Skin, hair, nails Flashcards
What is the importance of a skin assessment?
The skin is the largest organ
It is the first line of defense, and guards against trauma, pathogens, etc.
So when the patient’s skin integrity is broken the patient is at risk of infection and illness. We want to prevent this.
What are some functions of the skin?
Immune system function
Synthesis of vitamin D
Thermoregulation
wound repair
What are the layers of the skin?
- Epidermis- outer rugged protective layer
- Dermis- inner supportive layer
What does the epidermis consist of?
Basal cell layer (stratum basale)
Horny Cell layer (stratum corneum)
What does the basal cell layer (stratum basale) consist of?
inner later; Melanocytes are produced here. They produce melanin, which gives skin its color.
What does the horny layer (stratum corneum) consist of?
outmost layer; This is the layer that has dead skin cells that shed every four weeks.
What does the dermis consist of?
connective tissue (collagen)
elastic tissue
nerves, sensory receptors, blood vessels & lymphatics
What layer are the epidermal appendages embedded in (hair follicles, sebaceous glands, sweat glands)?
the dermal layer.
What are eccrine glands?
sweat glands that are all over the skin.
What are apocrine glands?
produce viscous lipid-rich sweat. looks yellowish.
What is the subcutaneous layer?
Lies beneath the two layers of the skin
Made of adipose tissue
stores fat for energy
provides insulation
soft cushion aids in protection
loose layer gives skin mobility over structures underneath.
What are some characteristics of aging skin?
Drier, flatter skin
Decreased sebum (oil) and sweat production
Decreased elasticity
Decreased number of functioning melanocytes
Decreased elastin, collagen, subcutaneous fat
change in thermoregulation (decreased function of the hypothalamus)
change in nails
T/F: there is increased vascular fragility in older individuals.
TRUE. Veins in older patients are stagnant, and kind of stay in place. This is due to decreased vascular + skin elasticity
Who is most at risk from damage to pressure due to changes in circulation and decreased ability to form new collagen?
Older patient. This is why mepilex bandages are used quite frequently in the hospital for older patients.
What are some strategies nurses can implement to reduce injuries of skin for older adults?
-Try not to apply really adhesive tape, it can cause tears on their skin
-apply lotion as it decreases dryness.
-increase hydration
- advise not to take a shower every day, or if they do, try to stay away from using soap and apply oxygen.
T/F: very thin and very obese patients are at higher risk for skin breakdown.
TRUE
What can cause pressure injury development?
External pressure
Friction and Shearing
immobility
nutrition and hydration
moisture
mental status
age
Define a stage I pressure injury.
Intact skin with nonblanchable erythema.
Meaning if you push down on the red skin, it does not change color upon pressure. Stays the same red color.
Define a stage II pressure injury.
partial thickness loss of the dermis. Presents as an abrasion or a blister.
Looks almost like a burn.
Define a stage III pressure injury.
Full-thickness skin loss and subcutaneous tissue may be visible and presents as a deep crater
Underlying muscle is visible and exposed to outside environment.
RYB wound classification.
The universal classification of wounds by color.
Red, yellow, black
Define a stage IV pressure injury.
Full-thickness skin loss. Tissue necrosis or damage to muscle, bone, or supporting structures.
Stage IV pressure injury must involve damage to muscle bone or supporting structures.
What would we do with a Yellow pressure wound?
Cleanse it. Get rid of the sluff (oozing, exudate, drainage).
cleaning needed. Irrigate it using a wet to moist dressing, nonadherent dressing, or topical antimicrobial medication.
What would we do with a black pressure wound?
We would debride (remove) it.
mechanical debridement- using a scalpel or scissors to cut away the dead tissue.
scrubbing wound or applying wet to moist/dry dressing
chemical debridement- using a collagenase enzyme or autolytic debridement to help body break down necrotic tissue.
What would we do with a Red pressure wound?
We would protect. Meaning prevent further damage.
gentle cleansing, use of moist dressings, application of a transparent dressing, change dressing when necessary.