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NUR 333 Funds II > Skin > Flashcards

Skin Flashcards

1
Q

what’s the largest organ of the body?

A

skin

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2
Q

What are the layers of the skin?

A

dermal, dermis, epidermis

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3
Q

What is the function of dermis?

A

middle layer

strength and support of inner organs

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4
Q

What is the function of the epidermis?

A

outer layer

basal layer

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5
Q

What is involved in a skin assessment

A

color
moisture
temperature
texture
turgor
vascularity
edema
leaions

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6
Q

Edema pitting scale

A

1+ little pitting, quick return
2+ some pitting
3+ deep pitting
4+ very deep pitting, longest return

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7
Q

Pallor

A

pale, loss of color

look in mucous membranes

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8
Q

What are indications of pallor?

A

anemia, shock, decreased blood flow

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9
Q

Cyanosis

A

bluish discoloration
can be yellow, grey in AA

look in mucous membranes, lips and nail beds

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10
Q

Indications for cyanosis

A

hypoxia
impaired venous return

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11
Q

Jaundice

A

yellow discoloration
look in sclera, mucous membranes

liver dysfunction

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12
Q

Indications for jaundice

A

liver dysfunction

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13
Q

Erythema

A

redness
palpate skin and look for warmth
look in face, skin, pressure spots

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14
Q

Indications of erythema

A

inflammation, vasodilation, sun exposure, increased temp

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15
Q

What should you do for erythemas to see growth?

A

mark the initial spot

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16
Q

Threats to skin integrity

A

impaired sensory perception
impaired mobility
altered LOC
shear
friction
moisture

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17
Q

Shear

A

when the skin slides but the underlying bones and muscles don’t move

skin is fixed and stretched

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18
Q

Friction

A

two surfaces rubbing against each other

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19
Q

Who is at risk of impaired skin integrity

A

older adults + trauma
spinal cord injuries
nutritional deficits
long term homes
acutely ill/hospice
DM patients
incontinence

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20
Q

Consequences of impaired skin integrity

A

pressure ulcers
localized injury
tissue ischemia

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21
Q

What is an example of a localized injury?

A

nasal cannula, skin breakdown behind ear and under nose

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22
Q

What are the factors of impaired skin development?

A

pressure intensity
pressure duration
tissue tolerance

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23
Q

Stages of pressure ulcers

A

stages 1-4 depending on severity
deep stage ulcer

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24
Q

Blanchable

A

skin returns red when pressure applied

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25
Nonblanchable
skin does not return red when pressure applied
26
Wound
disruption of integrity and function of tissues
27
Acute wound
normally time repair process return of normal and anatomical integrity
28
Chronic wound
gail’s to proceed through normal healing doesn’t return to normal integrity
29
Factors affecting wound healing
nutrition tissue perfusion infection age decreased circulation and oxygenation smoking
30
What nutritional factors are needed for healing?
high caloric intake high protein-BEEF LIVER vitamins A, C, copper, zinc
31
How is tissue perfusion affected by wounds?
decreased
32
What does infection do to the healing process?
delays it
33
How does age affect wound healing?
decreases with age
34
Braden Skin Scale
sensory, mental moisture mobility activity nutrition friction/shear
35
What does a lower braden skin scale score indicate?
higher chance of skin breakdown
36
Interventions for impaired skin
adequate nutrition incontinence management positioning
37
What tools can be used for impaired skin?
pads x flow pillow juven-supplement wedges special mattresses heel protectors
38
Wound management
assessing cleansing protection
39
What is included in a wound assessment?
appearance length, width, depth closed wound note drains/tubes pain around incision
40
How do measure wounds
1st-length: head to toe 2nd-width: side to side 3rd: depth
41
What is documented with wound drainage?
amount odor consistency color weight integrity of skin around wound
42
When weighing wound drainage, what does 1 mg =?
1 mL
43
serous exudate
watery, clear, slightly yellow
44
sanguinous exudate
reddish, thick, serum and blood seen in post op
45
serosanguinous exudate
pale pink color
46
What does purulant drainage indicate?
infection
47
Purulant exudate
yellow, green, brown color tissue debris and bacteria
48
Wound gauze
absorbs exudate
49
Nonadherent materials
doesn’t stick to wound or unhealthy skin
50
Wet to dry/moist dressing
mechanically debrides until granulation tissue starts to form
51
Transparent dressing
tegaderm Allows vision of any changes to wound
52
Hydrocolloid dressings
occlusive dressing that swells in presence of exudate maintains moisture 3-5 days
53
Hydrogel dressing
water gel after contact with exudate promotes autolytic debridment rehydrates and fills dead space
54
What shouldn’t hydrocolloid dressing be used for?
infections
55
What shouldn’t hydrogel dressing be used with?
draining wounds
56
Allginates dressing
nonadherent dressing that conforms to wound shape and absorbs exudate
57
Collagen dressing
powders, pastes, granules, gels, pastes helps absorb and heal wound
58
Wound vacs
use of foam strips into wound bed with occlusive dressing and NEGATIVE pressure
59
Does drainage count as input or output?
output
60
Hemorrhage
bleeding greatest risk 24-48 hours after surgery can be caused by clot dislodgment or blood vessel damage
61
What is internal bleeding indicated by?
swelling, distinction in area sanguinous drainage increased HR
62
Hematoma
local area of blood collection that appears blue or bruised
63
In an emergency, how should you care for a hematoma?
apply pressure dressing call HCP monitor VS
64
Dehiscence
partial or total rupture of a sutured wound separation of underlying skin layers
65
Who is at a higher risk of dehiscence?
obesity premature movement
66
Evisceration
dehiscence that involves the protrusion of visceral organs through wound openings
67
S/Sx of evisceration
increase in serosanguinous fluid on dressing sudden straining “popping or giving way”
68
Risk factors of dehiscence and evisceration
chronic disease elderly obesity invasive abdominal cancer infection dehydration/malnutrition vomiting excessive cough or sneeze abdominal surgery ineffective suturing
69
What kind of dressing should you cover purtruding organs?
sterile towels and NS saline
70
What diet should you place a patient in with purtruding organs?
NPO
71
S/Sx of infection
2-11 days after injury or surgery pain redness, edema, purulant drainage odor high HR, RR Increased WBC

NUR 333 Funds II (9 decks)

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