Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Nursing Fundamentals > C10- Integumentary > Flashcards

C10- Integumentary Flashcards

You may prefer our related Brainscape-certified flashcards:
Nursing Fundamentals flashcards Nursing Mental Health flashcards Nursing Management of Care flashcards NCLEX-PN® flashcards NCLEX-RN® flashcards Nursing Pediatrics flashcards Nursing Safety & Infection flashcards Nursing Pharmacology flashcards Nursing Maternity flashcards Family Nurse Practitioner (FNP) flashcards
1
Q

Impaired skin integrity

A

Break or disruption of skin or tissues

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Impaired skin integrity causes: (external)

A

Hyperthermia
Hypothermia
Chemical
Mechanical
Humidity/moisture
Radiation
Medication

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Impaired skin integrity causes: (Internal)

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Wound definition

A

Disruption or break in normal integrity of skin

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Acute wound

A

Heal within days to weeks
Wound edges are well approximated

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Intentional wound

A

Result of planned invasive therapy or treatment

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Wound healing process:

A

Skin reflects condition of body
Adequate blood supply
Proper nutrition

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Primary intention

A

Wound edges are well approximated

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Secondary intention

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Local factors

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

What type of organ is skin?

A

Sensory organ

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Psychological effects of wounds?

A

Pain
Anxiety & fear
Changes in body image

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

What are the 4 phases of wound healing?

A

Hemostasis
Inflammatory
Proliferation
Maturation/Remodeling

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

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

A

Hemostasis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

How fast is the inflammatory response?

A

Immediate

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

Which cells may be activated in the inflammatory phase?

A

Leukocytes
Macrophages
Epithelial cells

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions