Wk 5: neurosensory/ integumentary Flashcards
layers of the skin
epidermis (outside layer)
dermis (middle layer)
what is the largest organ in the body?
the skin
the dermis and epidermis are separated by what?
the dermal/epidermal junction
dermis
middle layer
provides strength and support for epidermis
protects layers underneath muscle, blood vessels and bones
epidermis
top outer layer
-basal layer=divides and proliferates, helping top cells slough off and die
primary purpose of skin
protection and sensory perception
integumentary assessment
-know norms vs concerning findings
-color (pallor, cyanosis, jaundice)
-moisture (MMM, diaphoresis)
-temperature (warm nml, cold can indicate poor perfusion, warm can indicate infection)
-texture (smooth, rough, tight, supple, thick, thin, indurated, elevated, soft)
-turgor (fluid balance, decreases with age)
-vascularity (color around vascular areas of skin, can be red/pink/pale, veins can be more or less visible, capillaries can be fragile, petechia)
-edema
-lesions (wounds/rashes/ any unusual findings)
pallor
pale, loss of color
in black skin tone can become grey
-look at palm of hands, lips or mucus membranes for people with darker skin
pitting edema
1+
2+
3+
4+
1+: 2mm depression, barley detectable, immediate rebound
2+: 4mm deep, few seconds to rebound
3+: 6mm deep, 10-12 seconds to rebound
4+: 8mm, very deep pitting, >20 seconds o rebound
hard, non-pitting edema is usually related to what?
an injury
pitting edema is d/t what
fluid issues/ overload
indications of pallor
anemia, shock, lack of blood flow
cyanosis
bluish discoloration
in darker skin tones pt can turn yellow-brown or grey
-check nail beds, lips, mucosa
indications of cyanosis
hypoxia, impaired venous return
Jaundice
characteristics/indications
yellow discoloration
look at sclera, mucus membranes
indicates liver dysfunction (RBC distruction)
-can look at palms of hands
erythema
redness
-in darker sin tones palpate skin as well to look for warmth and texture changes
-looks at face, skin pressure prone areas
indications for erythema
inflammation, vasodilation, sun exposure, elevated body temperature
risk factors for impaired skin integrity
impaired sensory perception
impaired mobility
ALOC
shearing
friction
moisture
shearing of skin
affecting DEEPER levels of skin
sliding movement of skin and SQ tissue when muscle and bone are NOT MOVING
Ex: head of bed is elevated, patient slides down in bed, skin is stuck to where it was but underlying tissues move
-affects underlying tissue capillaries (stretched/damaged, leading to ischemia)
friction
affecting OUTER layer of skin
two surfaces moving across one another
Ex: pulling a patient up in bed w/o draw sheet, or patient moves against draw sheet
how does moisture affect skin integrity?
it softens your skin making it more susceptible to damage
what kind of patients are at risk for impaired skin integrity
- older adults with trauma
- spinal cord injuries
- nutritional deficits
- those in long term homes
- Acutely ill
- hospice
- DM
- ICU pt / critical care Pt
- incontinence
what areas are most prone to pressure ulcers
back of head, upper back/shoulders, elbows, inner knees, coccyx, heels
other considerations: pts with nasal cannulas on (inside nostrils/behind ears)
tissue ischemia
pressure applied over a capillary that exceeds normal capillary pressure
three major factors involved in pressure injury development
- pressure intensity
- pressure duration
- tissue tolerance (depends on low blood pressure, poor nutrition, aging, hydration)
deep tissue injury
persistent non-blanchable deep red/maroon/purple discoloration
cannot tell what layers are involved
blanchable vs non-blanchable
blanchable: skin turns red when pressure is relieved
non-blanchable: redness does not occur
unstageable injury
obscured by infection or dying skin (sloughing/eschar), cannot determine involvement
different types of MASD (moisture associated skin damage)
- incontinence associated dermatitis
- intertriginous dermatitis (moist skin rubbing against each other, monitor groin/axillary area)
- periwound moisture associated skin damage
- peristomal moisture associated skin damage
acute wound
-normal timely repair
-return to normal function/anatomical integrity
Ex: trauma/surgical incision
chronic wound
-wound fails to heal normally
-does not return to normal function/anatomical integrity
Ex: pressure ulcer, wound d/t vascular insufficiency
what affects skin and wound healing
-nutrition (protein, Vit A/C, zinc, copper critical for healing. along with adequate caloric intake)
-tissue perfusion
-infection
-age/ loss of skin tugor
-loss of collagen
-overall wellness
-decreased WBC
-medications (steroids/ chemo/antiinflamatory)
-low Hgb
-chronic dz
what labs do you need to looks at for the nutritional status of a patient?
albumin
pr-albumin
what kind of patients are at risk for poor tissue perfusion, leading to poor wound healing?
diabetics
PVD pt
Which patient is most likely to experience delayed wound healing?
A. patient with high WBC
B. a 25 y/o male with no pertinent medical history
C. a 30 year old female who takes vitamin supplements everyday
D. A 85 year old male with DM
D. age can lead to slowed healing due to delayed inflammatory responses and delayed collagen synthesis. DM can cause poor perfusion.
what does a low braden risk assessment scale indicate?
low score= higher risk for skin impairment
integumentary interventions
nutrition
incontinence/moisture management
positioning /mobilization
pressure prevention pads
Z-flow pillow
heel protectors
which patient will not have a high chance of impaired wound healing?
A. a patient with PVD
B. a patient that is dehydrated with tenting of the skin
C. a patient with T1 DM
D. a patient admitted for constipation but now has regular GI movements
E. a 95 year old patient with decreased mobility
D. would not have a a higher chance to impaired wound healing, if his GI track was impaired and he was not absorbing nutrients adequately then he could.
rationale:
A. decreased circulation
B. loss of skin turgor / dehydration / decreased nutrients
C. impaired immune function
E. age/ mobility (age also causes decreases collagen)
three key components of wound management
- assessment
- cleansing
- protection
wound assessment
-appearance: red/yellow/black
-length/width/depth
sinus tracts, tunnels, redness/swelling
-closed wounds: skin edges should be well approximated (staples/ sutures/adhesives)
-drains/tubes present
-pain around incision
how to measure wounds
centimeters, chart in respect to a clock
first measure: head to toe
second: side to side
third: depth
note tunneling/undermining
what to document for wound drainage
amount of drainage
odor
consistency
color
integrity of surrounding skin
for accurate measurement, weight the dressing
1 g = __mL
1 mL
*or just state:s cant, moderate, large, copious amt of drainage
exudate color
serous drainage: watery clear
sanguineous: serum w/ red blood cells, thick/appears reddish
serosanguinous: serum an blood, watery, looks pale/pink
purulent: result of infection. WBC/tissue debris/bacteria. can be yellow, tan, green or brown
nursing interventions for patients with wounds
-hydration and nutrition (2.5 L fluid a day, protein, carbs, vitamins)
-monitor albumin/ pre-albumin
-wound cleansing
-remove sutures/staples
-administer pain meds
-give Abx
-monitor for effectiveness
-document descriptively and thoroughly
non-adherent wound dressing
to not breakdown skin integrity
hydrogel wound dressing
mostly water, gels after contact with excudate, promotes autolytic debridment, rehydrates and fills dead space
-may need secondary occlusive dressing
-not for wounds that drain a lot
-prevents skin breakdown i high pressure areas
-for infected deep wounds or necrotic tissue
hydrocolloid would dressing
occlusive dressing that swells in presence of exudate
self-adhesive/transparent wound dressing
temporary second skin
wet to dry wound dressing
used to mechanically debrid a wound until granulation tissue starts to form
alginate wound dressing
nonadherent
conform to wound shape
absorb exudate
collagen powders/pastes/gels are used for what?
to promote wound healing
-need an order for
wound vacs
-foam with occlusive dressing to create negative pressure
-helps with tissue generation, decreases swelling, enhances healing in moist and protective environment
-good for excessive draining
-need an order with set pressure
what are some different complications of surgical wounds that can occur?
adhesions, contractions, hemorrhage, dehiscence, evisceration, fistula formation, infection, excessive granulation tissue, keloid formation
when is a patient at greatest risk for hemorrhaging ?
24-48 hours after injury or surgery
what can cause a patient to hemorrhage (in regards to surgical wounds) ?
clot dislodgment, slipped suture, blood vessel damage
how does internal bleeding present?
swelling, distention, sanguineous drainage, increased HR, lower BP
hematoma
red/blue bruise
local area of blood collection
can be hard/firm or soft
wound hemorrhaging emergency protocol
apply pressure dressing
notify HCP
monitor VS
dehiscence
partial/ total separation of suture wound
-can include separation of underlying skin
-RF: obesity, infection
**dont re-suture, pack area with gauze usually
evisceration
visceral organs come out of wound opening
-normally d/t traumatic event
eviscerations manifestations
-increase flow of serosanguinous fluid
-h/o sudden straining
-sudden change in “popping or giving way” of wound area
-visualization on viscera
RF for dehiscence and evisceration
chronic Dz
advanced age
obesity
invasive abdominal cancer
vomiting
excessive straining, coughing, sneezing
dehydration
malnourished
ineffective suturing
abdominal surgery
infection
nursing management for dehiscence and evisceration
notify provider immediately (surgical intervention needed)
stay with patient
cover wound/organs with sterile towels or sterile dressings soaked in normal saline
DO NOT ATTEMPT to reinsert organs
supine position
stay calm
keep patient NPO
which method wound be correct when caring for a patient with a severe dehiscence or evisceration?
A. covering the area with a dry sterile towel
B. covering area with a sterile dressing soaked in NS
C. re-inserting the organs to prevent further damage to them
D. leave the viscera where it is, do not intervene, it can cause further harm. keep them hydrated with PO water until physician arrives
B. use sterile dressings soaked in NS
RF for infection with surgical wounds
age extremes, immune suppression, impaired circulation/oxygenation, wound condition & nature, malnutrition, chronic Dz, poor wound care
first step of a neurological assessment?
ABC’s
is the patient neurologically intact enough to breath on their own
three main components of a basic euro exam
- general survey
- LOC
- orientation (person, place, time, situation)
what kind of patients need neuro assessment?
h/o neuro disorder/Dz
neurological change
neuro abnormal finding
trauma
drug-induced states
neurological complaints
whenever there is a neurological issue we always want to rule out the four H’s (that are the most common causes of neuro changes), what are they?
hypoxia
hypoglycemia
hypotension
hypoventilation
what are some elements that need to be reviewed in a focused neuro assessment
subjective data, mental status, mood, memory, behavior, LOC, reflexes, sensations, coordination, proprioception, GCS, pupils, visual fields, muscle strength, speech, swallowing, gag
lethargic/ somnolent
not fully awake
drift off to sleep when not stimulated
drowsy
awakens to name
slow to respond but respond appropriately
obtunded
sleeps most of the time
difficult to arouse
confused when aroused
mumbled speech or incoherent
requires constant stimulation
stupor/ semi-comatose
spontaneously unconscious
responds only to vigorous shake or pain
groans
mumbles
do not stay awake
comatose
no meaningful response to stimuli
no purposeful movement
GCS/EMV
eye (4)
motor (6)
verbal (5)
possible score: 3-15
brain injury classification for GCS scale
severe: GCS of 8 or less
moderate: 9-12
mild : 13-15
proprioception
recognizing where your limbs are in space
-rubbing heel on opposite leg
coordination
rapid alternating movement
-touching thumb to each finger on the same hand quickly
what is the main goal for the plan of care with a patient who has neurological deficits
protect status and maintain safety
secondary: assist patient in gaining independence
care issues with neurologically complicated patient
elimination
moving
skin complications
sensory function (hearing/vision)
pain management
controlled environment (limit disturbances)
incorporate pt and family in care
know seizure precautions
suction
O2
rail protectors / pads
IV placed
why would a skull XR be ordered
look at bones of skull
mainly in children
not ordered often anymore
why would a spinal XR be ordered
first step in evaluating back/neck pain
traumatic injuries
usually done before CT or MRI
if a patient is in C-spine precautions and has a C-collar on, can it stay on when getting an XR of the head/neck?
yes, it has to stay on
CT scan
3D
info about organs, bones and tissues
when would contract be used/needed in a CT?
to check circulation, IV contrast
PO contrast can be used to check GI
nursing considerations for CT scan
informed consent (CTA)
allergies to iodine (CTA)
diet orders (possible NPO)
claustrophobic
removing metal
contrast
PO/rectal/IV
helps distinguish selected parts of the body from surrounding tissue
can be iodine based
CTA=CT angiogram (force fluids, monitor for allergic reactions, monitor kidneys)
MRI (magnetic resonance imaging)
3D imaging fron a 2D slice
more detailed
no exposure to radiation
expensive, last resort
remove all metal, screen for metal
remove medicated patches
EEG (electroencephalogram)
primarily used to Dx seizures
monitors brains electrical activity
can confirm brain death
use special conduction paste to stick to skull
factors influencing sensory function
age
meaningful stimuli
amount of stimuli
social interactions
environmental factors
cultural factors
what are the three main sensory alterations we need to know?
sensory deficits
sensory deprivation
sensory overload
common visual sensory deficits
presbyopia
cataracts
computer vision syndrome
dry eyes
glaucoma
diabetic retinopathy
macular degeneration
what are some hearing deficits ?
presbycusis
cerumen accumulation
balance deficits
dizziness
disequilibrium
taste deficits
xerostomia (thicker mucus, dry mouth)
tactile deficits
peripheral neuropathy
CNS injury
extremity injuries
expressive aphasia
inability to name common objects or express ideas
receptive aphasia
inability to understand written or spoken language
when caring for a patient with vision deficits, what are some nursing considerations?
announce presence
stay in field of vision
speak in warm, pleasant tones
explain care prior to staring care
orient to room
keep paths clear
put items in reach
assist with ambulation
encourage use of corrective devices
teaching material in large red/orange print
caring for a patient with auditory deficits
check cerumen impaction
amplify sounds
ad flashing lights for safety
slow speech in normal tones
communication boards
short sentences
augment teaching with written material
educate and ensure proper use of hearing aids
nursing considerations for taste and smell deficits
well seasoned food
separate textured foods
secure most appealing foods
stimulate smells when appropriate
limit strong odors/flavors
have them eat slowly
dont blend foods
patients with reduced olfaction (no smell) teaching points
check smoke detectors
check food dates and appearance before eating
danger of cleaning with chemicals
gas appliances
caring for patients with tactile deficits
touch therapy
turning/ repositioning
Pt can have hyperesthesia (minimize irritation stimuli)
adaptions for tactile sensations (water temp./ ice and heat therapy should be avoided/ shoes well fitted, check feet daily)
caring for pt with communication deficits
patience
normal tone
simple short questions/gestures (receptive aphasia)
yes/now questions or communication board (expressive aphasia)
sign language
sensory deprivation causes
isolation
loss/impairment of senses
confinement
emotional disorders
brain injury
effects of sensory deprivation (3)
- cognitive: reduced capacity to learn, inability to problem solve, confused, disoriented, decreased attention span
- affective: emotions and mood
- perceptual : changes in vision and coordination, less tactile accuracy, changes in spaces and time judgement
nursing care for sensory deprivation
opportunity for stimuli
meaningful interactions, well timed
tactile stimulation
reorientation
encourage visitors/ social stimulation
environment changes
assistive devices
what are some causes of sensory overload?
pain
lack of sleep
ICU care
visitors / staff
sensory overload can often be confused with what?
mood swings or disorientation
sensory overload symptoms
fatigue/ sleepiness
disorientation
scattered. restlessness/ anxiety
care for a patient going through sensory overload
orient
control stimuli (ear plugs, dark glasses)
uninterrupted periods
schedule (routine of care)
visitor control
provide new info gradually
migraines
recurring HA characterized by UNILATERAL throbbing pain
-common in females
-usually has premonitory Sx (aura)
caring for a patients with headaches
r/o intracranial or extracranial Dz (injury, tumor etc..)
meds: NSAIDS, Tylenol, aspirin, combo drugs
-triptan for migraines
high flow O2 for pts with cluster HA
