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Study Guide 28
Integumentary System
| Question | Answer |
|---|---|
| What does the Integumentary system stand for and what is its definition? | largest organ of the body that acts as a physical barrier to microbes |
| What are the accessory structures of the system? | Sebaceous glands (oil producing glands), sweat glands, hair, and nails |
| What do you "Tell the Nurse?" in regards to skin changes? | persons skin looks abnormally pale or flushed, or has a bluish tint or yellowish hue, new rash or changes in existing rash, mole has changed |
| What term is used to describe lesions? | |
| Excoriation? | an abrasion, or scraping away of the surface of the skin (can be caused by trauma, chemicals, burns, and prolonged contact w/ urine or feces) |
| Fluid Imbalance? | When you lose more fluid than you take in or when you take in more fluid than your body can filter out |
| Where is the coccyx? Sternum? | coccyx = very bottom of spine sternum = chest |
| Jaundice? What does it look like? | The yellowing of the skin due to liver failure |
| What are the types of lesions? | macules, papules, vesicles, and pustules |
| Macules? | a small flat, reddened lesion (from the rash that is seen in measles) |
| Papules? | a small raised, firm lesion (easily felt by passing finger lightly over the affected area) |
| Vesicles? | a small blister-like lesion that contains watery, clear fluid (form the rash that is seen in chicken pox) |
| Pustules? | a vesicle that contains pus, a thick, yellowish fluid that is a sign of infection (seen in acne) |
| Fissure? | a crack in the skin (caused by extreme dryness + fungal infections) |
| What can you do to prevent pressure ulcers? | Use observation skills (check for reddened areas on bony prominences), provide good skin + perineal care, anticipate toileting needs, encourage mobility, minimize skin injury caused by friction or shearing |
| Crater? How is it formed? | |
| What is the purpose of wound dressing? | to prevent microbes from gaining access to the body, to keep the wound edges moist, to keep the wound dry during procedures such as bathing, or to absorb drainage from the wound |
| What is a Montgomery tie? When is it used? | strip of adhesive attached to a cloth tie, dressing is placed on wound, then adhesive strip is applied to person's skin alongside dressing and ties are tied to keep the dressing in place (help to prevent skin damage by frequent removal + reapplication) |
| What is normal for the aging process of the integumentary system? | changes in physical appearance such as wrinkles, fragile and dry skin, thickening of the nails, and less effective temperature regulation |
| Melanin? | a dark pigment that gives our skin, hair, and eyes color as well as helps to protect the skin from exposure to sunlight |
| What causes body odor? When does this occur during your life span? | The apocrine glands which become active when a person reaches puberty |
| 1st degree burns? What do they look like? | redness and pain usually goes away within the couple of days / cause injury to the epidermis (sunburns, touching a hot pan) |
| 2nd degree burns? What do they look like? | penetrate into the dermis (blisters) / these burns are very painful and the loss of the epidermis increases the risk of infection |
| 3rd degree burns? What do they look like? | involve the epidermis and the dermis, the subcutaneous layer, and often the underlying muscles and bones (need surgery and skin grafts to heal) |
| How would you care for an elderly person's skin properly? What are things to do to help protect the skin and to prevent it from injury? | keep delicate nature of skin in mind, apply lotion, keep skin dry |
| What are the causes for pressure ulcers? | part of body presses against a surface, person is laying on wrinkled linens or object, sits on a bedpan, wears a splint or brace (all for long time) |
| What does skin exposed to sun produce? | it produces melanin and vitamin d |
| Intentional wounds? | result of planned surgical or medical intervention |
| Unintentional wounds? | an unexpected injury that usually results from some type of trauma (these can be open: surface of the skin is broken OR closed: skin is not broken, underlying tissues are damaged, redness, swelling, and bruising may occur) |
| What is VAC (vacuum assisted closure) therapy? Why is it used? | wound is covered with foam-like dressing and tube which vacuum pumps to create suction which removes drainage from the surface or the wound, stimulate blood flow, and growth of new tissue |
| What is the 1st stage of pressure ulcers? What layer of skin is involved? | a reddened area of skin that does not return to normal color after the pressure is removed, the area may then become very pale or white and develop a shiny appearance |
| Epidermis? | the outer layer of the skin, contains no blood vessels, produces keratin and melanin |
| Dermis? | layer of skin of blood vessels and nerves that supply the skin, where sensory receptors are, the sebaceous glands, sweat glands, and hair follicles are found in the dermis |
| Keratin? | a protein that causes cells to thicken and become water resistant |
| Sebum? | an oily substance that lubricates the skin, helps to protect it from drying out, protects it from harmful bacteria, and is slightly acidic |
| What are the two type of sweat glands? | Eccrine glands and apocrine glands |
| What is the function of the integumentary system? | protection, maintenance of fluid balance, regulation of body temp, sensation, vitamin d production, elimination and absorption |
| How does the body regulate in warm weather? | blood vessels in the dermis dilate, allowing more blood to flow close to the surface of the skin allowing the heat in the blood to radiate out of the body |
| How does the body regulate in cold weather? | blood vessels in the dermis constrict, causing less blood to flow to the surface of the skin |
| Why does skin become fragile when aging? | loss of collagen from the dermis, decreased blood flow to the dermis, number of sebaceous glands decrease with age (sebum decreases) |
| Necrosis? | tissue death as a result of a lack of oxygen |
| What is the 2nd stage of pressure ulcers? What layer of skin is involved? | the pressure ulcer looks like a blister, an abrasion, or a shallow crater / the epidermis peels away or cracks open, creating a portal of entry for microbes (dermis may be partially worn away) |
| What is the 3rd stage of pressure ulcers? What layer of skin is involved? | Epidermis and dermis are gone, subcutaneous fat may be visible in the crater and drainage from the wound may occur |
| What is the 4th stage of pressure ulcers? What layer of skin is involved? | the crater of damaged tissue extends from the tissues to the muscle or bone |
| What is the unstaged or unclassified stage of pressure ulcers? What layer of skin is involved? | Loss of epidermis, dermis, and subcutaneous tissue, covered with slough or eschar, need cleaning and debridement to determine exact stage and start healing process |
| What is the suspected deep tissue injury of pressure ulcers? What layer of skin is involved? | Pressure and shearing damage to underlying tissue, intact skin with purple or maroon colored or blood-filled blister, painful, firm or mushy, warm or cool, difficult to detect in dark skin |
| Wound? | an injury that results in a break in the skin (and usually the underlying tissues) |
| What is 1st intention wound healing? | open wounds are closed surgically with sutures or staples, helps speed up the healing process, minimizes scarring |
| What is 2nd intention wound healing? | infected or contaminated with dirt wounds may be cleaned + rinsed and left open to heal from the inside out, prevents an unresolved infection from delaying the wound healing process |
| What is 3rd intention wound healing? | a wound is left open for a period of time to make sure that an infection is not going to occur, the the wound edges are cleaned and closed with sutures or staples to speed the healing process |
| What should you look for when a patient or resident has lesions? | changes in color, bleeding, or drainage |
| Risk factors for developing pressure ulcers... | advanced age, poor nutrition and hydration, moisture on the skin, cardiovascular and respiratory problems, friction and shearing injuries |
Created by:
25smlyford