Week 3 Integument

Question 1

What are the primary purposes of skin?

Answer 1

• Protection

- Sensory proception

Question 2

Pallor

Answer 2

Loss of color

Look at mucous membranes

Indication: anemia, shock, lack of blood flow

Question 3

Cyanosis

Answer 3

Bluish discoloration

Nail beds, lips, mucosa

Indication: hypoxia, impaired venous return

Question 4

Jaundice

Answer 4

Yellow discoloration

Sclera, skin, mucous membranes

Indication: Liver dysfunction

Question 5

Erythema

Answer 5

Redness

Face, skin, pressure prone areas

Indication: inflammation, vasodilation, sun exposure, elevated body temp

Question 6

Risk factors for impaired skin integrity

Answer 6

• Impaired sensory perception (pain meds, anesthesia)
• Impaired mobility
• Altered level of consciousness
• Shearing: sliding movement, skin is fixed, underlying tissues move
• Friction: Two surfaces moving across one another
• Moisture: stool, urine, sweat

Question 7

Shear vs friction

Answer 7

Shear:

• Inner layers
• HOB elevated, pt falls down in bed, skin is fixed, underlying tissues move

Friction:

• Outer layer
• Two surfaces moving across one another
• Pulling pt up in bed w/ draw sheet

Question 8

Patients at risk for impaired skin integrity

Answer 8

• Older adults who have experienced a trauma
• Spinal cord injuries
• Nutritional deficits
• LTC homes
• Acutely ill or in hospice
• DM
• ICU/critical care
• Incontinence

Question 9

Three major factors involved in pressure injury development

Answer 9

1. Pressure intensity
2. Pressure duration
3. Tissue tolerance (low BP, poor nutrition, aging, hydration status all affect tolerance)

Question 10

Blanchable vs non-blanchable

Answer 10

Blanchable: skin turns red when pressure relieved

Non-Blanchable: redness does not occur

Question 11

Unstageable pressure ulcers

Answer 11

Obscured by infection or dying skin (slough/Eschar)

Cannot determine involvement

Question 12

Moisture Associated Skin Damage

Answer 12

• Incontinence related
• Intertriginous -> dermatitis
• Periwound -> wound or stoma’s, associated w/ exudate

Question 13

Wounds: acute vs chronic

Answer 13

Acute

• Normal repair process
• Return to normal function and integrity
• Trauma/surgical incision

Chronic

• Fails to proceed through normal healing process
• Does not return to normal function and integrity
• Pressure ulcer, vascular insufficiency wound

Question 14

Wounds and nutrition

Answer 14

• Protein, Vitamin A and C, zinc, copper -> critical for healing
• Adequate caloric intake
• Serum albumin & pre-albumin labs

Question 15

Wounds and infection

Answer 15

• Infection prolongs inflammation and delays healing
• Look for: purulent drainage, changes in color/volume/redness around the tissue, fever or pain
• Low WBC can delay healing due to inability to fight

Question 16

Wounds and aging

Answer 16

• Aging affects wound healing

- Delayed inflammatory responses, delayed collagen synthesis, and slower epithelization

Question 17

What does a low or high score on the Braden scale mean?

Answer 17

Low - HIGH RISK

High - NO RISK

Question 18

Interventions to prevent impaired skin integrity

Answer 18

Nutrition
Incontinence/moisture management 
Positioning 
Mattresses
Pillows

Question 19

Sensory perception intervention

Answer 19

• Reposition q2h or q1h
• Static air cushion in chair
• Early and often ambulation

Question 20

Friction and shear intervention

Answer 20

• Trapeze or lift sheet
• Overhead lift
• Keep pt pulled up in bed
• Float heels
• Moisturize the skin
• Foam dressing to bony prominences

Question 21

Moisture Pressure Injury Prevention

Answer 21

• Perineal care after Incontinence
• Barrier ointment
• No briefs while in bed
• No sting barrier film to protect skin
• Rectal/fecal bag

Question 22

Nutrition pressure ulcer prevention

Answer 22

• Weekly weight
• Nutrition consult
• Feeding assistance
• Swallowing problems identified
• Hydration
• Supplements