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Fundamentals of Nursing > 32 Skin Integrity + Wound Care > Flashcards

32 Skin Integrity + Wound Care Flashcards

1
Q

Factors that affect skin integrity

A
  • age, amt of underlying tissues, + illness all affect resistance to injury
  • nourished/hydrated body cells
  • good circulation
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2
Q

which age groups have thin skin?

A

infants, kids under 2 yrs, and older adults

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3
Q

Wound

A

break or disruption of normal integrity of skin and tissues

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4
Q

Partial-thickness

A

all or portion of dermis is intact

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5
Q

Full-thickness

A
  • entire dermis, sweat glands, + hair follicles are severed

- possibly exposed bone, tendon, or muscle

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6
Q

Unstageable

A

full-thickness loss where depth cannot be determined due to slough or eschar
-may involve deep tissue injury

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7
Q

Stages of Wound Healing

A

1 Hemostasis
2 Inflammatory Phase
3 Proliferation Phase
4 Maturation Phase

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8
Q

Hemostasis

A

occurs immediately after initial injury

  • bld vessels CONSTRICT, clotting begins (pltlet activn + clustrng)
  • bld vessels then DILATE to incr permeability (plasma + bld components leak into area, form EXUDATE)
  • exudate buildup causes swelling+pain
  • incr circ leads to heat + redness
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9
Q

Inflammatory Phase

A
  • last 2-3 days
  • WBC (leuk ingest bacteria + debri; + macrphg come later + stay longer + release growth factors)
  • pain, heat, redness, swelling
  • patient has incr temp, leukocytosis, + malaise
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10
Q

Proliferation Phase

A
  • lasts several weeks
  • GRANULATED TISSUE-new tissue built to fill the wound
  • FIBROBLASTS are connectv tissue cells that synth + secrete collage + produce specialized growth factors
  • –induce bld vessel formation + incr endothelial cells
  • CAPILLARIES grow across the wound (bring O2 + nutrients)
  • COLLAGEN synth peaks at 5-7 days
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11
Q

Maturation Phase

A
  • 3 weeks after injury
  • collagen is remodeled making the wound stronger + more like adjacent tissue
  • scar becomes flat + thin
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12
Q

if 3 stages of wound healing are identified, then…

A

hemostasis occurs w inflammatory phase

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13
Q

if 3 stages of wound healing are identified, then…

A

hemostasis occurs w inflammatory phase

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14
Q

Nutrients for Wound Healing

A

requires adequate proteins, carbs, fat, vitamins, + minerals

  • vit A C
  • Zinc
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15
Q

Vitamins A + C for wound healing

A

for epithelialization + collagen synthesis

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16
Q

Zinc

A

for proliferation in cells

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17
Q

Zinc

A

for proliferation in cells

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18
Q

Dehiscence

A

partial or total separation of wound layers as a result of excessive stress on wounds that arent healed

19
Q

Evisceration

A

most serious complication of dehiscence

-potrusion of a viscera

20
Q

what to do when dehiscence occurs

A

cover wound area w sterile towels moistened w sterile 0.9% NaCl soln

  • notify healthcare provider
  • medical emergency
21
Q

what to do when dehiscence occurs

A

cover wound area w sterile towels moistened w sterile 0.9% NaCl soln

  • notify healthcare provider
  • medical emergency
22
Q

Pressure Injury

A

new term for pressure ulcer

  • localized damage to skin + underlying tissue
  • develop when soft tissue is compressed bw BONY prominence + external surface for prolonged period
  • may occur fr soft tissue undergoes pressure w shear/friction
23
Q

Risk Factors for pressure injury

A
  • mobility + activity limitations are required conditions*
  • poor skin hygiene
  • diabetes mellitus
  • diminished sensory perception/pain awareness
  • fractures
  • hx of corticoid therapy
  • hx of pressure injury
  • significant obesity or thinness
  • term illness/dying process
  • microvasc dysfunction
24
Q

Stage 1 Pressure Injury

A

defined, localized area of intact skin w NONBLANCHABLE ERYTHEMA

  • area may be painful, firm, soft, warmer, or cooler than surrounding skin
  • color changes DO NOT include purple/maroon
25
Q

Stage 2 Pressure Injury

A

involved partial-thickness loss of dermis

  • presents shallow, open ulcer or ruptured/intact serum-filled blister
  • fat is NOT exposed
  • granulation, slough, eschar NOT present
26
Q

Stage 3 Pressure Injury

A

full-thickness tissue loss

  • subcutaneous fat may be visible
  • epibole (rolled wound edges) may occur
  • may have undermining, tunneling
  • bone, tendon, muscle is NOT exposed
27
Q

Stage 4 Pressure Injury

A

full-thickness tissue loss w exposed or palpable bone, cartilage, ligament, tendon, fascia, or muscle
-slough, eschar, epibole, undermining, tunneling may be present

28
Q

Deep Tissue Pressure Injury

A

persistent non-blanchable maroon/purple color

29
Q

Types of Wound Drainage

A
  • serous drainage
  • sanguineous drainage
  • serosanguineous drainage
  • purulent drainage
30
Q

Serous Drainage

A

clear watery serous portion of blood fr serous membranes

31
Q

Sanguineous Drainage

A

large number of RBC + looks like blood

bright red=fresh, darker=older

32
Q

Serosanguineous Drainage

A

mixture of serum + RBC

-light pink to blood-tinged

33
Q

Purulent Drainage

A

WBC, liquefied dead tissue debris, both dead + live bacteria

-thick, musty/foul odor, dark yellow to green color depending on causative agent

34
Q

Open System Drains

A

1 Gauze

2 Penrose

35
Q

Closed System Drains

A

1 Chest Tube
2 Hemovac
3 Jackson-Pratt
4 T-tube

36
Q

Gauze

A

allows healing fr base of wound

-gauze dressing packed loosely so wound is allowed to drain

37
Q

Penrose

A

drains blood + fluid
open drainage systm consisting of soft rubber tube that provides sinus tract

ex) drainage for abscess in ab surgery

38
Q

Chest Tube

A

mediastinal placement to drain blood

  • used after cardiac surgery
  • different fr chest tube used in pleural space
39
Q

Hemovac

A

neg-pressure suction device

-drains blood + fluid

40
Q

Jackson-Pratt

A

bulb suction device to drain blood + fluid

41
Q

T-tube

A

t shaped tube placed in the COMMON BILE DUCT

-collects bile after gallbladder surdery

42
Q

open vs closed wound care

A

open wound

43
Q

Wound Culture Collection

A 
1 assess for pain
2 prep items, adjust bed, position
3 remove old dressing w clean gloves
4 inspect COCA
5  doff gloves + HH
6 clean wound using NONantimicrobial cleanser
7 don clean gloves
8 obtain swabs on culturette tube
9 use area that is free fr necrotic tissue, apply sufficient pressure to express fluid

Fundamentals of Nursing (17 decks)

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