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Exam 3 > Skin integrity: Power Point > Flashcards

Skin integrity: Power Point Flashcards

1
Q

Purpose of Integumentary System

A 
Protection against infection
Major organ of sense
Temperature regulation
Prevents fluid loss
Elimination of wastes
Storage and synthesis
Absorption
Psychosocial wellness
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2
Q

Puritius

A

Itching

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3
Q

PQRSTU

A

provoke, quality, radiate, severity, time, u

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4
Q

presently altering skin integrity

A 
Demographics: age, gender, race
PQRSTU for skin!
Exposure to chemicals or irritants
Description of injury (if applicable)
Changes from baseline
Pain
Puritis
Exudate or drainage
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5
Q

health of…

A 
Rash history
Allergy history
Scarring history
Tanning/burning history
Smoking history
Chronic illnesses (especially autoimmune)
History is usually problem based
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6
Q

Jaundice

A

yellow color of the skin and whites of the eyes caused by excess bilirubin in the blood

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7
Q

Bilirubin produced by

A

normal breakdown of red blood cells

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8
Q

bilirubin is excreted through

A

the liver and excreted by bile from a result of hemolysis

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9
Q

influences on the skin… there are a ton!!!

A 
Illness
Extremes in weight
Fluid loss
Perspiration
Skin diseases
Jaundice
Decreased self care
Immobility
Poor nutrition
Dehydration
Decreased sensation
Vascular problems
Exposure to irritants
Chronic disease
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10
Q

Psychosocial factors

A 
Culture
Socioeconomic status
Access to running water
Emotional health
Personal preferences
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11
Q

Age related changes: infancy

A

Infancy
Skin is delicate
More prone to infections

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12
Q

Age related changes: childhood

A

Childhood

Increased resistance to injury

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13
Q

Age related changes: adolescence

A

Adolescence
Increased secretion of sebum
Increased incidence of acne

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14
Q

age related changes: Mid to late adulthood

A 
Skin becomes thinner
Decreases in elasticity
Less subq fat
Slower wound healing
Decreased insulating quality
Changes in pigmentation
Senile Lentigines
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15
Q

benign, localized brownish patch on the skin, often occurring in old age and usually in fair-skinned people with sun-damaged skin

A

age spot…Senile Lentigines

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16
Q

senile lentigines

A

age spots

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17
Q

a common, inflammatory skin condition that causes flaky, white to yellowish scales to form on oily areas

A

seborrheic ddermatitis

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18
Q

always look first

A

Inspection

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19
Q

skin inspection

A

Inspect in adequate light
Overall color
Localized variations
Presence of open areas or sores

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20
Q

Thick, leathery skin, usually the result of constant scratching and rubbing

A

lichenification

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21
Q

shapes of lesions

A

Round/Oval
Annular
Iris
Gyrate

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22
Q

patterns of lesions

A 
Singular/discrete
Grouped/clustered
Polycyclic
Confluent
Linear
Zosteriform
Generalized
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23
Q

while palpitating notice for…. (5)

A 
Texture
Temperature
Moisture
Skin turgor
Thickness
Callus
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24
Q

no need to…. while assessing

A

percussion, auscultation

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25
Q

lab/diagnostics

A

culture, biopsy

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26
Q

if purulent, considered…

A

infected

27
Q

skin teaching/health promotion (6)

A 
Cleanliness
Adequate hydration
Adequate nutrition
Use sunscreen
Don’t pick, lance, squeeze, or otherwise manipulate lesions
Keep open wounds covered
28
Q

Acute Wounds (3 types)

A

trauma, surgery, “healing chronic wounds”

29
Q

Traumatic Wounds: acute (5)

A 
Contusions
Abrasions
Avulsions
Lacerations
Punctures
30
Q

avulsions

A

is an injury in which a body structure is forcibly detached from its normal point of insertion by either trauma or surgery

31
Q

chronic wounds

A

Ulcers and wounds that take > 3 months to heal

32
Q

types of chronic ulcers

A

diabetic, pressure, and circulatory

Pressure ulcers
Venous ulcerations
Arterial ulcerations
Diabetic ulcerations

33
Q

the healing process

A

inflammation, proliferation, maturation

34
Q

1st step of the healing process

A

inflammation
24 hour period
endothelial cells release cytokines
Inflammatory Cascade

35
Q

2nd step of the healing process

A 
Proliferation Phase
2 days-3 weeks
Granulation
edges pull together
Epithelialization
36
Q

3rd step of the healing process

A

Maturation, Remodeling Phase
3 weeks-2 years
New Collagen

37
Q

scar tissue is only…

A

80% as strong as original tissue

38
Q

types of healing

A

primary, secondary, and tertiary

39
Q

Primary intention healing

A

Surgical closure of a wound

Closure is complete

40
Q

benefits of primary intention healing

A

Minimal tissue loss

Scarring is minimal

41
Q

Secondary intention of healing

A

Gap exists between tissue margins

Granulation tissue must fill gaps

42
Q

causes of secondary intention of healing wounds

A

too large, delayed wound closure

43
Q

tertiary intention is also called

A

delayed surgical closure

44
Q

reasons for tertiary intention of healing

A

dehiscence, infection, debridement needed

45
Q

wide scars are a result of what healing type….

A

tertiary intention

46
Q

the healing process is slow in what healing type…

A

secondary intention

47
Q

role of healing: protein

A

Fibroplasia, angiogenesis, collagen formation

and wound remodeling, immune function

48
Q

role of healing: zinc

A

Collagen formation, protein synthesis, cell

membrane and host defenses, Epithelialization

49
Q

zinc caution

A

large doses can be toxic

50
Q

role of Vitamin C

A

Collagen synthesis, capillary wall integrity,
fibroblast function, immunological function,
antioxidant

51
Q

role of Vitamin A

A

Epithelialization, wound closure, inflammatory

response, angiogenesis, collagen formation

52
Q

Vitamin A caution

A

Can reverse steroid effects on skin and delayed healig

53
Q

role of `Vitamin E

A

No known role in wound healing, antioxidant

54
Q

Vitamin E caution

A

blood thinner

55
Q

sources of vitamin E

A

fish, oysters, liver, dark meat, eggs, legumes

56
Q

important to wound healing…

A

Tissue Perfusion

57
Q

infection or contamination of a wound…

A

stops the wound from healing, increased costs, must be eradicated so healing can occur

58
Q

how does the infection stop a wound from healing…(4)

A

Prolongs inflammatory phase
Disrupts normal clotting mechanisms
Promotes disordered white cell response
Disrupts or prevents development of new blood vessels and granulation tissue

59
Q

wound assessment (7)

A 
Location
Size
Surrounding skin color
Drainage 
Wound surface
Induration
Granulation tissue
60
Q

measuring a wound….

A

diameter, depth in cm or mm

61
Q

saline, water, hydrogen peroxide, iodine, cotton gauze and swabs

A

cleaning wounds

62
Q

rule of thumb when cleaning wounds

A

“if you can’t put it in your eye, it doesn’t belong in a wound”

63
Q

things to look for in a good dressing…. (bunch)

A

Will remove excessive exudate but won’t let the wound dry out.
Will allow gas exchange.
Will be thermally insulating.
Will be impermeable to micro-organisms.
Will be free from particulate or toxic contamination.
Will be non-traumatic and will not adhere to the wound.
Will use minimal tape.

Exam 3 (9 decks)

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