tissue integrity part 1

• what are the three layers of the skin?

  epidermis, dermis, and subcutaneous
• what is the epidermis?

  the outermost layer of the skin
• what does the epidermis consist of?

  melanocytes, merkel cells, langerhans cells, and keratinocytes
• what are melanocytes?

  cells that produce melanin
• what is melanin?

  a pigment that determines hair and skin color
• what do melanocytes absorb and do?

  radiant energy from the sun and protects against harmful uv rays
• what do merkel cells detect?

  light touch especially in the palms of the hand and the soles of the feet
• what do langerhans cells do?

  ingest and package foreign antigens to be presented as lymphocytes
• what do lymphocytes trigger?

  an immune response in the epidermis
• what do keratinocytes do?

  protect the skin from water loss, pathogens, and injury
• where are keratinocytes formed?

  in the basal layer
• where do keratinocytes migrate from?

  the basal layer to the more superficial layers
• what happens to keratinocytes with time?

  they die and are removed from the skin through shedding
• where is the dermis layer?

  under the epidermis
• what does the dermis do?

  sustain and support the epidermis by providing strength, flexibility, and nourishment
• what does the dermis protect and assist with?

  it protects underlying structures from injury and assists with wound healing
• what are found in the dermis?

  collagen and elastin fibers
• what do collagen and elastin fibers provide?

  strength and elasticity which protects clients from alterations in tissue integrity
• what happens when collagen and elastin fibers are depleted?

  the risk increases for developing alterations in tissue integrity
• where is the subcutaneous layer located?


  under the epidermis and dermis
• what is the subcutaneous layer composed of?

  adipose tissue
• what does the subcutaneous layer do?

  insulates the body, absorbs shock, and pads the internal organs and structure
• what does the subcutaneous layer consist of?

  blood vessels and nerves that assist in thermoregulation and sensation
• how much body weight does skin take up?

  15%
• what vitamins does skin produce?


  vitamin a and d
• what are the risk factors for impaired skin integrity?

  age, mobility, obesity, cancer, and chronic illness
• what are infants and children at risk for in regards to skin?

  maceration and dermatitis
• what is maceration?

  irritation of the epidermis due to moisture
• what is dermatitis?

  red irritation of the epidermis due to feces, urine, stoma effluent, and wound secretions
• what are older clients at risk for in regards to skin?

  decreased collagen stores, thin skin, loss of elasticity, increased risk for skin tears and tissue trauma, and wrinkling
• what should you take into consideration during skin assessments?

  the clients overall status, nutrition status, and mobility status
• what are the major elements of a comprehensive skin assessment?

  gathering medical history, looking for factors that place clients at risk, assessing skin abrasions, edema, moisture, rashes, texture, and temperature
• what should be done if an alteration in the condition of the skin is present?

  the client should be asked questions about the presence and history of that condition
• what is a key factor in decreasing the risk of pressure injury formation?

  assessment of the skin and soft tissue
• what is a pressure injury?

  localized damage to the skin as a result of pressure or pressure in combination with shear
• what provides an opportunity to identify factors that predispose clients to developing pressure injuries?

  routine risk and skin assessments
• which clients should undergo skin assessment on admission?

  all
• what should the bony prominences be examined for?

  manifestations of erythema
• what is erythema?


  redness of the skin due to dilation of blood vessels and other tissue discoloartion
• what can erythema be?

  blanchable or nonblanchable