week 3 lecture

Question 1

what are the functions of the skin? (7)

Answer 1

1. protective barrier for the internal organs
2. senses changes in temperature, pressure, or pain
3. regulates body temperature
4. excretes fluid & electrolytes
5. stores fat
6. synthesizes vitamin D
7. provides a site for drug absorption

Question 2

what skin functions decline as we age? (4)

Answer 2

1. protective barrier function declines
2. skin injured more easily and heals slowly
3. sensory nerves & blood vessels decline, causing decreased sensation which affects drug absorption
4. blood vessels become more fragile which lead to benign aging vascular lesions

Question 3

common aging vascular lesions & nail issue & explain briefly

Answer 3

-senile purpura: similar to bruises
-venous stasis: poor return of blood
-venous lakes: on mouth
-cherry angioma: blood vessel bursts through skin
-nails: onychomycosis: fungal infection of the toenail

Question 4

what are factors that increase a person’s risk for pressure injuries?

Answer 4

-moisture
-poor nutrition
-poor circulation
-decreased sensory perception
-immobility
-friction & shearing
-pressure over time
-incontinence

Question 5

what is a pressure injury? common locations?

Answer 5

-eroded skin or mucous membranes →tissue death →poor perfusion & lack of blood flow
-common locations: bony parts of the body where you are laying on

Question 6

how do we predict pressure ulcer risk? what tool and scores?

Answer 6

use the braden scale
-high score = low risk
-low score = high risk

Question 7

what can we do to help treat a pressure injury? (6)

Answer 7

1. keep area clean
2. keep area dry
3. keep area free from infection of further pressure
4. maintain fluid and protein stores (vitamin supplements)
5. avoid general infections
6. cover with non stick dressings & irrigate PRN

Question 8

what can we do to prevent a pressure injury?

Answer 8

1. reposition every 2 hours
2. keep vulnerable areas clean & dry
3. keep bed linens dry & unwrinkled
4. use pillows to “float heels”

Question 9

macule lesion & example

Answer 9

-small less than 1 cm flat area
-color change
ex: freckle

Question 10

patch lesion & example

Answer 10

-greater than 1 cm
-flat
-no texture
*ex: vitiligo

Question 11

papule lesion & example

Answer 11

-small 1-2 cm
-small raised lesion
ex: mole that pokes up

Question 12

plaque lesion & example

Answer 12

-larger area that is raised
-greater than 1 cm
*ex: psoriasis *

Question 13

vesicle lesion & example

Answer 13

-small fluid filled
-less than 1 cm
ex: blister

Question 14

bulla lesion

Answer 14

-large fluid filled bubble
-larger than 1 cm

Question 15

pustule lesion & example

Answer 15

raised lesion but pus is evident
ex: abscess

Question 16

secondary lesions: excoriation & example

Answer 16

-scratch
ex: linear excoriation

Question 17

secondary lesions: lichenification & example

Answer 17

toughening or thickening of the skin
ex: eczema

Question 18

secondary lesions: scar

Answer 18

permanent alteration of the skin

Question 19

distribution: diffused

Answer 19

scattered all over

Question 20

distribution: localized

Answer 20

centralized to one area

Question 21

distribution: discrete

Answer 21

all separated from one another

Question 22

distribution: confluent

Answer 22

overlapping & running together

Question 23

distribution: linear

Answer 23

appearing in a line

Question 24

common bacterial infections (3)

Answer 24

1. impetigo (staphylococci)
2. syphilis
3. cutaneous abscess (MRSA)

Question 25

common viral infections (4)

Answer 25

1. verrucae (warts)
2. herpes simplex (oral/genital)
   -simplex 1 = oral
   -simplex 2 = genital
3. chicken pox (varicella)
4. herpes zoster (shingles)

Question 26

common fungal locations (4)

Answer 26

1. tinea corporis (body)
2. tinea cruris (groin)
3. tinea pedis (foot)
4. tinea unguis (onychomycosis)

Question 27

pressure injury: stage 1

Answer 27

non-blanchable erythema of intact skin

Question 28

pressure injury: stage 2

Answer 28

part thickness skin loss with exposed dermis

Question 29

pressure injury: stage 3

Answer 29

full thickness skin loss to subcutaneous layer
-may have undermining & tunneling

Question 30

pressure injury: stage 4

Answer 30

full thickness skin and tissue loss to tendon, cartilages, or bone
-undermining or tunneling

Question 31

pressure injury: unstageable

Answer 31

-depth of wound is obscured by eschar (black) or slough (yellow)
-can not tell how deep it is

Question 32

pressure injury: deep tissue injury

Answer 32

-persistent non-blanchable deep red, maroon or purple discoloration
-skin may or may not be intact

Question 33

difference between tunneling & undermining

Answer 33

tunneling = goes deeper than the rest of the wound
undermining = continues underneath the intact skin
both associated with stage 3 or 4

Question 34

skin preparation drugs (3)

Answer 34

1. isopropyl alcohol
2. povidone-iodine (Betadine)
3. chlorhexidine (chloroprep & Hibiclens)

Question 35

topical antipruritic drugs (2)

Answer 35

1. antihistamines
2. corticosteroids (hydrocortisone)

Question 36

topical medications (1)

Answer 36

topical vasodilator (helps with chest pain & causes vasodilation)

Question 37

what do we document when applying wound care?

Answer 37

-site of application
-drainage (color & amount)
-swelling, temperature
-odor, color, pain, or other sensations
-type of treatment given
-patient’s response