissipation, evaporation
Vitamin production: vitamin D
Immune response functio: dermatitis, asthma. Cells in skin are diff inppl with allergies than those who are healthy
bruising
ecchymosis
red, pinpoint spots from blood leakage
petechiae
itchy skin
pruitis
redness
erythema
bluish skin
cyanosis
pale skin
pallor
yellowing of the skin
jaundice
ease of rising of skin
tugor
ability of the skin to return to place
mobility
moles
nevus
what are the factors that affect the skin integrity?
physical, emotional and lifestyle
medical management
environment, socio-economic, care setting, potential for self-management
systems; health care support and communication
Detailed history of general health
Diabetes, age, peripheral artery disease, collagen vascular disease cancer, chemo, among others
physical, emotional and lifestyle
Overall health, OTC meds/creams, allergies, hydration, and nutrition, psychological factors
Pain assessment: painscales, one of the worst aspects of chronic wounds, lead to anx
Quality of life: mental and physical well being
medical management (listen)
Overall impressionL body language, effect, interaction, clothing, assistive devices
Skin assessment: skin and mucous membranes, mobility/tugor, maceration, bruising, red shiny lower legs, edema, nail thickness, hair distribution
medical management (look)
Skin temp, pitting edema, nutritional status, hemoglobin
medical management (touch)
Income
Working conditions, food, housing/env\
Early childhood development
edu/literacy
Social supports
Health behaviours/access to healthcare
Lower income negatively impacts health, lack of resources and social supports can lead to smoking, alcohol/substance abuse
environment, socio-economic, care setting, potential for self-management
Access to funding, access to services and wound-related products
Diagnostic services, service delivery personnel
systems; health care support and communication
what are the changes related to aging?
Skin dryness, wrinkling, thinning, decreased tugor, increased skin fragility
Loss of subcut tissue
Decreased blood supply
Thinning hair
Photoaging
what are the goals of care?
Should aim goals to SMART principle:
Specific – what needs to be accomplished (how, when, where
Measurable – how much, how many, how often
Attainable – realistically achievable
Rewarding –all should feel good when goal is achieved
Timely – realistic timeframe (short, intermediate and long
what are the factors associated with increased wound infection?
Characteristics of the Individual
Poorly controlled diabetes
Prior surgery
Radiation or chemo
Hypoxia, anemia, arterial/vascular disease, rheumatoid arthritis,shock)
Immune system disorders (AIDS, malignancy)
Malnutrition, alcohol, smoking, drug abuse
Contaminated wounds, trauma from delayed treatment
Pre-existing infection / sepsis
Penetrating wounds over 4 hours
acute wound
Duration of wound, large wound area, deep wound
Located near a site of potential contamination (perineum, sacrum)
chronic wound
what are the S&S associated with bacterial burden?
contamination
colonization
local infection
wound acquires microorganisms, if not successful in invading host they will not multiply or persist
contamination
microbial species grow and divide but does not cause damage or infection
colonization
bleeding, wound breakdown and enlargement, delayed healing, pain, odour
covert (subtle)
erythema, local swelling, purulent discharge, delayed healing, pain, odour
overt (classic)
what are the S&S of spreading infection?
Extending induration, erythema
Lymphagitis
Wound breakdown with dehiscence (wound rupture along surgical incision)
Malaise, nonspecific deterioration
Loss of appetite
Swelling of lymph glands
what are the S&S associated with systemic infection?
Severe sepsis
Septic shock
Organ failure
Death
identify and implement an evidence-informed plan to correct the causes that affect skin integrity…
Physical activity – beneficial effects physically and mentally
Nutrition – vital role in prevention and management of wounds
Moisture control – keep skin dry, avoid irritants, treat secondary infection (manage incontinence)
Pain management
Smoking cessation, weight management, stress management, mental health programs
normal saline, sterile water, tap water and antiseptics
wound cleansing
antimicrobial or antiseptics (povidone-iodine)
infected wounds
maggots liquify necrotic tissue and secrete substances that destroy bacteria
biological debridement
applying moistened gauze and periodically removing it (wet to dry dressing); non-traumatic irrigation systems (syringe and needle) 19 gauge needle gives 15 pounds of pressure; ultrasound (sound waves through saline)
mechanical debridement
specialized, powered surgical tool
hydrosurgical debridement
sodium hypochlorite
chemical debridement
self-digestion of enzymes naturally present in the wound
autolytic debridement
application of proteolytic substances to breakdown tissue
enzymatic debridement
fastest way to remove devitalized (slough), contaminated or infected tissue
surgical debridement
removal of only devitalized tissue with scalpel or scissors
conservative sharp wound debridement
how do we manage bacterial balance>
Optimize host response and wound environment
Reduce the number of microorganisms
Antibiotics – agents that kill selectively and require metabolic activity for action
non-selective agents that does not require metabolic action
antiseptics
umbrella term used to group antibiotics and antiseptics
antimicrobial
Greyish-blue tone, especially in nail beds, earlobes, lips, mucous membranes, and palms and soles of feet Ashen or greyish colour most easily seen in the conjunctiva of the eye, mucous membranes, and nail beds
cyanosis
Dark red, purple, yellow, or green colour, depending on age of bruise. Purple to brownish-black; difficult to see unless occurring in an area of light pigmentation
ecchymosis
Reddish tone, possibly accompanied by increased skin temperature secondary to localized inflammation Deeper brown or purple skin tone with evidence of increased skin temperature secondary to inflammation
erythema
Yellowish colour of skin, sclera, fingernails, palms of hands, and oral mucosa Yellowish-green colour most obviously seen in sclera of eye, palms, and soles
jaundice
Pale skin colour that may appear white or ashen; also evident on lips, nail beds, and mucous membranes May appear yellowish, ashen, or grey
pallor
Lesions appear as small, reddish purple pinpoints, best observed on abdomen and buttocks Difficult to see; may be evident in the buccal mucosa of the mouth or the conjunctiva of the eye
petechiae
May be visualized as well as felt with light palpation. Not easily visualized, but may be felt with light palpation
rash
Narrow scar line, usually white or pink. Higher incidence of keloid development, resulting in a thickened, raised scar
scar
collect subjective data about overall health, family history, medications, skin disorders, allergies
health history
assessment of all skin areas, mucous membranes, scalp, hair and nails
physical exam
color, vascularity, temperature, mobility, turgor, texture and edema
inspection and palpation
how do we assess lesions?
Type of lesion – primary or secondary (e.g. macule, papule, pustule, vesicle)
Color of lesion
Associated pain, redness, heat or swelling
Size and location
Configuration (pattern) of eruption
what does documentation include for skin lesions?
Wound bed – necrotic or granulation tissue, exudate, color and odor
Wound edges and margins – observe for extension of the wound under the skin surface
Wound size – measure in mm or cm to determine diameter and depth
Surrounding skin – color, suppleness and moisture and irritation
what is the ABCDE method for screening moles
A : Asymmetry – one half is not like the other half
B : Borders – irregular edges, ragged, notched and not well defined
C : Color – variation or change
D : Diameter – growth in size larger than a pencil
E : Evolution – change in size, shape, symptoms, surface elevation, bleeding, color
tissue obtained from nodules, plaques, blisters and other lesions for microscopic examination. Used to rule out malignancies or other disease
skin biopsy
identifies site of immunologic reaction using dye
immunofluorescence
applying suspected allergens to healthy skin
patch testing
tissue samples and scraped from suspected fungal lesions and examined under microscope (scabies)
skin scrapings
