Skin Assessment, Skin Care, and Supporting Patient Hygiene Flashcards
epidermis
outer layer of skin
visiable part of the nail
nail body
cresent shaped white area of the nial is known as the
lunula
Functions of the skin
- protection
- sensation
- tempurature regulation
- absorption
- secretion
constant exposure to miasture can cause
maceration
the buccal muscosa is also known as the
oral mucosa
chewing is also known as
mastication
how many permeant teeth are there for chewing
32
regular oral hygiene is nessasary to maintain the integrity of tooth surfaces and prevent
- gingivitis
- peridontal disease
where are hair follicles located
dermis
A patients personal preferances for hyginene can be influenced by
- social practices
- personal preferences
- body image
- socioeconomic status
- health benefits and motivation
- cultural variables
- physical conditions
risk factors for skin impariment
- immobilization
- reduced sensation
- nutrition and hydration alterations
- secretions and excretion on the skin
- vascular insufficenceny
- external devices
individuals with diabetes mellitus should be assed for
neuropathy
what is neuropathy
- degration of the peripheral nerves characterised by a loss of sensation, which can lead to injury
halitosis
bad breath
stomatitis
inflammation of the oral mucosal tissues
alopecia
loss of hair
Oral risks for hygiene
- inability to move the upper extremities
- dehydration
- presensce of nasogastric or oxygen tubes
- medications ( antihistamines)
- over the counter lozenges, cough drops, antacids, and chewable vitamins
- radiation therapy to head or nech
- oral surgury, trauma
- immunosepression
- diabetes
skin risks for hygiene
- immobilization
- reduced sensation (stroke)
- nutrition (limited protein or reduced hydration)
- excessive secretions (urine, feces, wound drainage)
- presence of external devices (restraints, casts, bandages, ect.)
foot risks for hygine
- inability to bend over
- inability to see feet
eye care risks for hygiene
- reduced dexterity and hand coordination
complete bed bath is used for patients
who are totally dependent and require total hygiene care
a partial bed bath includes bathing
parts of the body that would cause disconfort or odour if not cleaned
benefits of back rubs
- promotes relaxation, releives muscular tension, stimulates circulation, and improves sleep
enucleation
removal of eye
tissue ischemia
reduction in blood flow
pressure injury
- localized to the skin and underlying tissue
- usually over a boney prominance
- result of pressure, shear, friction or a combination of theses factors
hyperemia
redness
blanching occurs when
normal red tones of light skinned patients are absent
characterisitics of dark skin at risk for skin breakdown
- color
- tempurature
- appearance
- palpation
risks for pressure injury development
- impaired sensory perception
- impaired mobility
- alteration in level of conciouness
- shear, fiction
- moisture
- nutrition
- tissue perfusion
- infection
- pain
- age
- psychological impact of wounds
what is the Bradens Scale used for
to asses the risk of skin breakdown
what are the 6 characteristics of the bradens scale
- sensory preception
- mositure
- activity
- mobility
- nutrition
- shear and friction
what are the stages of pressure injuries
- stage 1
- stage 2
- stage 3
- stage 4
- unstageable
characteristics of a stage 1 pressure injury
- intact skin with localized nonblanchable erythema
- presensce of blanchable erythema or changes in sensation, tempurature, of firmness
- color changes do not include purple or maroon discoloartion
stage 2 pressure injuries characteristics
- partial thickness loss with exposed dermis
- wound bed is visible red or pink
- may also present as an intact or ruptured sebum filled blister
- adipose tissue is not yet exposed
stage 3 pressure injuries characteristics
- full thickness loss of the skin
- adipose tissue is visable
- epibole (rolled wound edges) are present
- undermining and tunneling can occur
stage 4 pressure injury characterisitics
- full thickness and tissue loss with exposed or directly palpatable fascia, muscle, tendon, ligament, cartilage or bone
- epibole (round wound edges) present
- undermining or tunneling often occurs
unstageable pressure injury characteristics
- full thickness skin and tissue loss in which the extent of damage within the ulcer cannot be confirmed because it is obstructed by slough or eschar
exudate
describes the amount, color, constiancy, and odour of wound drainage
- apart of the wound assesment
how to prevent pressure injuries
- positioning
- support surfaces
- education
- management of pressure injuries
elevating the head of the bed _____ degress or less will decrease the chances of pressure injuries developing
30
patients with some independent mobility should be encouraged to reposition every __ minutes
15
