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Nursing Fundamentals > C10- Integumentary > Flashcards

C10- Integumentary Flashcards

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1
Q

Impaired skin integrity

A

Break or disruption of skin or tissues

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2
Q

Impaired skin integrity causes: (external)

A

Hyperthermia
Hypothermia
Chemical
Mechanical
Humidity/moisture
Radiation
Medication

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3
Q

Impaired skin integrity causes: (Internal)

A

Altered metabolic or nutrition state
Altered circulation
Sensation
Pigmentation
Immune deficit
Altered fluid status

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4
Q

Factors placing a person at risk for skin alterations

A

Age
Changes in health status
Therapeutic measures can cause skin problems
Lifestyle variables

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5
Q

Wound definition

A

Disruption or break in normal integrity of skin

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6
Q

Acute wound

A

Heal within days to weeks
Wound edges are well approximated

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7
Q

Chronic wound

A

Do not progress through the normal sequence of repair
Wound edges often not approximated
Normal healing time is delayed
Often remain in inflammatory phase of healing

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8
Q

Open wound

A

Occur from intentional/unintentional trauma
Skin surface broken (portal of entry for microorganisms)
Bleeding
Tissue damage
Increased risk for infection
Delayed healing

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9
Q

Closed wound

A

Occurs from a blow, force, or strain
Skin surface not broken
Soft tissue damage
Internal injury and hemorrhage may occur

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10
Q

Intentional wound

A

Result of planned invasive therapy or treatment

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11
Q

Wound healing process:

A

Skin reflects condition of body
Adequate blood supply
Proper nutrition

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12
Q

Primary intention

A

Wound edges are well approximated

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13
Q

Secondary intention

A

Edges not well approximated
Take longer to heal and often develop scar tissue

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14
Q

Tertiary intention

A

Wounds left open for several days to allow edema or infection to resolve
Or fluid to drain

Then they are closed

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15
Q

Local factors

A

Factors that occur directly in the wound
Ex: pressure, maceration, trauma, edema, infection, excessive bleeding, necrosis, biofilm

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16
Q

Systemic factors: definition and examples

A

Not related to wound itself but prolong wound healing

Ex: age, circulation and oxygenation, nutritional status, medications, health status, adherence to treatment plan

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17
Q

What type of organ is skin?

A

Sensory organ

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18
Q

Psychological effects of wounds?

A

Pain
Anxiety & fear
Changes in body image

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19
Q

What are the 4 phases of wound healing?

A

Hemostasis
Inflammatory
Proliferation
Maturation/Remodeling

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20
Q

Blood clotting, platelet activity, brief vasoconstriction and increased capillary permeability are actions of which phase of wound healing?

A

Hemostasis

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21
Q

How fast is the inflammatory response?

A

Immediate

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22
Q

Which cells may be activated in the inflammatory phase?

A

Leukocytes
Macrophages
Epithelial cells

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23
Q

What type of reaction does the inflammatory phase produce?

A

Generalized (mild fever, increase WBC, malaise)

24
Q

How long does it take for proliferation to begin? How long does it last?

A

Within 2-3 days
Lasts 2-3 weeks

25
Q

Common phrase associated with proliferation

A

“Fill the divot”

26
Q

3 step associated with proliferation

A

Fibroblasts deposit fibrin

Blood flow reinstituted

Granulation tissue formed

27
Q

When does Maturation/Remodeling begin? How long does it last?

A

Begins ~3 weeks

Lasts for months or years

28
Q

Maturation/remodeling three steps

A

Collagen remodeled
More collagen deposited (compressing vessels)
Scar develops (avascular collagen)

29
Q

Which “intention” takes the longest to remodel?

A

Secondary intention

30
Q

Color classification system for wound beds (RYB)

A

Red=protect
Yellow=cleanse
Black=debride

31
Q

Red wound bed color indicates?

A

Ready for healing and responding to treatment
Granulation tissue
Good wound bed

32
Q

Yellow wound bed indicates?

A

Non-viable tissue needs debridement
Slough or tissue with poor blood supply

33
Q

Black wound bed indicates?

A

Necrotic tissue (eschar)

DEBRIDE dead tissue

34
Q

Peri-wound is defined as

A

Tissue surrounding the wound

35
Q

What are we assessing for peri-wound skin?

A

Intact?
Color?
Characteristics
-erythema (redness around wound)
-induration (increase in fiber elements in tissue)
-inflammation

36
Q

Exudate means?

A

Drainage

37
Q

Terms defining the amount of exudate drainage coming out of the wound

A

Scant
Minimal
Moderate
Copious

38
Q

Characteristics of exudate

A

Color
Odor
Type

39
Q

Serous wound drainage

A

Clear, watery plasma

40
Q

Purulent wound drainage

A

Thick, yellow, green, tan, or brown

41
Q

Serosanguineous wound drainage

A

Pale, red, watery:
Mixture of serous and sanguineous

42
Q

Sanguineous wound drainage

A

Bright red
Indicates active bleeding

43
Q

Infection signs and symptoms my occur ________-______ days after inury

A

2-7 days

44
Q

Infection produces an increase of:

A

Purulent drainage
Increased drainage
Pain
Redness and swelling (in and around wound)
Elevated temp and WBC count

45
Q

Greatest risk for hemorrhage when?

A

In the first 48 hours after surgery
-check wound frequently (2X shift)
-look for hematoma

46
Q

Hemorrhage treatment

A

Apply added pressure on the site and contact provider

47
Q

Dehiscence is?

A

Partial or total separation of the wound layers
-suture line pops open

48
Q

Evisceration is?

A

Complete separation and protrusion of the viscera and organs through incision

49
Q

Abscess and fistula are formed by:

A

Collection of infected fluid not draining
-abnormal passage/tunnel (organ to skin)

This results from delayed healing

50
Q

What four things would a nurse identify during a wound assessment?

A

Type of wound/cause
Appearance of wound
Stage of a pressure ulcer wound
Wound complications

Nurse would also assess (Pain, Vital signs, fever, labs)

51
Q

R.I.C.E. Wound healing

A

R- rest
I- Ice/ immobilization
C- compression
E- elevation

** oxygenation and infection control **

52
Q

What are pressure injuries?

A

Localized damage to the skin and underlying tissue that usually occurs over a bony prominence or is related to the use of a medical device

53
Q

Who is at risk for pressure injuries?

A

Older adults
Spinal cord & brain/neurological injuries

54
Q

Pressure injury assessment

A

Measure:
-size
Shape
Length and width
Unit label (inch, cm, mm)
Depth
-insert sterile moistened swab into wound
Measure depth on swab

55
Q

Nursing management of pressure injuries

A

Assess/monitor healing process
Role of nutrition
Pain assessment/management
Support surfaces and positioning
Cleansing debridement and dressings

Nursing Fundamentals (8 decks)

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