Nurse300

Skin anatomy

100

What does layer is the epidermis and what does it do?

1st and protective barrier

200

What layer is the dermis 

2nd

300

what does the dermis do?

-contains collagen and elastin.

-provides strength, mechanical support and protection to underlying muscles, bones, and organs

400

what layer is the subcutaneous tissue(hypodermis)?

3rd

500

what does the subtaneous tissue contain?

-layer of loose connective tissue that contains major blood vessels, lymph vessels and nerves

-stores fat, helps with temperature regulation, and acts as a cushion against truama

Skin Integrity

100

In what ways does the skin of neonates differ from that of older infants?

-Thin skin

-more permeability

-less subcutaneous fat

-nonfunctiontional aprocrine glands

200

In what ways does the skin of adolescents differ than neonates and infants

-experience increased apocrine and sebaceous gland activity

-produces more oily skin and acne

300

Which of the following are common changes or findings in the skin of older adult patients? (SATA)

1. Pigmentation.  2.Moisture.     3.Thickness.

4.Texture   5.SubQ tissue.  6.Pain   7.Blood Supply. 8.Mast cells, fibroblasts and Langerhan cells

All 8 are common changes in older adults 

400

What (4) are included in Skin assessment?

-Inspection

-Palpation

-Focus on High-risk areas

-Documentation

500

What is all included for the INSPECTION for skin assessment?

-COLOR: pallor, erythema, cyanosis, jaundice

-LESIONS: Moles, rashes, wounds

-INTEGRITY: breaks, ulcers, surgical wounds

Skin Integrity Cont

100

What is all included for the PALPATION for skin assessment?

-TEMP: warm, cool

-MOISTURE: dry, clammy, sweaty

-TURGOR: hydration, elasticity

-EDEMA: pitting +1 to +4

200

What is all included for the FOCUS ON HIGH RISK AREAS for skin assessment?

-Bone prominences (heels, sacrum, elbows, hips)

-Skin folds, under medical devices

300

What is all included for the DOCUMENTATION for skin assessment?

-describe size, location, color, exudate, surrounding tissues.

-use tools (Braden scale for pressure injury risk)

400

TRUE/FALSE: 

When scoring the Braden Scale, a HIGHER number means they are at severe risk

FALSE.

Scoring:

 15-16= Mild Risk

12-14= Moderate Risk

<11 = Severe Risk

500

six (6) tools to screen clients risk of skin breakdown

1. sensory perception

2. moisture

3. activity

4. nutrition

5. friction and shear

Pressure ulcer staging

100

Pressure Ulcer: stage 1

-Skin is intact

-Non-blanchable redness to a localized area.

200

pressure ulcer: stage 2

• Superficial damage to skin.
• Partial-thickness skin loss. 
• Extends through the epidermis and into the dermis

300

Pressure ulcer: stage 3

• 
  
  • Full-thickness skin loss.
  • Ulcer extends to the subcutaneous tissue.
  • Slough or eschar could be visible.

400

pressure ulcer: stage 4

• Full-thickness tissue loss with exposed bone, tendon, and/or muscle.
• Often includes undermining or tunneling.
• Eschar or slough may be present.

500

what is an Unstageable Pressure Injury?

• Full thickness tissue loss but base of ulcer is covered by slough or eschar. 
• 
  
• Cannot determine depth.

Skin Ulcers

100

How is Arterial Insufficiency defined? and symptoms

• Decreased blood flow through one or more of your arteries.
  • Narrowed or blocked arteries
  • Clot or atherosclerosis
• Symptoms include: cool, pale skin, non-healing wounds, intermittent claudication pain, rest pain, loss of hair and dry scaly skin over lower extremity, decreased or absent peripheral pulses, and arterial ulcer formation.

200

Treatment for Arterial Insufficiency

Treatment:

• Assess pain
• Assess for signs of ulcer formation or signs of gangrene.
• Exercising
• Walking to the point of claudication, stopping to rest, then resume walk.
• Avoid things which cause vasoconstriction:
• Exposure to cold, caffeine, and tobacco products
• Surgery to improve arterial blood flow.

300

How is Venous Insufficiency defined? and what are the symptoms?

• Veins have issues returning blood back to the heart.
• Prolonged venous hypertension
• Leads to pooling of blood which causes edema and leads to ulcers and/or cellulitis on the lower extremities.
• Symptoms include:
• Swelling, edema, brown discoloration in lower extremity, ulcer formation, and heavy exudate from wounds.

400

Treatment for Venous Insufficiency:

• Focus on decreasing edema and promoting venous return of blood from the affected area.
• Leg elevation is usually prescribed.
• TED hose
• Avoid prolonged sitting/standing

500

Venous ulcer VS Arterial Ulcer

Venous: Swollen w/ drainage, Granulation tissue present, Edges irregular, Shallow

Arterial: Very little drainage, very little granulation (ttissue is pink/yellpw soemtimes black) "punched out" edges" , Deeper