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NUR 333: > Skin > Flashcards

Skin Flashcards

1
Q

Largest organ in body

A

Skin

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2
Q

Layers of skin

A

Dermis
Epidermis

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3
Q

What separates the two layers of skin

A

Dermal epidermal junction

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4
Q

Role of epidermis

A

Divides and proliferates, sloughs off dead cells

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5
Q

Role of dermis

A

Provides strength and support or upper layers, protects underlying layers (muscles, bones)

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6
Q

Primary purpose of skin

A
  • protection
  • sensory protection
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7
Q

Main assessments of skin

A
  • color
  • moisture
  • temperature
  • texture
  • turgor
  • vascularity
  • edema
  • lesions
  • have you noticed any changes or issues?
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8
Q

Pitting edema

A

1+ 2 mm deep, barely detected
2+ few seconds to rebound
3+ 10 -12 secs to rebound
4+ more than 20 secs to rebound

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9
Q

Pallor

A

Loss of color, in black skin tones it can be gray
- mucous membranes
- indications: anemia, shock, lack of blood flow

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10
Q

Cyanosis

A

Bluish discoloration, brown/dark skin can turn yellow-brown, gray
- nail beds, lips, mucous membranes
- indications: hypoxia, impaired venous return

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11
Q

Jaundice

A

Yellow discoloration
- sclera, skin, mucous membranes, can do palms of hands
- indication: liver dysfunction (RBC break down causing yellow)

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12
Q

Risk factors for impaired skin integrity

A
  • impaired senseroy perception
  • impaired mobility
  • altered LOC
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13
Q

Shear

A

Sliding movement of skin and subq tissue when muscle and bone are not moving
- more dermal layer
- affects capillary, stretch and damage, cause ischemia

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14
Q

friction

A

Two surfaces moving across one another
-most common, easy to identify
- occurs when pulling up pt in bed
- outer layer of skin

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15
Q

Moisture

A

Duration and amount of moisture determine risk, softens your skin making it susceptible to damage (incontinence, sweating, wound exudate)

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16
Q

who’s at risk for skin integrity

A
  • older adults: trauma
  • spinal cord injuries
  • nutritional deficiencies
  • long term homes
  • acutely ill, hospice
  • diabetes
  • ICU, critical care
  • incontinence
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17
Q

Pressure injuries

A

Impaired skin related to prolonged, unrelieved pressure
- localized
- can be caused by medical device
* pressure applied over a capillary (weak) exceeds normal capillary pressure then it can lead to ischemia *

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18
Q

Major factors of pi

A

Pressure intensity (can be affected by heavier wt)
Pressure duration
Tissue tolerance

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19
Q

Deep tissue injury

A

Persistent non-blanchable deep red, maroon, purple discoloration
- can’t tell what layers are involved

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20
Q

Unstageable

A

Obscured by infection or dying skin, cannot determine involvement

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21
Q

Blanchable

A

Skin turns red when pressure relieved

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22
Q

Non blanchable

A

Redness does not occur

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23
Q

MASD

A

Moisture associated skin damage
- incontinence related
- intertriginous: inflammatory dermatitis, moist skin or rubbing together
- periwound/peristoma: wounds or stoma related, enzyme in exudate associated w breakdown

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24
Q

Wound

A

Disruption of the integrity and function of the tissue

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25
Q

Acute wounds

A
  • proceeds through normal and timely repair
  • results in return to normal and sustained function and anatomical integrity
  • ex: trauma/surgical incisions
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26
Q

Chronic wounds

A
  • wound that fails to proceed through normal healing process
  • does not return to normal function/anatomical integrity
  • ex: pi, vascular insufficiency wound
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27
Q

Nutrition for wounds

A
  • def result in delayed healing
  • protein, vitamin a,c, since, copper
  • adequate calories
  • labs: serum albumin, pre albumin
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28
Q

Tissue perfusion

A

Ability to perfume tissues w oxygenated blood crucial to wound healing
- diabetes and peripheral vascular at risk

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29
Q

Infection and wounds

A
  • prolongs inflammation and delays healing
  • will have purulent drainage, changes in color, fever, pain
  • low WBC can delay healing, dec ability to fight
30
Q

Age and wounds

A
  • affects healing
  • delayed inflammatory responses
  • delayed collagen synthesis,
  • slower epitheliation
31
Q

Braden Risk Assessment

A

table 48.3, 1244
- 6-23
- lower the score, the increased risk of impairment
- not great for ICU so use a diff one

32
Q

Interventions to prevent impaired skin

A
  • nutrition: extra supplements, protein, calories, nutrients
  • incontinence/moisture management: moisture barrier, products that wick moisture away
  • positioning: q2, move to chair, use assist device to prevent drag, specialized equipment
    slide 78
33
Q

Factors that affect wound healing

A
  • age, loss of skin turgor, skin fragility, dec collagen
  • dec circulation and oxygenation
  • slower tissue regeneration
  • dec absorption of nutrients
  • impaired immune function
  • dehydration
34
Q

Factors affecting wound healing pt 2

A
  • overall wellness
  • dec WBC
  • infection
  • medications
  • low HgB levels
  • obesity, smoking, chronic disease
  • malnutrition
35
Q

Inflammation

A

Localized protective response to injury to destruction of tissue

36
Q

3 components of management

A
  • assessment —> thorough and document
  • cleansing
  • protection
37
Q

Wound assessment

A
  • Appearance: red, yellow, black
  • length, depth, width
  • closed: well approximated?
  • drains, tubes?
  • pain
38
Q

Wound assessment: appearance

A
  • red: signs of inflammation, good thing is localized
  • yellow: likely indication of infection
  • black: eschar that requires surgical debridement
39
Q

Wound assessment: length, width, depth

A

Sinus tracks, tunnels, redness/swelling
- common in the vaginal, sacral, anal areas
- mark and measure areas around too that are not normal

40
Q

Wound assessment: closed wound

A

Edges are well approximated (clean and closed)
- staples, sutures, tissue adhesive
- can break open bc too much movement, swelling, etc
- always consider how long the staples should be there

41
Q

Wound assessment: drains/tubes

A
  • where are the drains located
  • what is the color of drainage
  • how much drainage is present
  • making sure the drains are not clogged
42
Q

Wound assessment: pain

A
  • pain is typically good bc its a indicator that something is wrong and we can solve that problem
  • control it w meds
  • understand if the pain is appropriate for the wound
43
Q

Wound drainage

A
  • can be normal/abnormal
  • doc amount, odor, consistency, color
  • note integrity of skin surrounding
  • can weigh dressing for amount of drainage (1g=1ml) but most ppl just say scant moderate large copious)
44
Q

Types of exudate

A
  • serous
  • serosanguinous
  • sangiuneous
  • purulent
45
Q

Serous exudate

A

Portion of blood (serum) that watery and clear or slightly yellow in appearance
- think blisters

46
Q

Serosanguinous

A

Contains serum and blood, more watery
- looks pale pink

47
Q

Sanguineous

A

Serum and red blood cells, thick and appears reddish
- brighter red is indicative of actual bleeding
- darker red is indicative of older bleeding

48
Q

Purulent

A

Thick, contains WBC, tissue debris, and bacteria
- results of an infection
- yellow, tan, green, brown (any color not pink or red)

49
Q

Nursing intervention for pt wounds

A
  • adequate hydration and nutrition
  • monitor albumin and prealbumin
  • wound cleaning
  • remove sutures
  • admin analgesics
  • admin antimicrobials and monitor effectiveness
  • document
50
Q

Wound dressing types

A
  • woven gauze
  • non adherent material
  • wet to dry
  • self adhesive, transparent
  • hydrocolloid
51
Q

Purpose of gauze sponges

A

Helps absorb exudate

52
Q

Purpose of non adherent material

A

Don’t want dressing to stick to wound bed

53
Q

Purpose of wet to dry

A

Used to mechanically debride a wound until granulation tissue starts to form
- mechanically: remove damage skin off wound

54
Q

Self adherent, transparent purpose

A

Allow you to watch the wound w out having to
- typically superficial wounds
- not really good for fragile skin

55
Q

Hydrocolloid

A

Occlusive dressing that swells in the presence of exudate
- forms seal abound wound surface preventing evaporation from the skin
- helps maintain granulating wound bed
some can last 3-5 days, but if the dressing is filled w exudate then change it

56
Q

Hydrogels

A

Mostly water, gels after contact w exudate
- promoted autolytic debridement
- rehydrates and fills dead space
- used for infected deep wounds or necrotic tissue
- dont use if lots of drainage
- provides moist wound bed and reduce pain
- prevents skin breakdown in high pressure areas

57
Q

Alginates

A

Non adherent dressing that conform to wounds shape and absorb exudate
- provides moist wound bed
- back wounds
- support debridement

58
Q

Collagen

A

Powders, pastes, granules, gels
- helps stop bleeding, promotes wound healing

59
Q

Vacuum assisted closure system

A

Use foam strips into wound bed with occlusive dressing, create negative pressure to occur once tubing is connected
- helps w tissue generation, dec swelling, and enhance healing in moist protective environment
- suctions wound close and brings blood supply towards wound
- some can infuse antibiotics

60
Q

Complications wound healing

A
  • adhesions
  • contractions
  • hemorrhage
  • dehiscence
  • evisceration
  • fistula formation
  • infection
  • excessive granulation tissue
  • keloid formation
61
Q

Hemorrhage

A

Blood ruptures from vessel
- greatest risk first two days after surgery
- can be caused by clot dislodgment, slipped suture, blood vessel damage
- may be swelling, distinction, sanguineous drainage
- subtle change in vs
- can be emergency

62
Q

Hematoma

A

Local are of blood collection that appears as red or blue bruise

63
Q

Hemorrhage emergency actions

A

Apply pressure dressing, notify provider, monitor vs

64
Q

Dehiscence

A

Partial or total rupture of a sutured wound, usually w a separation of underlying skin
- inc risk if obese, move too early
- will not be resutured, left to heal/close on own

65
Q

Evisceration

A

A dehiscence that involved the protrusion of visceral organs through wound opening
- typically traumatic incidents or occurs around vaginal/anal canals

66
Q

Eviscerations manifestations

A

Significant inc in flow of serosanguinous fluid on the wound dressing
- immediate history of sudden straining (coughing, vomiting, going to the bathroom)
- pt reports sudden change/popping/giving way
- visualize viscera

67
Q

Risk factors for dehiscence and evisceration

A
  • chronic disease
  • advanced age
  • obesity
  • invasive abdominal cancer
  • vomiting (other excessive strains like coughing, sneezing)
  • dehydration
  • malnutrition
  • ineffective suturing
  • abdominal surgery
  • infection
68
Q

Dehiscence and evisceration, nursing management

A
  • notify provider
  • stay w pt
  • cover wound w gauze and any organs w sterile towel/sterile dressings soaked w sterile saline
  • dont try to put organs back
  • position pt supine with hips and knees bent
  • calm environment
  • NPO
69
Q

Infection info

A
  • big risk always being monitored for
  • risk factors: age extremes, immune suppression, impaired circulation/oxygenation, wound condition, chronic disease, poor wound care
  • 2-11 days after injury: pain, redness, swelling, edema, purulent drainage, fever, chills, odor, inc pulse/RR/WBC
70
Q

Infection, nursing interventions

A

-prevent infection by using aseptic technique w dressing changes
- provide optimal nutrition
- provides adequate rest
- administer antibiotics therapy

NUR 333: (10 decks)

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