T3: Integumentary (CH. 27) Flashcards
Most obvious effects of aging are the changes involving
the ___ system
integumentary
Past ___ practices greatly influence the integumentary system.
health
Problems involving other body systems can result from
an ___ integumentary system
unhealthy
__ can play important role in promoting healthy
skin.
Nursing
Effects of aging on the skin includes ___ of the dermal-epidermal junction.
flattening
There is reduced __ and __ of the dermis.
thickness
vascularity
There is a reduction of epidermal ___.
turnover
There is a ___ of elastic fibers.
degeneration
There is increased __ of collagen.
coarseness
There is a reduction in ___.
melanocytes
There is atrophy of hair __ and decline in the rate of hair and __ growth.
bulbs
nail
There is increased __ of the skin.
fragility
These skin changes potentially affect body image, self-concept, reactions from others, socialization, and other __ __.
psychological factors
To promote skin health what are some ideas?
- avoid agents that irritate the skin
- good skin nutrition
- promote activity
- hydration using bath oils, location, and massage
- avoid excessive bathing
- early treat of pruritus and skin lesions
Individuals should avoid exposure to UV rays by:
- using sunscreen
- wear sun glasses
Encourage ___ of entire body on a regular basis.
self-inspection
Individuals need to detect abnormalities by using (ABCDE), which stands for what?
asymmetry border irregularity color diameter elevation in height
Encourage your patient to look their best and make the most of their ___.
appearance
Efforts to avoid normal outcomes of aging can be
fruitless and __.
frustrating
When somebody wants surgery, assess the ___ for seeking this cosmetic surgery.
reasons
Nurses have the best opportunity with the most direct contact to __ the skin.
assess
What are some components of physical examination?
- skin surface
- lesions
- turgor
- pressure
- tolerance
- temperature
Most common dermatologic problem among older adults
pruritis
What are some causes of pruritus?
atrophic changes alone could be responsible, conditions that dry skin, excessive bathing, and heat
This condition is also referred to as actinic or solar ___.
keratosis
These are small, light colored lesions, gray or brown in color, on exposed areas of skin.
keratosis
Dark, wart-like projections on the skin on various parts of body
seborrheic keratosis
Body locations of seborrheic keratosis?
trunk, face and neck
Seborrheic keratosis are __ lesions.
benign
Most common form of skin cancer?
basal cell carcinoma
Basal cell carcinoma grows __ and rarely ___.
slowly
metastasized
Small, done-shaped elevations covered by small blood vessels
Basal Cell Carcinoma
- Resemble small benign flesh-colored moles w/ “pearl” appearance
- May appear more dark than shiny w. melanin pigments in growth
basal cell carcinomas
Firm, skin-colored or red nodules
Squamous cell carcinoma
Common locations of squamous cell carcinoma?
scar tissue, lower lip, and on epidermis but CAN metastasize
Which cancer tends to more easily metastasize?
melanoma
3 types of Melanoma?
Lentigo maligna melanoma, superficial spreading melanoma, nodular melanoma
This black, brown, white, or red pigmented flat lesion occurs predominately on sun-exposed areas of the body. With time, it enlarges and becomes progressively irregularly pigmented. The mean age at diagnosis is 67.
Lentigo maligna melanoma.
Most melanomas are of this type. The lesion appears as variable pigmented plaque with an irregular border. It can occur on any area of the body. Its incidence peaks in middle age and continues to be high through the eighth decade.
Superficial spreading melanoma.
This melanoma can be found on any body surface and presents as a darkly pigmented papule that increases in size over time
Nodular melanoma.
There are weakened __ walls in the older adult.
vein
There is reduced ability of veins to __ to increased venous pressure.
respond
Fluid build up in the legs is called __ __.
stasis dermatitis
An inflammatory condition associated with chronic venous insufficiency.
stasis dermatitis
Venous return can be enhanced by:
- elevating the legs several times a day
- by preventing interferences to circulation, such as standing for long periods, sitting with legs crossed, and wearing garters.
- Elastic support stockings
__ __ often appear on the medial aspect of the tibia above the malleolus and, prior to skin breakdown, present as a dark discoloration of the skin.
stasis ulcers
Tissue anoxia and ischemia resulting from pressure can cause the__, __, and __ of tissue.
necrosis, sloughing, and ulceration
Common sites of pressure ulcers?
bony prominences
What stage: A persistent area of skin redness (without a break in the skin) that does not disappear when pressure is relieved. Usually over a bony prominence
stage 1
What stage: A partial-thickness loss of skin layers involving the epidermis that presents clinically as an intact or open/ruptured blister, or open shallow crater
stage 2
What stage: A full thickness of skin is lost extending through the epidermis and exposing the subcutaneous tissues; presents as a deep crater with or without tunneling and undermining adjacent tissue
stage 3
What stage: A full thickness of skin and subcutaneous tissue is lost, exposing muscle, bone, or both; presents as a deep crater that may include necrotic tissue, slough, or eschar. Tunneling and undermining often is present
stage 4
What stage: Full-thickness loss of tissue with base covered by slough and/or eschar. Stage cannot be determined until sough or eschar is removed to
expose the base and actual depth of wound.
unstageable
What stage? Localized area of non-blanchable deep red or purple discoloration with
a dark wound bed or blood-filled blister due to intense or prolonged pressure or shearing force. Skin may be intact or nonintact.
DTI- Deep Tissue Injury (also considered unstageable)
__ is the priority intervention of pressure ulcers.
Prevention
With pressure ulcers, it is essential to avoid unrelieved __.
pressure
What are some nursing interventions to prevent pressure ulcers?
Encourage activity, reposition q 2 hr, avoid shearing forces, not
elevating HOB greater 30 degrees, do not pull patients up in bed, use of
pillows, alternating pressure mattresses, water beds
What is the pressure ulcer scale??
BRADEN SCALE!!!!
___: fluid that accumulates in a wound; may contain serum, cellular debris, bacteria, and white blood cells
Exudate
__ drainage: comprised of white blood cells, liquefied dead tissue debris, and both dead and live bacteria
Purulent
___ drainage: composed of clear, serous portion of the blood and from serous membranes
Serous
___ drainage: mixture of serum and red blood cells
Serosanguineous
___ drainage: containing or mixed with blood
sanguineous
___: stage of wound healing in which epithelial cells form across the surface of a wound; tissue color ranges from the color of “ground glass” to pink
Epithelialization
___: thick, leathery scab or dry crust that is necrotic and must be removed for adequate healing to occur
Eschar
____ : occurs when two surfaces rub against each other; the resulting injury resembles an abrasion and can also damage superficial blood vessels directly under the skin
Friction
___ tissue: new tissue that is pink/red in color and composed of fibroblasts and small blood vessels that fill an open wound when it starts to heal
Granulation
___ : softening through liquid; overhydration
Maceration
___: death of cells and tissue
Necrosis
___: force created when layers of tissue move on one another
Shear
