Skin Flashcards
Roles of Integumentary System(6)
- provides barrier
- regulates body temperature
- synthesize Vitamin D
- sensory perception
- excretion of metabolic wastes
- wound repair
ALSO: identity, non-verbal communication?!?
Layers of the skin (3)
- Epidermis (No blood vessels)
- —– a. stratum corneum
- ——b. stratum germinativum - Dermis (blood vessels, connective tissue, sebaceous glands, hair follicles)
- Subcutaneous
Pigments (4)
- Melanin
- carotene
- Oxyhemeglobin
- Deoxyhemeglobin
Jaundice
deposition of (too much) bilirubin
Yellowish color
Easiest to see in sclera, nails, palms and soles of feet
Cyanosis
Bluish Color
lack of oxygen (central)
lack of blood flow ( peripheral)
Vellus
Short fine baby fuzz hair, inconspicuous, unpigmented
Terminal hair
Coarser, thicker, conspicuous, pigmented
Sebaceous Glands
Produce sebum, lubricates skin and hair, reduces water loss through skin
Sweat glands ( 2 Types)
eccrine- widely distributed, open to surface, help control body temp
Apocrine- in axillary or genital areas, stimulated by emotional stress- Body odor
Health Hx Questions
- History of skin disease
- Diabetes or peripheral vascular disease?
- allergies or food sensitivities
- Burns or sun burns
- Corticosteroids/medications
- Family Hx
erythemia
Redness of skin
ecchymosis
Bruising of the skin
caratonemia
Orange tint form too much carrots
Vitiligo
loss of skin color
Mobility vs. Turgor
Mobility- the ease at which it picks up
Turgor- speed with which it returns into place
Edema
Localized- Injury
Systemic- puffy tight skin
Pitting- Interstitial fluid mobile
Pitting Edema Scale
1+ - 2mm
2+- 4mm
3+- 6mm
4+ - 8mm
What Vitamins/Minerals needed for Collagen formation
Vitamin C
Zinc
Copper
Non-pitting edema
Local infection or trauma ; Brawny edema
Macules
Sm flat mole < 1 cm
Papules
Raise mole <1 cm
Patches
Flat lesion, discoloration, > 1 cm,
Plaques
elevated, superficial, solid lesion, > 1 cm in diameter.
Nodules
Small Solid Tumor
Wheals
edemas of the skin, raised red, that appear suddenly - often related to allergic reactions
uticaria
Hives
Vesicles
filled with serous fluid, superficial blisters < 1/2 cm
cysts
semi solid, or liquid, goes into dermis
Bullas
filled with serous fluid, superficial blisters > 1/2 cm
Erosion
The partial loss of the epithelium, with the basement membrane left intact
Excoriation
Scratch to the skin
Fissure
cracks to the skin, like in eczema
Ulcer
A skin ulcer is a sore on the skin. Skin ulcers often form when blood circulation is impaired. Bed sores
Stages of Bed Sores ( 4)
Stage 1 - epidermis
stage 2- dermis
stage 3 - subcutaneous tissue, fat
stage 4- muscle & bone
Who is at risk for bed sores
IMMOBILE PATIENTS
INCONTINENT PATIENTS
Braden Scale (6 risk factors) whats good/whats bad
six major risk factors:
- sensory perception
- moisture
- activity
- mobility
- nutrition
- Friction/Sheer.
lower the score, the more likely the patient will develop a pressure ulcer.
18< risk
12< HIGH RISK
Asses upon admission and again 48-72 hours
Assessing moles for cancer
ABCDE-EFG
Asymmetry of one side to the other Borders-irregular=bad Change in color Diameter >6 mm =bad Evolving over time - Elevated Firm to palpation Growing progressively
Pruritus
Itching
Reactive hyperemia
is the transient increase in organ blood flow that occurs after a period of ischemia (ex: arterial occlusion)
linear
in a line
Geographic
scalloped boarders, resembling the boarders of a map
gyrate
ring
target
multiple rings- bullseye
zosteriform
follows nerve root
annular
ring like arrangement
discrete
separate distinct lesions, not joined to one another
Arciform
Arch shape
serpiginous
(of a skin lesion or ulcerated region) having a wavy margin.
Paronychia
infection of the skin folds around the nails
Leukonychia
transverse white lines, commonly known as Mees lines in the nails
Seborrheic kerotosis -Older adults
A noncancerous skin condition that appears as a waxy brown, black, or tan growth.
Angle of nail base
160*
Clubbing nails
Angle of nail base is > 160*
heart and lung diseases
peripheral vascular disease
Classification of wounds (5)
- Open/Closed
- acute/chronic
- clean/contaminated/Infected
- superficial/partial or Full thickness
- Penetrating
Primary Intention
edges are approximated
examples: Surgical incisions, paper cuts, and small cutaneous wounds usually heal by primary closure. - Minimal scarring
Secondary intention
wound edges not approximated
tissue loss
heals from inner layer to surface
requires a granulation tissue matrix to be built to fill the wound defect.
Tertiary intention
granulating tissue brought together
delayed closure of wound edges
Regeneration
In epidermal wounds
NO scar
Partial Thickness wound repair (3)
- inflammatory response ( vasodilation, redness, swelling, moderate amount of serous exudate
- Reproduction, migration and reestablishment of epidermal layers
- reestablishment of epithelial layers
Full thickness wound repair (4)
- Hemostasis- control blood loos, establish bacterial control, seal defect
- Inflammatory response- vasodilation, exudate
- proliferative healing- granulated tissue, contraction of wound, surface repair
- remodeling- final stage, scar tissue
Important labs for Wounds
WBC- too low =bad Hemoglobin level blood coagulation serum protein analysis, pre-albumin wound C&S Tissue biopsy
Serous fluid
clear/slightly yellowish tinged fluid, excreted by serous membranes
purulent
puss drainage
serosanguineous
serous fluid + Blood
sanguineous (hemmorhagic)
Blood drainage
Penrose Drain
A Penrose drain is a soft, flexible rubber tube used as a surgical drain, to prevent the buildup of fluid in a surgical site.
lies under a dressing, at time of placement a pin or clip is place through the train to prevent it from slipping further into the wound,
Jackson -Pratt Drain
(also called a JP Drain) is a closed-suction medical device that is commonly used as a post-operative drain for collecting bodily fluids from surgical sites. The device consists of an internal drain connected to a grenade-shaped bulb via plastic tubing.
Color Guide for wound care
Red- Protect
yellow- Cleanse
Black - Debride
INtrinsic factors for pressure ulcer development
Immobility impaired sensation malnourishment aging fever
Extrinsic factors
Friction
pressure
shearing
exposure to moisture
WOCN
Wound ostomy continence Nurse
How to prevent Bed sore ( position)
30 * lateral position
Debriding syringe information
35mL ; 19 gauge Angiocath
Avoiding skin trauma
smooth, firm surfaces semi fowlers position frequent weight shifts exercise and ambulation reposition q2 hrs
mattresses beds, wedges and pillows