integumentary system

Question 1

skin functions

Answer 1

protection, body temp regulation, psychosocial, sensation, vitamin D, immunologic, absorption, elimination

Question 2

cross section for normal skin

Answer 2

epidermis, dermis, subcutaneous tissue

Question 3

factors affecting skin

Answer 3

unbroken and healthy skin and mucous membrane defend against harmful agents, resistance to injury affeted by Age tissue and illness, adequately nourished body cells r good, need good circulation too

Question 4

children under 2 yrs

Answer 4

weak and thin skin when compare to adults

Question 5

infants

Answer 5

skin and mucous membranes easily injure and subject to infection, Childs skin becomes increasingly resistant to injury and infection.

Question 6

older ppl

Answer 6

maturation of epidermal cells is prolonged so skin is thin and easily damaged. also collagen and circulation is impaired so risk for damage is greater

Question 7

skin alteration causes

Answer 7

thin and obese ppl are more susceptible to skin injury, fluid loss during illness causes dehydration, skin appears loose and flabby, jaundice can cause yellowish and itch skin, excessive sweating can make skin breakdown during illness, lesions can occur

Question 8

wound types

Answer 8

intentional or unintentional
open or closed
acute or chronic
partial or full or complex thickness

Question 9

principles of wound healing #1

Answer 9

intact skin is first line of defense against microorganisms, careful hand hygiene when wound care takes place, body response systemically to any trauma, need good blood supply for normal body respons to injury, normal healing is promoted when wound is free of foreign material

Question 10

wound healing principles #2

Answer 10

extent of damage an persons state of health affect wound healing, response to wound is kore effective if u have proper nutrition

Question 11

wound healing phases

Answer 11

hemostasis, inflammatory, proliferation, maturation

Question 12

do wounds fully heal

Answer 12

no like scar tissue occur

Question 13

hemostasis

Answer 13

occurs right after initial injury, involved blood vessels constrict and clotting begins, exudate forms so swell n pain occurs, increased perfusion results in heat and redness, platelets stimulate other cells to migrate to injury to make healing happn

Question 14

inflammatory phase

Answer 14

follows hemostasis, lasts 2-3 days
WBC mostly leukocytes and macrophages move to wound
macro stay for a while
ingest debris and release GF to attract fibroblasts to wound
pt has generalized body respons e

Question 15

proliferation phase

Answer 15

lasts for several weeks, new tissue is built to fill wound space thru fibroblast actions, capillaries grow across wound, thin epithelial cells from across wound, granulation tissue forms foundation for scar tissue

Question 16

maturation phase

Answer 16

final stages, about 3 weeks after injury can continue months or years, collagen is remodeled, new collagen tissue deposited, scar is flat thin and whit

Question 17

local factors affecting wound healing

Answer 17

pressure, desiccation or maceration (dehydrate or overhydrate), trauma, edema, infection, excessive bleeding, necrosis, biofilm

Question 18

edema is bad when wound healing b/c

Answer 18

no vasculature there, can’t heal properly

Question 19

biofilm

Answer 19

group of microorganisms has to be remove d

Question 20

systemic factors affecting wound healing

Answer 20

age - children and healthy adults heal faster
circulation and oxygenation - need good blood flow
nutritional status
wound etiology - condition of wound affects healing
health status - corticosteroids and postoperative radiation therapy delay healing
immunosuppression
med use
adherence to treatment plan

Question 21

what kind of meds can hinder healing

Answer 21

steroids

Question 22

diet for wound healing

Answer 22

vitamin C for collagen, not too much salt, need protein to build back up, vitamin K for clotting, zinc

Question 23

wound complications

Answer 23

infection, hemorrhage, dehiscent and evisceration, fistula forms

Question 24

wound dehiscence

Answer 24

muscle is still intact but open tissue

Question 25

wound evisceration

Answer 25

muscle is separated, bowel protruding

Question 26

psychological effects of wounds

Answer 26

pain anxiety fear impact on daily living and image change

Question 27

factors affecting pressure injury development

Answer 27

aging skin, chronic illness, immobility, malnutrition, fecal and urinary incontience, altered consciousness, spinal or brain injury, neuromuscular disorders

Question 28

mechanisms in pressure injury development

Answer 28

external pressure compressing blood vessels, friction or forces tearing or injuring blood vessels

Question 29

pressure injury Stges

Answer 29

1-4 are the stages but we gotta delve into It

Question 30

stage 1 pressure injury

Answer 30

nonblanchable (push down, skin won't turn white) erythema (red) of intact skin. NOT a blister. ex ; push on red area, stays red EPIDERMIS

Question 31

stage 2 pressure injury

Answer 31

partial thickness skin loss with exposed dermis, blister, dermis is exposedddd, can be a scratch

Question 32

stage 3 pressure injury

Answer 32

full thickness skin loss, not involving underlying fascia, not fat bones or muslce but it is thru the dermis so can be epi or hypo

Question 33

stage 4 pressure injury

Answer 33

full thickness skin and tissue loss, mostly on sacrum. older pt from lying in bed, we should turn pt e2h. ensure piss n poo is not in the wound bc they li down so much. pads can also add sweat and moisture. muslce may atrophy

Question 34

unstageable pressure injury

Answer 34

obscured full thickness skin and tissue loss. cannot see bc there is slough

Question 35

deep tissue pressure injury

Answer 35

persistent nonblancable deep red maroon or purple discoloration. we do not know damage but it Will go away eventually.

Question 36

example of a necrotic heel;

Answer 36

hard place to offload pressure, can lose foot. should be black and dry. don't do anything if it is. BUT if it is edema stinky wet we need to bet rid of It.

Question 37

measuring a pressure injury

Answer 37

size, depth, presence of undermining tunneling or sinus tract. note as a clock.

Question 38

we measure how

Answer 38

in to out and top to bottom

Question 39

cleaning pressure injury or wound

Answer 39

clean with each dressing change, use new gauze for each wipe and clean from top to bottom and or from center to outside. use .9 saline solution to irrigate and clean injury. once it is clean, dry it using gauze sponge. report drainage or necrotic.

Question 40

wound drainage

Answer 40

serous - clear sanguineous - bright red serosanguineous - red w clear, pink purulent - pus or cream

Question 41

wound assessment

Answer 41

inspect sight and smell, palpate for appearance, drainage and pain. look for drainage. sutures drains tubes can manifest issues

Question 42

wound dressing purpose

Answer 42

provide comfort, control infection, absorb drainage, maintain moisture balance of wound, protect wound from further damage, protect skin surrounding wound,deebride if u can, change when needed

Question 43

infection presence

Answer 43

wound swollen, deep red in color, feels hot, drainage increased and purulent, foul odor may be noted, wound edges may be separate

Question 44

types of wound dressings

Answer 44

telfa - won't stick, so it won't hurt gauze transparent

Question 45

bandage types

Answer 45

roller, circular and spiral turn, figure of eight turn

Question 46

binder types

Answer 46

slings, abdominal binder, chest binder, T binder

Question 47

drains systems

Answer 47

open - penrose closed - JP or hemovac

Question 48

pressure injury assessment

Answer 48

risk assess, mobility, nutrient status, moisture and incontiencne, appearance of an existing pressure injury, pain assessment/

Question 49

branden scale

Answer 49

used to assess skin and likelihood of breakdown, as well as if they need help moving.

Question 50

if pt can feel pain

Answer 50

won't move

Question 51

home health care teaching

Answer 51

supplies, infection prevention, wound healing, appearance of skin and changes, acitivtyt and mobility, nutrition, pain, elimination

Question 52

factored affecting response to hot and cold treatments

Answer 52

method or duration of application, degree of temperature, age and condition, body surface covered.

Question 53

effects of applying heat

Answer 53

dilates peripheral blood vessels, increases tissue metabolism, reduces blood viscosity and increases capillaries, reduces muscle tension, relieve pain

Question 54

cold affects

Answer 54

constricts peripheral blood vessels reduces muslce spasms promotes comfort

Question 55

skin cancers

Answer 55

most common type has 3 types - melanoma, basal cell carcinoma, squamous cell carcinoma asians less susceptible

Question 56

ABCDE for risk reduction in skin cancer

Answer 56

assymetry, borders, colors, diameter, evolution

Question 57

diet needed for skin cancer reduction

Answer 57

vitamin B3

Question 58

normal changes in aging skin hair n nails

Answer 58

pale skin lesions dry loses turgor =. hair thinner and nails thicken yellow brittle

Question 59

scar is what color

Answer 59

black

Question 60

sloughis

Answer 60

yellow

Question 61

type iof tissue we wanna see w wound healing

Answer 61

red granulation tissue moist cobblestone appearance