Skin Integrity Flashcards
What is tissue integrity?
The skin being in tact for protecting other tissues from trauma, fluid loss, and infectious organisms. Opposite of that would be impaired skin. Skin is the largest organ in the body.
What is the outermost layer of skin? What is another term for the skin?
The Epidermis layer has flat dead cells, protects everything under it, & allows water evaporation. Absorbs medications as needed. Another term for the skin is integument.
Where are the mucous membranes and its function?
They are located in the nose, ears, mouth, urethral, anal areas & and the Epidermis layer of the skin. The are not in a layer by themselves. They secrete/produce mucous & protects against foreign substances entering the body.
What is the second layer of skin?
The Dermis Layer has connective tissue, blood vessels, nerves, sweat glands (temp.), and provides protection for bones/muscles. Injections given here intradermal (Insulin).
What is the last layer of skin?
Subcutaneous fat (middle section)and it keeps us warm, protects internal organs from anything that is traumatic/absorption layer for shock(car accident or fall down to prevent issues with organs). Blood vessels that go through fat layer.
What does arteries do?
Vessel that carries blood away from the heart.
What does veins do?
Vessel that carries blood to the heart.
What does nerves do?
They detect pain, cold, warmth. It tells your brain what is going on also if your hurting or too cold.
What is the protection layer?
The epidermis and dermis are the layers of protection. The epidermis absorbs shock and protects, insulates. The Dermis provides cells for wound healing, collagen and elasticity, & Houses nerves for inflammation. Also as Homeostasis mechanism (water loss and skin dries up.) The skin dilates when cold or you will constrict. When your hot you’re going to dilate & when cold constrict. Body is trying to keep something fluids. Cells close when water loss to prevent dehydration.
What is temp. regulation?
If cold the glands are going to constrict. If hot we are going to dilate & sweat by releasing some of the heat in our bodies. So skin acts as a temp. regulation.
How does the nerves in the skin act as a sensory organ?
To let you know if something is painful or too hot or water is too hot or cold. Sensory nerves signal goes to brain.
The skin acts as a vitamin synthesis how?
Vitamin (D)-synthesis calcium, Bones need Calcium to function & be strong. Vitamin D helps synthesize Calcium. Sun best source of Vitamin D. Vitamin D is also in some foods that we eat. If you don’t have enough Vitamin D then you can’t synthesize Calcium.
Psychosocial is the last function of the skin. What is involved with that function?
Good place psychologically. Feel good when dressed & makeup is on, but a patient with burns on face, arms, legs will not feel as good. Skin acts as a barrier psychologically. The more good you feel about yourself, the better you are psychologically.
How does the function of the skin different in infants, children, and adolescents?
Infants & toddlers have less subcutaneous fat and can’t regulate the body temp(at first not able to regulate but as they get older they can-higher in infants), fluid loss (sick-dehydrated quickly because can’t control fluid loss), and sweat glands don’t function until puberty. So they don’t sweat and smell as bad. They are also incontinent & have to depend on others for toileting/being changed & if not done in a timely manner can cause skin breakdown.
How is the function of the skin different in older adults?
The geriatric population are prone to skin tears due to loss of elasticity. They also have flatter sub. Fat. Apocrine glands are nonfunctional until puberty resulting in more oily skin and acne (children don’t sweat/have no smell). Adults is very thin/fragile (skin can tear easily)-Nurses should be careful taking tape off pt. skin (epidermis layer of skin can be torn off), No shear force (use draw sheet due to thin skin), bed bath (tears easily-skin grows new cells(epidermis/dermis) but older pts want grow new cells, soap tries out, older pts. Don’t sweat as much) Clean perineal/anal area and dry good. Check brief for clean & dry. Check every two hours on pt. & bath every other day.
What are some other things about an older adults skin?
Older pts. Immune system is decreased. Inflammatory response decreased so they will get skin tears quicker. Burnt quicker in sun due to not having enough melanin. Less elastic fibers in dermis (skin doesn’t stretch as much & you see wrinkles) & skin tone decreased. Check skin turgor on chest & not arms it will be false tenting. Reduced nerve endings (Can’t feel as well-at risk for cuts, burns, bath (too hot water), also Diabetics should check their water as well.
What are the 6 Major Categories of Impaired Tissue Integrity?
1.Trauma (Tear in skin)/Injury-Intentional (Surgical) & Unintentional ranging superficial abrasion to deep (skin tear )or Full thickness-through Dermis & Epidermis or Partial Thickness-through part of skin)
2.Loss of perfusion-Tissue needs continuous supply of oxygenated blood. Tissue dies & turns black & Has to be removed. Needs continuous oxygen to have good tissue & repair damaged tissues Diabetes-decreased perfusion in lower extremities (venous/artery diseases-limbs that aren’t there anymore
3.Immunologic Reaction-Visible allergy responses. (creams, lotions, & perfumes) there will be swelling, Redness, rash, or raised area, or break in skin from scratching
4.Infections and Infestations (Bacteria, fungus on skin) or parasites-(Living thing that grows on you)-worms that grow in skin, scabies, lice (Wash hair with special shampoo), ticks (Wash body with special body wash & do two weeks later for eggs & wash all coverings), crabs/Isolate pt. & wear gown & gloves
5.Thermal or Radiation Injury (Burns, chemotherapy/radiation, sun, Hot water-scalds)
6.Lesions (Moles, keloids-knot in skin from piercing, skin cancers)
