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NU 101 test 1 > chapter 32 > Flashcards

chapter 32 Flashcards

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1
Q

factors that effect skin integrity

A

age
the amount of underlying tissue
illness conditions

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2
Q

what is a wound

A

a break or disruption in the normal integrity of the skin and tissues

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3
Q

how does wound repair occur

A

primary intention
secondary intention
tertiary intention

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4
Q

what is a primary intention

A

minimal tissue loss

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5
Q

what is a secondary intention

A

the wound has edges that are not well approximated
require more tissue replacement
take longer to heal

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6
Q

the tertiary intention

A

delayed primary closure

left open for several days to allow edema or infection resolve for fluid to drain and then are closed

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7
Q

what are the phases of wound healing

A

phase one: hemostasis
phase two: inflammatory response
phase three: proliferation phase
phase four: maturation phase

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8
Q

what is a scar

A

an avascular collagen tissue that does not sweat, grow hair, or tan in sunlight

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9
Q

what is phase one: hemostasis

A

occurs immediately after the initial injury

blood vessels involved constrict to allow blood clotting to be through the platelet activation and clustering

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10
Q

what is phase two inflammatory response

A

follows hemostasis and lasts about 2 to 3 days
WBC move to the wound
leukocytes arrive first to ingest bacteria
then macrophages 24 hours after

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11
Q

what is what three proliferation phase

A

lasts for several weeks

new tissue is built to kill wound space, through the action of fibroblasts

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12
Q

what is the phase for maturation phase

A

the final stage of healing
begins about 3 weeks after the injury - continues for months or years
collagen deposited
new collagen is still deposited and compressing blood vessels and forming a scar

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13
Q

infection

A

patients immune systems fail to control the growth of microorganisms

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14
Q

hemorrhage

A

slipped suture, a dislodged clot at a wounds site, infection or erosion of a blood vessel by a foreign body

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15
Q

dehiscence

A

partial or total separation of wound layers as a result of excessive stress on wounds that are not healed

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16
Q

evisceration

A

a complication of dehiscence. occurs in the abdominal it completely separates, with protrusion of viscera through the incisonal area

17
Q

fistula

A

the abnormal passage from an internal organ or vessel to the outside of the body

18
Q

what is a pressure ulcer (pressure injury)

A

localized damage to the skin and underlying tissue that usually occurs over a bony prominence

19
Q

what are factors in pressue injury development

A

external pressure

friction and shear

20
Q

what are common supine position bony prominences

A 
occipital bone
scapula
vertebrae
sacrum
coccyx
calcaneus
21
Q

what are common prone position bony prominences

A 
frontal bone
mandible
humerus
sternum
tuberosity of pelvis
patella
tibia
22
Q

what are common sims positions bony prominences

A 
scapula
ribs
iliac crest
greater trochanter of femur
lateral knee
lateral malleolus
medial malleolus
23
Q

what are the risks for pressure injuries

A 
Aging skin
Vascular disorders
Obesity
Immobility and incontinence
Diabetes
Skin friction
Poor nutrition
Reduced RBC's (anemia)
Edema
Sensory deficits
Sedation
24
Q

what are the warning signs of a pressure ulcer

A

blanching of skin

skin can feel warm

25
Q

what is the Braden scale

A

assess patients for pressure ulcers
low risk: 22-23
less risk: 19-21
high risk: < 18

26
Q

what is a type one pressure ulcer

A

skin is intact
nonblanchable redness
swollen tissue
darker skin - may appear blue/purple

27
Q

what is a type two pressure ulcer

A 
partial-thickness
epidermis and the dermis
superficial ulcer
abrasion or ulcer
- no fatty tissue is visible
28
Q

what is a type three pressure ulcer

A 
full-thickness SKIN loss
damage to necrosis or subcut tissue
no exposed muscle or bone
ulcer extended down to the underlying fascia but not through it
deep crater without tunneling
29
Q

what is a type four pressure ulcer

A

full-thickness TISSUE loss
destruction of tissue
damage to muscle and bone
deep pockets of infection and tunneling

30
Q

what is an unstageable pressure ulcer

A

when the stage cannot be determined due to eschar or slough covering the visibility of the wound making the depth unknown.

31
Q

prevention of pressure ulcers

A

relive pressure
proper nutrition
skin hygiene
repositioning

32
Q

what is a skin assessment

A

inspection and palpation used to assess the integumentary system

NU 101 test 1 (15 decks)

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