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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
Q

Nonblanchable

A

skin does not return red when pressure applied

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26
Q

Wound

A

disruption of integrity and function of tissues

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27
Q

Acute wound

A

normally time repair process
return of normal and anatomical integrity

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28
Q

Chronic wound

A

gail’s to proceed through normal healing
doesn’t return to normal integrity

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29
Q

Factors affecting wound healing

A

nutrition
tissue perfusion
infection
age
decreased circulation and oxygenation
smoking

30
Q

What nutritional factors are needed for healing?

A

high caloric intake
high protein-BEEF LIVER
vitamins A, C, copper, zinc

31
Q

How is tissue perfusion affected by wounds?

A

decreased

32
Q

What does infection do to the healing process?

A

delays it

33
Q

How does age affect wound healing?

A

decreases with age

34
Q

Braden Skin Scale

A

sensory, mental
moisture
mobility
activity
nutrition
friction/shear

35
Q

What does a lower braden skin scale score indicate?

A

higher chance of skin breakdown

36
Q

Interventions for impaired skin

A

adequate nutrition
incontinence management
positioning

37
Q

What tools can be used for impaired skin?

A

pads
x flow pillow
juven-supplement
wedges
special mattresses
heel protectors

38
Q

Wound management

A

assessing
cleansing
protection

39
Q

What is included in a wound assessment?

A

appearance
length, width, depth
closed wound
note drains/tubes
pain around incision

40
Q

How do measure wounds

A

1st-length: head to toe
2nd-width: side to side
3rd: depth

41
Q

What is documented with wound drainage?

A

amount
odor
consistency
color
weight
integrity of skin around wound

42
Q

When weighing wound drainage, what does 1 mg =?

A

1 mL

43
Q

serous exudate

A

watery, clear, slightly yellow

44
Q

sanguinous exudate

A

reddish, thick, serum and blood

seen in post op

45
Q

serosanguinous exudate

A

pale pink color

46
Q

What does purulant drainage indicate?

A

infection

47
Q

Purulant exudate

A

yellow, green, brown color
tissue debris and bacteria

48
Q

Wound gauze

A

absorbs exudate

49
Q

Nonadherent materials

A

doesn’t stick to wound or unhealthy skin

50
Q

Wet to dry/moist dressing

A

mechanically debrides until granulation tissue starts to form

51
Q

Transparent dressing

A

tegaderm
Allows vision of any changes to wound

52
Q

Hydrocolloid dressings

A

occlusive dressing that swells in presence of exudate

maintains moisture

3-5 days

53
Q

Hydrogel dressing

A

water gel after contact with exudate

promotes autolytic debridment

rehydrates and fills dead space

54
Q

What shouldn’t hydrocolloid dressing be used for?

A

infections

55
Q

What shouldn’t hydrogel dressing be used with?

A

draining wounds

56
Q

Allginates dressing

A

nonadherent dressing that conforms to wound shape and absorbs exudate

57
Q

Collagen dressing

A

powders, pastes, granules, gels, pastes

helps absorb and heal wound

58
Q

Wound vacs

A

use of foam strips into wound bed with occlusive dressing and NEGATIVE pressure

59
Q

Does drainage count as input or output?

A

output

60
Q

Hemorrhage

A

bleeding

greatest risk 24-48 hours after surgery

can be caused by clot dislodgment or blood vessel damage

61
Q

What is internal bleeding indicated by?

A

swelling, distinction in area
sanguinous drainage
increased HR

62
Q

Hematoma

A

local area of blood collection that appears blue or bruised

63
Q

In an emergency, how should you care for a hematoma?

A

apply pressure dressing
call HCP
monitor VS

64
Q

Dehiscence

A

partial or total rupture of a sutured wound

separation of underlying skin layers

65
Q

Who is at a higher risk of dehiscence?

A

obesity
premature movement

66
Q

Evisceration

A

dehiscence that involves the protrusion of visceral organs through wound openings

67
Q

S/Sx of evisceration

A

increase in serosanguinous fluid on dressing
sudden straining
“popping or giving way”

68
Q

Risk factors of dehiscence and evisceration

A

chronic disease
elderly
obesity
invasive abdominal cancer
infection
dehydration/malnutrition
vomiting
excessive cough or sneeze
abdominal surgery
ineffective suturing

69
Q

What kind of dressing should you cover purtruding organs?

A

sterile towels and NS saline

70
Q

What diet should you place a patient in with purtruding organs?

A

NPO

71
Q

S/Sx of infection

A

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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