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Adult Health I > Chapter 32: Skin Integrity > Flashcards

Chapter 32: Skin Integrity Flashcards

1
Q

4 Processes involved in wound healing

A
  1. hemostasis
  2. inflammatory phase
  3. proliferation phase
  4. maturation phase
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2
Q

2 categories of factors that affect wound healing

A
  1. local

2. systemic

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3
Q

9 local factors that affect wound healing

A
  1. pressure
  2. desiccation
  3. maceration
  4. trauma
  5. edema
  6. infection
  7. excessive bleeding
  8. necrosis
  9. biofilm
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4
Q

6 systemic factors that affect wound healing

A
  1. age
  2. circulation and oxygenation
  3. nutritional status
  4. wound etiology
  5. medications and health status
  6. Immunosuppression
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5
Q

6 factors placing person at risk for skin alterations

A
  1. Age
  2. Lifestyle variables (homosexuality, IV drug use, multple sexual partners, occupation w/ prolonged sun exposure, body piercings)
  3. Changes in health state (dehydration, malnutrition, paralysis, local nerve damage, circulatory insufficiency)
  4. Illness (diabetes)
  5. Diagnostic measures (GI series -diarrhea)
  6. Therapeutic measures (bed rest, casts, aquathermia unit, meds, radiation therapy)
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6
Q

6 factors to assess in skin assessment

A
  1. Appearance of Skin
  2. Recent changes in skin
  3. Activity/mobility
  4. nutrition
  5. pain
  6. elimination
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7
Q

4 types of wound complications

A
  1. infection
  2. hemorrhage
  3. dehiscensce and evisceration
  4. fistula formation
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8
Q

2 factors in Pressure Injury development

A
  1. external pressure

2. friction and shear

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9
Q

5 factors placing person at risk for pressure injury development

A
  1. immobility
  2. nutrition and hydration
  3. moisture
  4. mental status
  5. age
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10
Q

3 pressure injury risk assessment scales

A
  1. Norton Scale
  2. Waterlow Scale
  3. Braden Scale
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11
Q

Hemostasis

A

Vasoconstriction, platelet aggregation, and clot formation are part of the first phase of wound healing

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12
Q

Inflammatory Stage

A

the inflammatory phase, is marked by vasodilation and phagocytosis as the body works to clean the wound

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13
Q

Proliferative phase

A

In partial-thickness wounds, in the third phase, the proliferative phase, epidermal cells reproduce and migrate across the surface of the wound in a process called epithelialization

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14
Q

Maturation

A

Maturation is the final stage of full-thickness wound healing, in which the number of fibroblasts decreases, collagen synthesis is stabilized, and collagen fibrils become increasingly organized.

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15
Q

Avulsion

A

tearing of structure from normal anatomic position

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16
Q

laceration

A

tearing of skin with blunt or irregular instrument, tissue not aligned, often with loose flaps of skin

17
Q

possible systemic reactions to wound

A 
increase in temp
increase in HR
increase in resp rate
anorexia
vomiting
musculoskeletal tension
hormonal changes
18
Q

Nutrition and wound healing

A

Vitamin A - collagen synthesis and epithelializiation
Vitamin B - cofactor of important enzyme reacitons
Vitamin C - collagen synth, capillary formatin, resistance to infeciton
Vitamin K - prothrombin synth
Zinc, copper, iron - collagen synth
Manganese - enzyme activator

19
Q

proliferation phase alternate names

A

fibroblastic phase
regenerative phase
connective tissue phase

20
Q

connective tissue that synthesize and secrete collagen and produce specialized growth factors responsible for inducing blood vessel formation and increasing number and movement of epithelial cells

A

fibroblasts

21
Q

epidermal stripping

A

unintentional removal of epidermis with tape

22
Q

hematoma

A

localized mass of usually clotted blood

23
Q

risk factors for wound complications

A 
obese
smoking
excessive coughing, vomiting, straining
malnourished
anticoagulants
infection
24
Q

dehiscence and evisceration response

A
  1. low fowlers
  2. cover exposed abdominal contents with saline moist sterile towels
  3. contact provider immediately
  4. NPO
25
Q

with 2 hour repositioning, how long before a reddened area due to reactive hyperemia fades

A

60-90 minutes

26
Q

what stage would a large intact serum filled blister be

A

stage 2

27
Q

Focused critical thinking guide

A
  1. identify goal of thinking
  2. asses adequacy of knowledge
    - pertinent circumstances
    - prerequisite knowledge
    - room for error
    - time constraints
  3. Address potential problems
  4. consult helpful resources
  5. Critique judgement/decision
28
Q

Focused skin assessment

A
  1. appearnce of skin
  2. recent changes in skin
  3. activity/mobility
  4. nutrition
  5. pain
  6. elimination
29
Q

skin assessment based on setting

A

acute care: on admission, reassess every shift and with any change in condition
long-term care: on admission then reassess weekly for 4 weeks, then quarterly and whenever condition changes
Home health care: on admission, then reassess at every visit

30
Q

T-tube

A

T-shaped tube placed in common bile duct,, collects bile after gallbladder surgery

31
Q

Braden scale

A
  1. mental status
  2. continence
  3. mobility
  4. activity
  5. nutrition
32
Q

autolytic debridement

A

uses occlusive dressings, such as hydrocolloids, or transparent films, uses body’s own enzymes

Adult Health I (11 decks)

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