Tissue Integrity Flashcards
Epidermis
- surface or outermost part of the skin
- consists of epithelial cells
- 4 or 5 layers, depending on location
- -5 layers over the palms of the hands and soles of the feet
- -4 layers over the rest of the body
Dermis
- second, deeper layer of skin
- flexible connective tissue
- richly supplied with blood cells, nerve fibers, and lymphatic vessels
- most hair follicles, sebaceous glands, and sweat glands are located in the dermis
- papillary and reticular layer
SubQ tissue
aka hypodermis
- lies below the dermis
- loose connective tissue
- stores roughly half the fat cells of the body
- serves as insulator and cushion for the body
- stores energy from the fat
Keratin
- fibrous, water-repellent protein
- gives epidermis its tough, protective quality
Melanin
- forms a shield that protects the keratinocytes and the nerve endings in the dermis from the damaging effects of ultraviolet light
- accounts for the difference in skin color
Sebum
an oily secretion of the sebaceous glands.
Vernix caseosa
a greasy deposit covering the skin of a baby at birth.
-cheese like protectant
Pruritis
severe itching of the skin, as a symptom of various ailments.
functions of skin
- protection
- sensation
- temp regulation
- secretion
- excretion
Newborn
- thin skin
- less subQ fat
- increased absorption of topical meds
- decreased ability to shiver
Eldery
- decreased thickness and collagen
- decreased elasticity
- decreased subQ
- decreased sensation
- decreased thermoregulation
- increased healing time
- increased skin tearing
- decreased melanin
Dark skin
- increased susceptibility to inflammatory processes and keloids
- post-inflammatory hypo- or hyperpigment action
- increased sebum production and sweat due to larger pores
- prone to scarring after acne
- age slower
- produces more melanin than light skin
Asians
- less protective
- more sensitive
culturally and ethnically diverse patients may…
use home remedies for hair and skin
intact skin
normal skin and skin layers uninterrupted by wounds
3 types of skin disorders
infectious
Inflammatory
neoplastic
infectious skin disorder
caused by microorganisms
-bacteria, virus, fungi, or parasite
inflammatory skin disorder
caused by pathologies
-acne, burns, eczema
neoplastic skin disorder
caused by skin cancers
primary lesions
arise from healthy skin (papules, macules, vesicles)
secondary lesions
result from a change in a primary lesion (scar, keloid)
Skin Assessment
- inspect for color, lesions, scars, tattoos
- inspect for alterations in integrity (redness, tears)
- inspect skin surrounding tubes, pins, caths, stomas
- note any odors
- palpate for temp, turgor, edema
turgor
checking for hydration status
good/brisk: if it is elastic and returns quickly
Risk factors for compromised skin integrity
- immobilization
- reduced sensation
- poor nutrition and/or hydration
- secretions/excretions
- altered cognition
Hair/scalp assessment
- inspect for hair distribution
- inspect for hair texture
- inspect for lesions
Nail assessment
- nail curvature
- nail color even
- not too thick
90% of African Americans have
pigmented bands
yellow nail
fungal; psoriasis
trauma to nail
turns dark color
normal nail curvature
160 degrees
clubbing
180 degrees
- CHD in children
- lack of oxygen or long term smoking in adults
tinea unguium
yellow, thick nail
- fungal, hard to treat
- oral antifungal
melanonychia
dark pigmented band in nail
common in His/Afr.Amer./Asians
Whites: could be melanoma, get checked immediately
Types of diagnostic tests for skin integrity
- biopsy
- culture
- wood lamp
- patch/scratch
biopsy
pathology
culture
infection; not prevention
-what is growing??
wood lamp
fungal skin infections
patch/scratch test
allergies
Wounds can be…
- intentional or unintentional
- open or closed
intentional
surgical incision
unintentional
road rash
open
papercut
closed
hematoma
clean
closed wounds
clean contaminated
surgical wounds
contaminated
fresh, accidental wounds
dirty or infected
dead tissue, w/ evidence of infection
incision
scapel, knife
contusion
bruise, sharp blow
abrasion
surface scrape
puncture
penetration of skin and underlying tissues, sharp instrument
-can be intentional or unintentional
laceration
tissues torn apart; often accidents
penetrating
penetration of skin and underlying tissues
usually unintentional
Untreated wounds
- control bleeding
- prevent infection
- control swelling and pain
- assess for signs of shock related to bleeding
signs of shock related to bleeding
- rapid, thready pulse
- cold and pale skin
- low BP
Treated wounds
- observe healing
- observe for signs of infection
- document
-if covered; assess dressing and document
C/D/I
clean/dry/intact
Types of wound drainage
serous
sanguineous
sero-sanguineous
purulent
serous
thin, watery, clear
sanguineous
thin, bright red (bloody)
sero-sanguineous
thin, watery, pale red to pink
bloody and serous fluid
purulent
thick or think, color may be tan to yellow or green; may have offensive odor
-infectious looking
Wounds by depth
partial thickness
full thickness
partial thickness
heals on its own by regeneration
-contained in epidermis and dermis
full thickness
needs help healing through connective tissue repair
-involves, epidermis, dermis, subQ (hypodermis), muscle and bone possibly
dehiscence
see tissue underneath; partial or total rupture of sutured wound; usually involves abdominal wound
evisceration
protrusion of internal viscera through an incision
-usually abdominal contents showing or coming out
Pressure Ulcers
- develop over bony prominences
- external pressure impairs blood flow and lymph
- worsens with friction and shearing
event timeline of PU
ischemia–>necrosis–>pressure ulcer
ischemia
inadequate blood supply to an organ or part of the body
shearing
when moving patient in bed and bones move opposite of skin or skin stays put; skin tears
Risk of factors for pressure ulcers
- immobility
- poor nutrition
- incontinence
- decreased mental status
- decreased sensation
- increased temp of skin
- increased age
______ is key for PU
prevention
Prevention of Pressure Ulcers
- assess the skin!!!!!
- relieve pressure on body areas
- Q 2hr turning
- airflow beds
- provide nutrition
- maintain skin hygiene
- promote ROM/OOB/Mobility
Nutrition
- supplemental nutrition to increase calories, protein, vitamins, and iron
- monitor hemoglobin, albumin
- monitor weight
- monitor intake and output (I&Os)
Stage 1 Pressure Ulcer
non-blanchable
erythema of intact skin
can be painful, soft, firm, warm or cool
Stage 2 Pressure Ulcer
partial thickness skin loss (abrasion, blister, shallow crater)
involves epidermis and possibly dermis
Skin NOT intact
Stage 3 Pressure Ulcer
full thickness skin loss involving subQ tissue (deep crater)
-may have undermining or tunneling
Stage 4 Pressure Ulcer
full thickness skin loss, tissue necrosis or damage to muscle, bone, or supporting structures (tendon or joint capsule)
-typically wheelchair bound patients
Unstageable Pressure Ulcer
full thickness tissue loss where the base of the ulcer cannot be seen
- covered by yellow, tan, brown, or black tissue
- not sure how deep the ulcer goes
Deep tissue injury
pressure-related deep tissue injury under intact skin
-purple or maroon localized area of discolored intact skin or blood-filled blister
Pressure Ulcer Treatment
- collaborative/interdisciplinary
- depends on stage
- wound management
- debridement, dressing
- surgical flap
- wound vacs
- drains, irrigation
- nutrition
- antibiotics
- maggots
Topical Corticosteroids
relieves inflammation and pruritus
- apply thin layer to avoid toxicity
- No more than 7 to 14 days
- assess for atrophy and hypo-/hyperpigmentation
Antiacne
gets worse before gets better
minimize sun exposure
antibacterials/antibiotics
monitor for signs of allergic rxn
antifungals
monitor for allergic rxn
antivirals
may take several weeks
herpes not cured
teach standard precautions
anesthetics
avoid applying in large areas
avoid eyes
antihistamines
avoid taking both oral and topical simultaneously
avoid applying over large areas or broken skin
topicals are applied as…
creams
lotions
ointments
Braden scale
assess risk for pressure ulcer
-most commonly used assessment tool in US for predicting pressure sore risk
6 categories of Braden scale
sensory perception moisture activity mobility nutrition friction and shear
total of 23 pts possible
