Week 6: Tissue Integrity, Peripheral Perfusion, H2T Assessment Flashcards
How does the nurse perform an assessment of the integumentary system?
this is not completed as a separate step of the health assessment but integrated throughout the complete examination of the patient
focuses on inspection and palpation (from IPPA)
what are the physiological and embody (social) functions of skin?
Physiological Functions
Protection
Prevention of penetration
Temperature regulation
Wound repair
Absorption and excretion
Production of vitamin D
Embody (Social) Functions
Perception - sensory
Communication - blushes, startled
Identification - culturally
what is the subjective data - integumentary system?
- Previous history of skin disease (allergies, hives, psoriasis, or eczema)
- Change in pigmentation
- Change in mole (size or colour)
- Excessive dryness or moisture
- Pruritus
- Excessive bruising
- Rash or lesion
- Medications
- Hair loss
- Change in nails
- Environmental or occupational hazards
- Self-care behaviours
what is the objective data - integumentary system?
(A) Consider the colour of the patient’s skin:
Widespread colour change:
Pallor (white)
Erythema (red)
Cyanosis (blue)
Jaundice (yellow)
if darker - look at palms and feet (less pigment)
Areas of lighter pigmentation (vitiligo – absence of melanin pigment)
what follows under clinical context: widespread colour change?
pallor - clinical term for pale (under eyeballs
Jaundice - yellowish skin (enlarged belly) alcoholism - liver disease
what are objective assessments that can be done on the integumentary system?
consider the thickness of the patients skin - Are there any calloused areas? Is the skin thin or shiny?
What does general survey, head-to-toe assessment and system/focused assessment?
general survey is for safety and immediate concern
Head to Toe assessment - is or baseline, ( how is this individual doing, clinical manifestations)
system/focused assessment - in-depth focus on specific system ( focusing it and narrowing it)
Tissue integrity : When would a nurse prioritize an in-depth focused assessment of a patient’s skin?
burns, lesions, rash, and any obvious signs
who are the most prone for skin breakdown?
older client ( bed ridden)
From the following what are the integumentary system : subjective data ?
a. previous history of skin disease
b.change in pigmentation
c.change in mole
d.erythema
e.jaundice
a b c
true or false. Excessive dryness or moisture, excessive bruising and hairloss and pallor are a part of subjective data of integumentary.
false, although excessive dryness or moisture, excessive brusing, and hair loss is, pallor is not this is objective
integumentary System: objective data
what do you have to consider?
A) YOU HAVE TO CONSIDER the patient’s skin
areas of darker pigmentation ( freckles, moles, birthmarks)
areas of lighter pigmentation ( vitiligo- absence of melanin pigment)
B) Palpate the temperature of the patient’s skin
- Hypothermia or hyperthermia ?
- Use the back of your hand
C) Consider the moisture of the patient’s skin?
- diaphoresis or profuse perspiration
-dryness
-dehydration - oral mucous membranes
D) Consider the texture of the patient’s skin
- smooth, firm , with an even surface
Integumentary System : Objective data . true or false. widespread colour change can be a clinical manifestations to lead something is wrong with this patient?
true
What are the widespread colour change ?
1) pallor
2) erythema
3) cyanosis
4) jaundice
What color do these indicate?
Pallor
erythema
cyanosis
jaundice
white
red
blue
yellow
what are some indications of these terms :
pallor ( white )
erythema ( red )
cyanosis ( blue )
jaundice ( yellow )
anemia, not enough blood
fever, infection, C02 poisoning
not enough oxygen
not enough oxygen
something is wrong with the liver
If somebody has a darker skin tone ? what could be a big sign of a widespread colour change ( where in the body could we see this)?
mouth ( oral( or lips
palm of the hands
looking for cellular differences
when doing an integumentary system: objective assessment, what do we have to consider?
a) consider the thickness of the patient’s skin
- are they any calloused areas?
-is the skin thin or shiny?
b) Palpate the patient’s skin for edema
- unilateral edema: local or peripheral cause
-bilateral edema or generalized edema ( anarsaca) : central problem
Nonpitting or brawny edema
Pitting Edema
What are the ranges for pitting edema ?
1+ = mild pitting, slight indentation, no perceptible swelling of the leg
2+ = moderate pitting, indentation subsides rapidly
3+ = deep pitting, indentation remains for a short time, swelling of leg
4+ = very deep pitting, indentation lasts a long time, gross swelling and distortion of leg
what else do we have to consider when it comes to integumentary system : objective assessments?
re-call :
- consider the thickness of the patient’s skin
-palpate the patient’s skin for edema
what else?
palpate the mobility and turgor of the patient’s skin
inspect vascularity and bruising
note the presence of any rashes or lessions
Go into further details about these objective assessments when it comes to integumentary system
palpating the mobility and turgor of the patient’s skin
inspect vascularity and bruising
note the presence of any rashes and lessions
-pinch up a large fold of skin on the anterior aspect of the chest under the patient’s clavicle
-mobility = skin’s ease of rising
-turgor = skin’s ability to promptly return to place
Cause of any bruises ?
signs of recreational IV drug use ( track marks)
Types of lessions, how to describe
focuses on :
1) different types of lessions what’s the first you wanna know
(feel them)
aute and chronic
notice what we can observe
Abnormal Finding : Lesions
what are the two things we should categorize?
1) Type
- Primary
-Secondary
2) Assessment
- health history
-inspection
-palpation
Abnormal Findings: Lesions
1. Type
Primary and Secondary
Go in depth with this ?
Primary : when a lesion develops an unaltered skin
Secondary : When a lesion changes over time ( scratching/itching)
True or false. Health history links to pain, healing, cause, when/where did it start spreading, contagious, environmental, itching fever, stress
true
true or false. Inspection links to colour, elevation, pattern or shape, size, location, and distribution on the body, any excaudate
true
True or false. Palpitation links to depth, pain, temperature, easily removed ‘brushed off’ - cause of bleeding> blanch with pressure?
true
Types ( Structure ) of Lesions
Primary Skin Lesions are what kind?
macule & patch
papule & plaque
nodule & tumour
wheal & urticaria ( hives )
vesicle & bulla
cyst pustule
Types ( Structure ) of Lesions Secondary skin lesions
crust
scale
fissure (tear)
erosion
ulcer ( pressure sore)
excoriation ( scratch or abrasion)
scar
atrophic scar
keloid
lichentication
Skin terminology : lesions and wounds
Common shapes and configurations
annular
confluent
discrete
grouped
gyrate
target
linear
polycyclic
zosteriform
circular
merged, multi shaped
distinct, separate
cluster
snakelike, coiled
iris, bullseye
scratch, streak
annular grow together
along nerve route
what is configurations?
pattern of the body ( the shapes)
true or false. closely monitor mole (can become malignant cancer –> skin cancer)
true
How do you assess moles ?
ABCDE characteristics
Asymmetry
Border irregularity
Colour variation
Diameter > 6mm
Evolution
Rapidly changing
The ugly duckling sign
Integumentary System : objective assessment
when assessing the nail beds for any abnormalities and hygiene ( name the examples )
clubbing, discoloration
When is a good time to check the patient’s oral cavity ?
by checking their temperature ( orally)
As nurses we are obligated to inspect the patient’s cavity, when we are doing our integumentary system subjective assessment?
false. Yes as nurse we are obligated to inspect their cavity, however it is not subjective but rather OBJECTIVE
name the examples of inspection we are looking for when inspecting a patient’s oral cavity.
moist mucous membranes
any lessions
halitosis
furrowed tongue
condition of the teeth ( broken, clean, bleeding gums)
what is clubbing associated with ?
could be associated with lung disease
true or false. when doing an integumentary system, objective assessments. We palpate and inspect the scalp.
true
What do we look for when palpating and inspecting the patient’s scalp?
tenderness
sores/lessions
infestations ( head lice )
Tissue Integrity - Laboratory Assessment
what are the assessment?
wound cultures
albumin
biopsy
True or false. Protein in the blood is important for the healing?
True, it is important.
True or false. If someone has a really bad wound, it is recommended to eat high protein and high calories.
true
name the biopsy methods
curettage
shave
punch biopsy
excisional
incisional
If you have low albumin and you have a big wound, what happens?
if the albumin is low, there’s not enough to heal for the wound–> takes longer
What are the 4 types of tissue
muscle
neural
connective
epithelial
What is the scope of tissue integrity ?
intact skin tissue
damaged skin tissue ( partial thickness injury and fullness thickness injury)
what are ways how a cell can die ?
( causes of lethal cell injury )
cellular ischemia ( doesn’t have enough oxygen)
physical damage
- heat, cold, radiation, electrothermal, mechanical
microbial injury
-bacteria can come ( like a pimple etc.)
immunological injury
- damage caused by body’s own immune system
normal substances with unintended contact
- gastric acid leads into abdominal cavity
neoplastic growth ( benign or cancer)
True or false. Normal substances with unintended contact ( e.g gastric acid leads into abdominal cavity) . This can cause a leakage and cause cellular injury or death.
true
Cell Death: Necrosis : What does this mean?
uncontrollable passive pathological process of cell death ; occurs when cells are exposed to extreme conditions
causes swell and rupture, leading to inflammation and damage of surrounding tissue
True or false. When having a heart attack, the heart cells looks normal but it’s actually dead.
True
What are the terms we need to know that undergoes cell death : necrosis
coagulative
liquefactive
caseous
gangrene
- dry gangrene
-wet gangrene
when describing the term coagulative , what does it mean?
caused by ischemia, free radical, still looks like a cell for a while
what is liquefactive, identify the term
caused by the body releasing enzymes to kill bacteria, causes damage ( liquefy) of neighbouring cells ( abscess)
what does caseous mean ?
a distinctive from coagulative necrosis, where tissue no longer recognizable, cheese-like appearance. caused by mycobacterial infections ( tuberculosis) or tumor necrosis.
what does gangrene mean ?
build up decomposing dead tissue, usually refers to appendage/limb /with ischemic necrosis