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36 Cards in this Set
- Front
- Back
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What are some anticipated changes in the integumentary system of the older adult?
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baldness, thinning gray hair
loss of eyelid elasticity changes in pigmentation loss of subq tissue and thinning of the dermis decrease in aprocrine, eccrine, and sebaceous glands decrease in elastin and tensile strength decrease in melanocytes increase in vascular lesions redistribution of fat decreased blood flow decreased touch receptors decreased proliferative potential onchomycosis |
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What is photoaging?
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Changes in skin appearance from chronic UV ray exposure
changes include: dark spots, wrinkles, droopy skin, yellowish tint, broken blood vessels, leathery skin, and skin cancers |
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What is actinic keratosis?
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the most common skin precancer
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What is the most common skin cancer?
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basal cell
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What is squamous cell cancer?
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malignant proliferation of keratinocytes
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What is the sixth most common cancer?
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melanoma
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What is melanoma?
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a malignant tumor originating in the melanocytes
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What is the cure rate for melanoma?
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if caught early, nearly 100%
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What is cellulitis?
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an acute bacterial infection of the skin and subq tissue
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what are risk factors for cellulitis?
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aging, altered immune response, diabetes, vascular disease, obesity
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What are the symptoms of celluliutis?
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pain, heat, redness, swelling, fever, leukocytosis, lymphadenopathy
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What is the treatment for cellulitis?
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antimicrobials, bed rest, elevation
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What is herpes zoster?
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activation fo the varicella-zoster virus
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Who do you commonly see with herpes zoster?
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frequent occurence in immunocompromised patients
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What does herpes zoster look like?
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linear patches of vesicles on a red base. Will be unilateral, burning pain. Neuralgia will precede the outbreak
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What is onchogryphosis?
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hypertrophy of the nails possibly caused by trauma or peripheral vascular disorders, most often secondary to neglect
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What is onchomycosis?
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any fungal infection of the nail
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What is paronchia?
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a painful bacterial or fungal infection where the nail and skin meet.
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What are the nursing responsibilities for nail problems?
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assess!
risk reduction skin/wound care teaching medication administration emotional support and encouragement |
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In what facilities do people get the most pressure ulcers?
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long term facilities
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Where do people get the least amount of pressure ulcers?
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acute care facilities
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What are risk factors for developing pressure ulcers?
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too thin or too fat
poor nutrition immobility use of assistive devices |
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What are contributing factors to developing a pressure ulcer?
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shearing force
moisture (perspiration or incontinence) friction |
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What score on the braden scale requires intervention for prevention of pressure ulcers?
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16 or less
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What score on the Braden scale indicates a high risk for pressure ulcers?
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12 or less
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What are the characteristics of a stage one pressure ulcer?
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nonblanchable redness, skin is intact
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What are the characteristics of a stage 2 pressure ulcer?
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partial thickness loss of the dermis, abrasion, blister, shallow center
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What are the characteristics of a stage 3 pressure ulcer?
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full-thickness loss of dermis, damage to the subcutaneous tissue
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What are the characteristics of a stage 4 pressure ulcer?
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damage to muscle and bone, necrosis
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What is does a 0 on the PUSH scale man?
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the wound is completely covered with epithelium (new skin)
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What is the PUSH scale used for?
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measures pressure ulcer healing
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What is a 4 on the PUSH scale mean?
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necrotic (eschar) tissue
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What does a 3 on the PUSH scale mean?
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slough (yellow or white tissue that adheres to the ulcer bed in strings or in thick clumps, or is mucinous)
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What does a 2 on the PUSH scale mean?
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granulation tissue (pink or beef red tissue with a shiny, moist, granular appearance)
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What does a 1 on the PUSH scale mean?
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epithelial tissue - for superficial ulcers, new pink or shiny tissue that grows in from the edges or as an island on the ulcer surface
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What are components of ulcer care?
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1. cleanse the wound with a noncytotoxic cleanser (saline) during each dressing change
2. if necrotic tissue or slough is present, consider the use of high-pressure irrigation 3. debride necrotic tissue 4. do not debride dry, black eschar on heels!! 5. perform wound care using topical dressings determined by wound appearance and availability 6. choose dressings that provide a moist wound environment, keep the skin surrounding the ulcer dry, control exudates, and eliminate dead space |
