week 3 lecture Flashcards
what are the functions of the skin? (7)
- protective barrier for the internal organs
- senses changes in temperature, pressure, or pain
- regulates body temperature
- excretes fluid & electrolytes
- stores fat
- synthesizes vitamin D
- provides a site for drug absorption
what skin functions decline as we age? (4)
- protective barrier function declines
- skin injured more easily and heals slowly
- sensory nerves & blood vessels decline, causing decreased sensation which affects drug absorption
- blood vessels become more fragile which lead to benign aging vascular lesions
common aging vascular lesions & nail issue & explain briefly
-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
what are factors that increase a person’s risk for pressure injuries?
-moisture
-poor nutrition
-poor circulation
-decreased sensory perception
-immobility
-friction & shearing
-pressure over time
-incontinence
what is a pressure injury? common locations?
-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
how do we predict pressure ulcer risk? what tool and scores?
use the braden scale
-high score = low risk
-low score = high risk
what can we do to help treat a pressure injury? (6)
- keep area clean
- keep area dry
- keep area free from infection of further pressure
- maintain fluid and protein stores (vitamin supplements)
- avoid general infections
- cover with non stick dressings & irrigate PRN
what can we do to prevent a pressure injury?
- reposition every 2 hours
- keep vulnerable areas clean & dry
- keep bed linens dry & unwrinkled
- use pillows to “float heels”
macule lesion & example
-small less than 1 cm flat area
-color change
ex: freckle
patch lesion & example
-greater than 1 cm
-flat
-no texture
*ex: vitiligo
papule lesion & example
-small 1-2 cm
-small raised lesion
ex: mole that pokes up
plaque lesion & example
-larger area that is raised
-greater than 1 cm
*ex: psoriasis *
vesicle lesion & example
-small fluid filled
-less than 1 cm
ex: blister
bulla lesion
-large fluid filled bubble
-larger than 1 cm
pustule lesion & example
raised lesion but pus is evident
ex: abscess
secondary lesions: excoriation & example
-scratch
ex: linear excoriation
secondary lesions: lichenification & example
toughening or thickening of the skin
ex: eczema
secondary lesions: scar
permanent alteration of the skin
distribution: diffused
scattered all over
distribution: localized
centralized to one area
distribution: discrete
all separated from one another
distribution: confluent
overlapping & running together
distribution: linear
appearing in a line
common bacterial infections (3)
- impetigo (staphylococci)
- syphilis
- cutaneous abscess (MRSA)
common viral infections (4)
- verrucae (warts)
- herpes simplex (oral/genital)
-simplex 1 = oral
-simplex 2 = genital - chicken pox (varicella)
- herpes zoster (shingles)
common fungal locations (4)
- tinea corporis (body)
- tinea cruris (groin)
- tinea pedis (foot)
- tinea unguis (onychomycosis)
pressure injury: stage 1
non-blanchable erythema of intact skin
pressure injury: stage 2
part thickness skin loss with exposed dermis
pressure injury: stage 3
full thickness skin loss to subcutaneous layer
-may have undermining & tunneling
pressure injury: stage 4
full thickness skin and tissue loss to tendon, cartilages, or bone
-undermining or tunneling
pressure injury: unstageable
-depth of wound is obscured by eschar (black) or slough (yellow)
-can not tell how deep it is
pressure injury: deep tissue injury
-persistent non-blanchable deep red, maroon or purple discoloration
-skin may or may not be intact
difference between tunneling & undermining
tunneling = goes deeper than the rest of the wound
undermining = continues underneath the intact skin
both associated with stage 3 or 4
skin preparation drugs (3)
- isopropyl alcohol
- povidone-iodine (Betadine)
- chlorhexidine (chloroprep & Hibiclens)
topical antipruritic drugs (2)
- antihistamines
- corticosteroids (hydrocortisone)
topical medications (1)
topical vasodilator (helps with chest pain & causes vasodilation)
what do we document when applying wound care?
-site of application
-drainage (color & amount)
-swelling, temperature
-odor, color, pain, or other sensations
-type of treatment given
-patient’s response
