Chapter 19: Assisting with Hygiene, Personal Care, Skin Care, and Prevention of Pressure Injuries

Flashcards covering Chapter 19 content on integumentary anatomy, aging skin changes, pressure injury stages and prevention, wound healing phases, and nursing care.

What components make up the human integumentary system?

Skin, hair, nails, sweat glands, and sebaceous glands.

Why are hair and nails described as accessory structures containing pure keratin?

Because they contain no nerves and no blood supply.

What is the body's largest organ, and what are its two main layers?

The skin; its two main layers are the epidermis and dermis.

What cell structure composes the stratum corneum layer of the epidermis?

Stratified squamous keratinized epithelium cells.

What does the term "stratified" mean in reference to epidermal tissue?

It means many layers.

What does the term "squamous" describe regarding cell shape?

Cells that are squished like a pancake.

What is keratin and what are its primary physical properties?

Keratin is a protein that is waterproof and tough.

Does the epidermal layer of skin contain blood vessels?

No, it does not contain blood vessels.

Which cells located at the bottom of the epidermis produce melanin when exposed to UV light?

Melanocytes.

What is melanin and what is its main protective function in skin cells?

Melanin is the main determinant of skin color; it covers and protects the nucleus (DNA) of cells.

What type of skin cancer occurs from damage to melanocytes?

Melanoma.

Where in the epidermis does basal cell carcinoma originate?

In the lowest layer of the epidermis.

How do secretions from dermal glands exit the body?

Sweat glands and sebaceous glands located in the dermis pass through the epidermis.

What essential nutrient is produced in the skin under sunlight to support calcium absorption?

Vitamin D.

Why does damage limited to the epidermis produce no bleeding?

Because the epidermis has no blood supply.

What are two examples of transdermal substances that the epidermis can absorb?

Nicotine and hormones (such as estrogen).

Which structures in the dermis regulate body temperature through dilation and constriction?

Blood vessels.

What sensory inputs are detected by nerve fibers located in the dermis?

Touch, pain, and pressure.

What substance is released by sebaceous glands and what is its main function?

Sebum (oil); it protects and lubricates the hair follicle and acts as an antibacterial on the skin surface.

What happens when the muscle attached to a hair follicle contracts during cold exposure?

It makes the hair stand up.

Where are eccrine sweat glands specifically located on the body?

On the palms and soles.

Where are apocrine sweat glands located?

In the axilla and groin area.

What tissue layer lies directly beneath the dermis?

Subcutaneous tissue (hypodermis).

What are the two main physiological functions of subcutaneous tissue listed in the notes?

Energy source and thermoregulation.

What tissue type is primarily found within the subcutaneous layer?

Adipose tissue.

What angle of insertion is required for an intramuscular medication injection?

$90^\circ$.

What angle of insertion is required for a subcutaneous medication injection?

$45^\circ$.

What angle of insertion is required for an intravenous injection?

$25^\circ$.

What angle range is used for an intradermal injection?

$10^\circ\text{--}15^\circ$.

What tissue structure composes mucous membranes?

Epithelial tissue lying over a deeper layer of connective tissue.

What are three core functions performed by mucous membranes?

Protect against bacterial invasion, secrete mucus, and absorb fluids and electrolytes.

What structural change in aging skin causes it to wrinkle and sag?

Loss of elastic fibers.

What skin symptoms result from decreased sebaceous gland activity in older adults?

Skin becomes dry and itchy, and temperature control is altered.

Why does hair lose its color as a person ages?

Loss of melanocytes.

Name four factors that contribute to skin fragility and slower tissue regeneration in older adults.

Thinner skin, decreased collagen, decreased peripheral circulation/oxygenation, and impaired immune system function.

How is hygiene defined in relation to infection and disease prevention?

Proper care of the skin, hair, teeth, and nails protecting the body from infection and disease.

What are four individual factors that affect personal hygiene practices?

Socioeconomic background, economic status, knowledge level, and ability to perform self-care.

What Body Mass Index threshold constitutes obesity as a risk factor for pressure injuries?

$\text{BMI} > 30$.

What are four primary risk factors for pressure injury development related to patient condition?

Immobility/inactivity, moisture (incontinence, diaphoresis), malnutrition, and friction/shear.

What assessment tool is recommended upon admission to predict pressure sore risk?

The Braden Scale.

When conducting a skin assessment for pressure injuries, where should the nurse pay closest attention?

Over bony prominences.

When should pressure areas be checked during routine nursing care?

When turning and repositioning the patient.

What six categories are evaluated on the Braden Scale?

Sensory perception, moisture, activity, mobility, nutrition, and friction & shear.

On the Braden Scale, what sensory perception level corresponds to a score of 1?

Completely limited (unresponsive to painful stimuli due to diminished consciousness/sedation or limited ability to feel pain over most of the body).

On the Braden Scale, what nutritional status corresponds to a score of 1 (Very Poor)?

Never eats a complete meal, rarely eats more than $1\%$ of food offered, eats $2$ or fewer servings of protein per day, or NPO/clear liquids/IVs for more than $5\,\text{days}$.

Under the Braden Scale Activity subscale, how is a score of 4 (Walks Frequently) defined?

Walks outside room at least twice a day and inside room at least once every $2\,\text{hours}$ during waking hours.

What wound classification includes surgical incisions, lacerations, and abrasions?

Open wounds.

What does the medical abbreviation DTI stand for in wound care?

Deep tissue injury.

What does the medical abbreviation IAD stand for?

Incontinence associated dermatitis.

What does the abbreviation MDRPI stand for?

Medical device related pressure injury.

What primary vascular mechanism leads to the formation of a pressure injury?

Local interference with circulation.

What is reactive hyperemia?

The process where skin becomes darker as blood supply returns after pressure is removed.

Name three common pressure injury sites located on the posterior body in a supine position.

Occiput, sacrum and coccyx, and heels.

Name three pressure injury sites susceptible to breakdown when a patient is in a side-lying position.

Trochanter, side of head, and malleolus.

How frequently must bed-bound patients be repositioned to prevent pressure injuries?

At least every $2\,\text{hours}$.

What defines a Stage 1 pressure injury?

An area of reddened skin that does not blanch when touched and does not resolve in $30\text{--}45\,\text{minutes}$ without pressure.

How may Stage 1 pressure injuries present in individuals with dark skin tones?

Discoloration, warmth, edema, induration, or purple hues.

What visual and structural changes characterize a Stage 2 pressure injury?

Partial-thickness skin loss that may look like an abrasion, blister, or shallow crater.

What characterizes a Stage 3 pressure injury?

Full-thickness skin loss looking like a deep crater, extending into the fascia, with damaged or necrotic subcutaneous tissue.

What characterizes a Stage 4 pressure injury?

Full-thickness skin loss with extensive tissue necrosis or damage to muscle or supporting structures, which may appear dry and black.

Why is a pressure injury covered in eschar or slough classified as unstageable?

Because necrotic tissue obscures the assessment of actual depth of tissue destruction.

What colors may be observed in wound slough?

Yellow, tan, gray, green, or brown.

How is a Deep Tissue Injury (DTI) defined?

Intact or nonintact skin with a localized area of non-blanchable discoloration.

What is considered the main factor in preventing pressure injuries?

Excellent nursing care.

How frequently should a patient in a wheelchair shift their weight?

At least once an hour, preferably every $15\,\text{minutes}$.

Why should nurses avoid massaging reddened skin over bony prominences?

Massaging damaged skin causes further injury; circulation should be restored by rubbing around the area instead.

What are the three steps in the initial care of a pressure injury?

Debridement, wound cleansing, and application of dressings.

What medical treatment is required if a pressure injury becomes infected?

Antibiotic therapy.

What are three examples of closed wounds?

Contusion (bruise), hematoma, and sprain.

What are four examples of open wounds?

Incision, laceration, abrasion, and puncture.

How do partial-thickness wounds regenerate lost tissue?

They heal rapidly by producing new skin cells, using a fibrin clot as a framework.

How do full-thickness wounds heal when no dermal layer remains?

They heal by contraction after all necrotic tissue is removed.

What are the three distinct phases of wound healing in order?

Inflammatory phase, proliferation or reconstruction phase, and maturation or remodeling phase.

When does the inflammatory phase of wound healing begin and how long does it last?

Begins immediately and lasts $1\text{--}4\,\text{days}$.

What four primary local signs occur during the inflammatory phase?

Swelling/edema, erythema (redness), heat/increased temperature, and pain.

When does the proliferation stage of wound healing begin and end?

Begins on the 3rd or 4th day and lasts $2\text{--}3\,\text{weeks}$.

What role do macrophages and fibroblasts play during the proliferation phase?

Macrophages clear wound debris and stimulate fibroblasts, which synthesize collagen.

When does the maturation phase of wound healing begin and how long can it persist?

Begins about $3\,\text{weeks}$ after injury and may take up to $2\,\text{years}$.

How should a clock face be positioned when documenting wound assessment characteristics?

Position 12:00 toward the client's head.

What does the acronym CACO stand for in describing wound exudate?

Color, Amount, Consistency, Odor (where $1\,\text{g} = 1\,\text{mL}$).

What does the term "epiboly" refer to during wound edge assessment?

Rolled wound edges.

What is maceration of periwound skin?

Softening of tissue resulting from excessive moisture exposure.

What step must a nurse perform before swabbing a wound for culture?

Cleanse the wound with $0.9\%$ sodium chloride to rinse away resident bacteria.

Where on the wound should the applicator swab be applied to obtain a culture?

In the center of the wound, avoiding contact with surrounding skin.

What are six clinical manifestations of internal wound hemorrhage?

Decreased BP, increased pulse rate, increased respirations, restlessness, diaphoresis, and cold, clammy skin.

Name three primary bacterial organisms responsible for wound infections.

Staphylococcus aureus (S. aureus), Escherichia coli (E. coli), and Streptococcus pyogenes (S. pyogenes).

What is an abscess?

A localized infection featuring an accumulation of pus from debris due to phagocytosis.

What are the characteristic properties of serous wound exudate?

Clear, thin, and watery fluid.

What characterizes serosanguineous exudate?

Thin and watery fluid with a light red or pink hue.

What characterizes sanguineous exudate?

Bright red, fresh blood.

What characterizes purulent exudate?

Thick, opaque, and odorous buildup resulting from infection.

What defines primary (first) intention wound healing?

Healing of a wound with little tissue loss and approximated edges (e.g., surgical incision), resulting in rapid healing and minimal scarring.

What defines secondary intention wound healing?

Healing of a wound with tissue loss where edges are not approximated, filling with granulation tissue over a longer duration with higher infection risk.

What is tertiary intention wound healing?

Delayed closure of a deep, heavily contaminated or edematous wound that is left open until infection resolves before suturing.

What is wound dehiscence?

The spontaneous opening or separation of underlying skin layers in a sutured wound.

What drainage change often signals impending wound dehiscence?

An increased flow of serosanguineous drainage.

What is wound evisceration?

A dehiscence involving the protrusion of internal visceral organs through a wound opening.

What key emergency nursing interventions must be performed immediately upon detecting wound evisceration?

Place patient in supine position, cover viscera with large sterile dressings soaked in sterile normal saline, notify surgeon immediately, keep patient NPO, and prepare for surgery.

What head-of-bed angle limit is recommended to prevent shear and pressure on the sacrum?

Keep the head of the bed at or below a $30^\circ$ angle (or flat).

What serum albumin level signals protein deficiency that increases skin breakdown risk?

Less than $3.5\,\text{g\,dL}^{-1}$.