Fundamentals of Nursing (Integumentary System & Skin Care) – Flashcards
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Skin is comprised of what two components?
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Water and Protein
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How often does the body replace the outer layer of cells or dermis?
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Every 6 Weeks
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True or False: Exercise has no affect on your skin.
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False. Exercise actually stimulates circulation that feeds the skin cells.
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True or False: Sleep is not important for the skin.
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False. Sleep helps assimilate nutrients.
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What causes skin to age the quickest?
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Dehydration
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What are the purposes of lotions and creams?
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To "seal" in moisture already present on the skin.
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How does smoking hurt your skin?
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It inhibits the amount of cellular O2.
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True or False: The best way to protect the lips from sun damage is using a lip balm with high SPF.
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True
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Why would Vitamin B3 or Niacin create a healthy glow in skin?
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Vit.-B3 and Niacine cause blood vessels to dilate, providing for more O2 and nutrients to the skin.
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_____ is the partial of total separation of wound layers.
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Dehiscence
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_____ is the second layer of skin.
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Dermis
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_____ is the top layer of skin.
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Epidermis
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The epidermis is composed of layered _____ cells.
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Stratified Epithelial
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_____ is the complete seperation of wound with viscera protruding out of the wound.
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Evisceration
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_____ is a liquid composed of plasma and blood components.
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Exudate
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_____ is an abnormal passageway from an internal organ to the outside of the body or to another organ.
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Fistula
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_____ is deficiency of blood to a certain area.
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Ischemia
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_____ is death of tissue.
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Necrosis
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_____ is drainage with WBC's, liquefied dead tissue, and both dead and live bacteria. It is usually thick with a musty or foul odor and varies in color from dark yellow to light green.
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Purulent
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_____ is drainage with a large amount of RBC's. It is red and looks like blood.
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Sanguineous
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_____ is drainage with a mixture of serum and RBC's. It is light pink to blood tinged.
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Serosanguineous
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_____ is drainage composed of the clear serous portion of blood. It is clear and watery.
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Serous
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_____ is the under layer of skin that anchors the skin to other tissue.
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SubQ Tissue
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What are the six functions of the integumentary system?
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- Protective barrier - Sensory Organ - Insulation / Thermoregulation - Aides in elimination of waste - Aides in maintenance of water-electrolyte balance
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True or False: Urine/feces may cause burning if left on skin for a prolonged period of time.
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True
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_____ is the same as a pressure ulcer, but is mostly due to prominent cause (ulcer from bony prominence).
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Decubitus Ulcer
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A pressure ulcer can develop in _____ to _____ hours.
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1 to 2
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The most common causes of pressure ulcers are _____
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Bony Prominence
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Two surfaces rubbing together can be defined as...
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Friction
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One layer of tissue sliding over another layer can be defined as...
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Shearing
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A loss of O2 can be defined as...
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Anoxia
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Pressure, immobility, shearing and moisture are all major causes of...
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Pressure Ulcers
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Identify the following description as a stage 1, 2, 3, or 4 pressure ulcer: The epidermis or topmost layer of the skin is broken creating a shallow open sore. Drainage may or may not be present.
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Stage 2
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Identify the following description as a stage 1, 2, 3, or 4 pressure ulcer: The breakdown extends into the muscle and can extend as for down as the bone. Usually lots of dead tissue and drainage are present.
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Stage 4
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Identify the following description as a stage 1, 2, 3, or 4 pressure ulcer: The skin is not broken, but is red or discolored. The redness or change in color does not fade within 30 minutes after pressure is removed.
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Stage 1
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Identify the following description as a stage 1, 2, 3, or 4 pressure ulcer: The break in the skin extends through the dermis into the subQ and fat tissue.
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Stage 3
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A score of _____ or less on the *norton scale* and a _____ or less on the *braden scale* denote high risk for pressure ulcer development.
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A score of *10* or less on the *norton scale* and a *10-12* or less on the *braden scale* denote high risk for pressure ulcer development.
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A key indicator for malnutrition that may affect pressure ulcer development is...
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Albumin Level
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True or False: It is recommended to massage the ulcer to promote circulation of O2 and nutrients to promote healing.
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False. You never want to massage an ulcer. This can put further pressure on the sore and make it worse.
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If an ulcer is clean and free of infection, it should be nearly healed within _____ weeks.
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2 - 4
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True or False: It is appropriate to offer pain medication before cleansing an ulcer.
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True
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What solution would the nurse use to clean and irrigate an ulcer?
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0.9% NSS
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True or False: To inhibit bacterial growth, the nurse should use iodine and hydrogen peroxide on the wound.
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False. Iodine and hydrogen peroxide could very well irritate the wound. This is not recommended.
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A rule of thumb in accordance with nursing guidelines regarding pressure ulcer dressings, the nurse should...
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Keep the ulcer tissue moist and the surrounding skin dry
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_____ dressings should be used for debridement.
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Wet to Dry
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Which of the following is not an area of criteria on the Norton Scale? (A) Physical Condition (B) Activity (C) Mobility (D) Continence (E) Hygiene
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Hygiene
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True or False: Mental State is a criteria listed on the Braden Scale.
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False. The Braden Scale does not include the mental state as a scaled criteria.
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A "blister" can be defined as a [Stage 1, 2, 3 or 4] pressure ulcer.
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Stage 2
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Parasitic insects that infest mammals are referred to as...
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Lice
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_____ is an infestation with lice.
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Pediculosis
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Head and pubic lice eggs hatch every _____ days.
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7 - 10
