Skin Integrity Flashcards
1
Q
concepts that impact tissue integrity
A
- sensory perception
- mobility
- nutrition
- perfusion
- gas exchange
- elimination
2
Q
concepts that are negatively impacted when tissue integrity is disrupted
A
- infection
- pain
- fluid & electrolytes
- thermoregulation
3
Q
a & p of integument
A
- hair – present everywhere but palms/ soles, root formed in dermis, thermal insulation, filter debris, color by melanin
- nails – keratin, protects finger/toes - preserves sensory fns, growth slows w/ aging
- skin – epidermis (epithelial cells w/ keratin = waterproof, no blood vessels, depend on underlying structures), dermis (nerves, hair follicles, glands/ blood vessels), subcutaneous tissue (anchors skin layers to underlying tissues, fat storage-energy, heat, insulator, cushioning)
- glands – sebaceous - produce sebum assoc w/ hair follicles, lubricate/soften skin, sweat - water and salt/cerumen, output depends on location, thermoregualtion
4
Q
function of skin
A
- protection – thickened areas palms/soles s/t inc trauma
-
sensation – receptors located in skin - temp, pain, light touch, pressure
-** fluid balance** - can absorb water or excrete as sweat, about 600ml lost/day through sweat = insensible perspiration
-** temp regulation** - evaporation of sweat, controlled blood flow thru skin -
vitamin production – vitamin D made w/ melanin
-** immune response** – Langerhans cells facilitate uptake of allergens
5
Q
changes in skin integrity
A
- state of individual health = direct impact on skin condition
- very thin/ obese
- fluid loss
- ecessive moisture
- jaundice
- skin disorders
6
Q
risk factors for impaired skin integrity
A
- lifestyle variables
- age
- change in health status
- illness
- diagnostic procedures
- therapeutic measures – immobility
7
Q
categories of impaired tissue integrity
all
A
- trauma
- loss of perfusion/ gas exchange – = pressure ulcers
- immunological disorders
- thermal radiation
- infection – bacterial, fungal, viral, infestations
- lesions
8
Q
categories of impaired tissue integrity
Trauma
A
- incision (intentional)
- contusion
- abrasion (scrape)
- lacertatin (cut)
- puncture
- penetrating
- avulsion
- chemical
- thermal
- irradiation
- superficial, internal
9
Q
categories of impaired tissue integrity
loss of perfusion/ gas exhange
A
- pressure ulcers/ bed sores
- venous statis ulcers
- diabetic ulcers
- arterial ulcers
- poor venous return, peripheral artery disease
10
Q
categories of impaired tissue integrity
immunological disorders
A
- psoriasis
- Steven- Johnson Syndrome
- contact dermatitis
11
Q
Steven-Johnson Syndrom
A
- potentially fatal acute skin disorder - high infection risk (sepsis, multi-organ failure - 5% mortality rate)
- characterized by: widespread erythema, macule formation, blistering, epidermal detachment/ sloughing
- typically triggered by reaction to medication – antibiotics (common offender), anit-seizure, NSAIDs, tylenol
- treatment – discontinue offending med, fluid/electrolyte replacement, supportive care – fluids, pain intervention
12
Q
contact dermatitis
A
- allergic – latex, poison ivy, cosmetics, jewelry
- irritant – soap, diaper rash, pper spray, bleach
- s/s – pruritus, burning, edema, swelling, papule/ vesicle formation
13
Q
categories of impaired tissue integrity
thermal/ radiation
A
- sunburn, radiation therapy
- not chemical burns – irritant dermititis
14
Q
categories of impaired tissue integrity
infection
A
- bacterial – cellulitis, impetigo (staff/strep), acne
- fungal – candida albicans, tinea (ringworm)
- viral – herpes (shingles)
15
Q
categories of impaired skin integrity
infestations
A
- pediculosos humanis capitis (head lice)
- pediculosis pubis (crabs)
- scabies
