Anatomy of the Integumentary system
Consists of stratified epithelial tissue and no blood vessels
What is the epidermis
Most important role of the nurse in regards to pressure injuries.
What is prevention?
A patient is lying on there back for 30 minutes and the nurse notices a red area. After 20 minutes, the redness persists and the skin does not turn white after applying pressure with finger.
What is a Stage 1 pressure injury?
Interference with circulation that causes skin to turn white or dark skin to become pale.
What is blanching?
Made of dense connective tissue and gives the skin strength and elasticity.
What is the Dermis?
Immobility, moisture, malnutrition, altered sensory perception
What are risk factors for pressure injuries?
Localized maroon or purple skin that may be painful, mushy and warm.
What is a deep tissue pressure injury?
When I have confidence and do not change my answers on an exam.
What is "Own What I Know?"
Made of keratin and have no blood supply or nerve endings,
What are hair and nails?
Loss of elastic fibers, adipose tissue and collagen fibers in the dermis
What are changes in the integumentary system that occur with aging?
Subcutaneous tissue is damages, fat is visible, undermining and tunneling may be present.
What is a stage 3 pressure injury?
Assessment tool used to predict risk for development of pressure injury.
What is the Braden Scale?
An oily substance secreted from the sebceous glands to lubricate the skin.
What is sebum?
Economics, ability to perform self care, cultural practices and personal preference.
What factors affect personal hygiene?
Full thickness skin loss with damage to muscle, bone, or supporting tissue.
What is a stage 4 pressure injury?
Connective tissue formed in the healing process which is red, fragile and bleeds easily
What is granulation tissue?
Absorbs light and protects the skin from ultraviolet rays.
What is Melanin?
Includes the patient, family, healthcare professionals and skin care team.
Who is on the team to develop the most effective treatment plan for pressure injuries?
Loss of full thickness of tissue with eschar covering bed of wound or the base of the injury containing slough which can be green, brown, gray or tan.
What is an unstageable pressure injury?
Dark necrotic tissue in a wound bed resulting from severe damage.
What is eschar?