-
functions of the skin
- insulation, cushioning
- prevents loss of fluids/dehydration
- body temp regulation
- homeostasis
- protection
- excretion of waste
- vitamin D synthesis
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strata, stratum germinativum, stratum cornium, keratin, melanocytes, and melanin
EPIDERMIS
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true skin, blood vessels and nerves, glands, hair follicles, collagen, elastic connective fibers
DERMIS
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connects skin to muscle, adipose tissue
stores H2O and fat, insulates, protects, provides pathway
provides shape and contour
SUBCUTANEOUS LAYER
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Appendages of skin
- SUDORIFEROUS GLANDS
- CERUMINOUS GLANDS
- SEBACEOUS GLANDS
- HAIR
- NAILS
- ARECTOR PILI
-
PRODUCE SWEAT
NO ODOR UNTIL BREAKDOWN ON SKIN
SUDORIFEROUS GLANDS
-
PRODUCE EAR WAX
YELLOW-ORANGE, STICKY
CERUMINOUS GLANDS
-
LUBRICATE HAIR
NO ODOR UNTIL BREAKDOWN ON SKIN
SEBACEOUS GLAND
-
CAUSE GOOSE BUMPS
ARECTOR PILI
-
ABNORMAL TISSUE FOUND ON OR IN AN ORGANISM, OFTEN DAMAGED BY DISEASE OR TRAUMA
LESION
-
BALDING, HAIR LOSS
ALOPECIA
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A FLUID THA OOZES OUT OF BLOOD VESSELS DUE TO INFLAMMATION AND IS DEPOSITED IN NEARBY TISSUE
EXUDATE
-
RUBBED RAW, ABRASION, SCRATCH, DIAPER RASH
EXCORIATION
-
FLAT AREA THAT HAS SOME CHANGE IN THE COLOR OF THE SKIN, LESS THAN 1cm DIAMETER
MACULE
-
-
FLAT MOLE, BIRTH MARK
NEVI
-
-
HIVES, RAISED, ITCHY, LOOK LIKE RED WELT. CAN BE PHYSICAL OR MENTAL CAUSE
URTICARIA
-
ELEVATED SUPERFICIAL LESION FILLED WITH SEROUS FLUID. LESS THAN 1cm DIAMETER
VESICLES
-
ELEVATED, IRREGULARLY SHAPED AREA OF CUTANEOUS SWELLING
WHEALS
-
ELEVATED FIRM AREA. LESS THAN 1cm DIAMETER
PAPULE
-
WHERE CAPILLARIES BREAK AND LEAVE LITTLE RED DOTS. FORM OF MACULE. CAN TURN INTO A BRUISE
PETECHIAE
-
GROWS ON SKIN, USUALLY BROWN OR BLACK, ALONE OR IN GROUPS.
MOLE
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LOSS IN PIGMENT OF SKIN, CAN EXPAND, PATCHES
VITILIGO
-
ELEVATED, SUPERFICIAL LESION FILLED WITH PUS
PUSTULE
-
ELEVATED, ENCAPSULATED LESION IN DERMIS OR SUB Q LAYER
CYST
-
IRREGULARLY SHAPED, EEVATED, PROGRESSIVELY GROWING SCAR
KELOID
-
FIBROUS TISSUE THAT REPLACES NORMAL SKIN AFTER AN INJURY
SCAR
-
LINEAR CRACK OR BREAK. MOIST OR DRY AREA
FISSURE
-
LOSS OF PART OF THE EPIDERMIS. LEAVES A DEPRESSED AREA, MOIST AND GLISTENING
EROSION
-
LASS OF EPIDERMIS AND DERMIS, CONCAVE, VARIES IN SIZE
ULCER
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DRIEDSERUM, BLOOD OR PURULENT EXUDATE. SLIGHTLY ELEVATED, SIZE VARIES
CRUST
-
CUT MADE ON PURPOSE. CLEAN CUT
INCISION
-
-
WOUND THAT OPENS ITSELF UP(EX.AFTER SURGERY) BY COUGHING,THROWING UP, INCREASED PHYSICAL ACTIVITY
DEHISCENCE
-
INTERNAL ORGANS ON THE OUTSIDE
EVISCERATION
-
SURGICAL INCISION WITH LESS THAN 5% CHANCE OF INFECTION
CLEAN
-
SURGICAL PREP AND INCISION ARE STERY; BUT CUTTING INTO CONTAMINATED AREA
CLEAN-CONTAMINATED
-
SURGICAL TECHNIQUE BROKEN,NOW CONTAMINATED (RUPTURED SPLEEN)
CONTAMINATED
-
OUTER SKIN ALREADY CONTAMINATED. EX.GANGREEN
DIRTY
-
STOP BLEEDING,PROTEINS, PLATELETS AND FIBRIN
HEMOSTASIS
-
INCREASED WBC, WARMPTH, SWELLING
INFLAMMATION PHASE
-
STARTS 3 DAYS AFTER INJURY AND CAN LAST UP TO 3 WEEKS
RECONSTRUCTION
-
FOODS TO HELP WITH HEALING OF WOUNDS
- VEGI= CARROT, SQUASH, YAMS= INCREASED VIT C ANDANTIOXIDANTS
- FRUIT= ORANGES,MANGOS,CANTELOPE
- PROTEIN= CHICKEN, FISH, BEEF, LIVER
-
FACTORS INFLUENCING HEALING
- AGE
- NUTRITIONAL STATUS
- PHYSICAL CONDITION
- PREEXISTING HEALTH
- MEDICAL HABITS
- INTAKE
-
INTAKE TO PROMOTE HEALING SHOULD BE
2000-2400ml/24h
-
ACTIVE BRIGHT RED BLEEDING
SANGUINEOUS
-
PALE, PINKISH, WATERY MIXTURE OF BLOOD AND SERUM
SEROSANGUINEOUS
-
CLEAR WATERY PLASMA
SEROUS
-
YELLOW-GREEN-BROWN, FOUL ODOR
PURULENT
-
CAVITY IN BODY THAT CONTAINS PUS, SURROUNDED INFLAMMED SKIN
ABSCESS
-
BAND OF SCAR TISSUE THAT BINDS TOGETHER 2 ANATOMICAL STRUCTURES THAT WOULD NORMALY BE SEPARATE
ADHESIONS
-
INFECTION OF SKIN
CELLULITIS
-
COLLECTION OF BLOOD IN TISSUES UNDER THE SKIN
HEMATOMA
-
NSG DX FOR PT WITH SKIN PROBLEMS
- RISK FOR INFECTION
- IMPAIRED PHYSICAL IMOBILITY
- IMPAIRED COPING
- LOW SELF-ESTEEM
- IMPAIRED SKIN INTEGRITY
- ALTERED BODY IMAGE
-
GOALS/OUTCOMES FOR PT
- DEMONSTRATE WOUND CARE
- DISCUSS S/S OF INFECTION
- " RISK FACTORS
- WOUNDS HEAL W/O COMPLICATIONS
- PT HAS MINIMAL PAIN
-
NSG INTERVENTIONS
- SKIN HYDRATION
- SURGICAL WOUNDS
- RISK INFECTION
- SELF ESTEEM
- RASHES
- IMPAIRED MOBILITY
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