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Nursing > Chapter 37 Skin Integrity And Wound Care > Flashcards

Chapter 37 Skin Integrity And Wound Care Flashcards

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0
Q

Impaired skin integrity resulting from pressure
Localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure or pressure in combination with shear and/or friction

A

Pressure ulcer

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1
Q

Braden scale

A

Lower score higher the risk

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2
Q

Body’s largest organ

A

Skin

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3
Q

Primary defense against infection

A

Skin

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4
Q

Disruption in the integrity of the body tissue

A

Wound

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5
Q

Surface damage caused by the skin rubbing against another surface that often results in an abrasion

A

Friction

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6
Q

Loss of the epidermis
Eschar
Abrasion

A

Abrasion

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7
Q

Thick layer of dead dry tissue that covers a pressure ulcer or thermal burn
It may be allowed to be sloughed off naturally or it may need to be surgically removed
Like a scab

Eschar
Abrasion

A

Eschar

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8
Q

A wound with little or no tissue loss such as a clean surgical incision which heals by
Skin edges approximate or close together and risk for infection is minimal
Healing rapidly with minimal scarring
Low risk for infection
Healing occurs in four stages

A

Primary intention

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9
Q

A wound involving loss of tissue such as a severe laceration or a chronic wound such as a pressure ulcer heals by
The skin edges cannot come together because of the extensive tissue loss and healing occurs gradually
Edges widely separated
Large scar occurs
Increased potential for infection
Healing time longer
Healing from bottom up

Primary
Secondary

A

Secondary intention

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10
Q

Pink pebbly tissue
Red moist tissue consisting of blood vessels and connective tissue, covers the wound base
Wound contraction brings the wound together and the wound closes with scar formation
Layers of pink pebbly tissue is new granulation tissue
As layer gets thick it becomes beefy red

Ecchymosis
Granulation

A

Granulation tissue

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11
Q

Cessation of bleeding

A

Hemastasis

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12
Q

Partial or total separation of layers of skin and tissue above the fascia in a wound that is not healing properly

A

Dehiscence

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13
Q

Occurs when wound layers separate below the fascial layer and visceral organs protrude through the wound opening
This is a medical emergency. This happens in abdominal incision where it splits open when you may sneeze or pick up something heavy.
Have patient lay on floor so things will not fall out, take pressure off, sterile equipment, moisten soak in sterile solution and put it in wound and cover do internal organs will not dry out and call surgeon and schedule for surgery. Do not push things back in. Do not put anything on it to bind it.

A

Evisceration

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14
Q

Discoloration of the skin or bruise caused by leakage of blood into subcu tissues as a result of trauma to the underlying tissues

Ecchymosis
Dehescience

A

Ecchymosis

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15
Q

Softening of the skin caused by moisture

A

Maceration

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16
Q

Removal of dead tissue from a wound

A

Debridement

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17
Q

Sensitive vascular layer of the skin directly below the epidermis composed of collagenous and classic fibrous connective tissues that give the dermis strength and elasticity

Dermis
Exudate

A

Dermis

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18
Q

Approximate

A

To come close together as in the edges of a wound

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19
Q

Injury to the skins surfaced caused by abrasion

A

Excoriation

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20
Q

Fluid, cells or other substances that have been slowly discharged from cells or blood vessels through small pores or breaks in cell membranes

A

Exudate

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21
Q

Clear, watery plasma

A

Serous

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22
Q

Fresh bleeding

A

Sanguineous

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23
Q

Pale, more watery
Combination of plasma and red cells
May be blood streaked

A

Serosanguinous

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24
Q

Thick, yellow, green or brown, indicating the presence of dead or living organisms and WBCs

A

Purulent

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25
Q

Abnormal passage from an internal organ to the body surface or between two internal organs

A

Fistula

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26
Q

Skin and subcu layers adhere to surface of bed and muscle and bone slide in the direction of body movement

A

Shearing force

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27
Q

Protective reaction that neutralizes pathogens and repairs body cells

Remodeling
Inflammatory response

A

Inflammatory response

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28
Q

Nonblanchable erythema of the intact skin
Only the epidermis is involved
Reversible if pressure removed
Which stage pressure ulcer

A

Stage I

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29
Q

Partial thickness skin loss involving epidermis and/or dermis
Skin tears
Superficial
Presents as an abrasion, blister or shallow crater
May be swollen or painful
More painful than IV
which stage of pressure ulcer

A

Stage II

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30
Q

Full thickness skin loss with damage or necrosis of subcu tissue that may extend to but not through the underlying fascia
Presents as deep crater with or without undermining
May have foul smelling drainage
Which stage of pressure ulcer

A

Stage III

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31
Q

Full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone or supporting structures
Undermining/tunneling may be present
Which stage of pressure ulcer

A

IV

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32
Q

Decreased blood supply to a body part such as a skin tissue or to an organ such as the heart

A

Ischemia

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33
Q

External factors that increase patients risk for developing an ulcer

A

Pressure
Shear
Friction
Moisture

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34
Q

Internal factors that increase patients risk for a pressure ulcer

A

Nutrients
Infection
Age

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35
Q

What nutrient is needed to maintain skin

A

Protein

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36
Q

Low protein levels cause

A

Edema or swelling

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37
Q

Edema increases the risk for pressure ulcer formation because

A

Changing pressures in capillary circulation and capillary bed resulting in decreased blood supply and retention of waste products in the edematous tissue

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38
Q

Does edema increase or decrease elasticity

A

Decease

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39
Q

Inhibit wound healing

A

NSAID

Steroids

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40
Q

Most common sources of moisture

A

Incontinence

Fever

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41
Q

Exposure of moisture leads to

A

Maceration

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42
Q 
Temperature greater than 101
Leads to swearing and maceration
Increases metabolic
Sign of infection
Triggers immune response which uses calories and nutrients
A

Fever

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43
Q

Are these primary or secondary defenses

Skin and normal flora
Mucous membranes
Sneeze, cough, tearing reflexes
Elimination and acidic environments 
Circulatory system
A

Primary

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44
Q

Physical barrier

Inhibits growth traps infection

A

Mucous membranes

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45
Q

Trap and propel mucous from lung

A

Cilia

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46
Q

Physical expulsion

A

Sneeze/cough

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47
Q

Flushing mechanism

A

Tears

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48
Q

Primary or secondary defenses

Inflammatory response
Immune response

A

Secondary

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49
Q

White blood cells
Second line of defense
Ingest and destroy microbes

A

Leukocytes

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50
Q

Normal range of leukocytes

A

Less than 10,000

51
Q

Which stage of inflammatory response

Initial injury precipitates release of chemicals
Activates the inflammatory response

A

Stage 1

52
Q

Which stage of inflammatory response

Erythema
Produces the characteristic signs of redness and increased warmth

A

Stage 2

53
Q

Increased blood flow to inflamed area

A

Erythema

54
Q

Which stage of inflammatory response

Increases capillary permeability with leakage of large quantities of plasma into damaged tissue
Infection is walled off
Nonpitting edema occurs

A

Stage 3

55
Q

Which stage of inflammatory response

Damaged tissue invaded by leukocytes that engulf the bacteria and necrotic tissue
Produces purple to exudate (pus)

A

Stage 4

56
Q

Which stage of inflammatory response

A

Destroyed tissue cells replaced by identical/similar cells and/or fibrous tissue
Promotes tissue healing or formation of scar tissue
Functional capacity of tissue may be reduced

57
Q

Cardinal signs and symptoms of inflammation

A

Redness - blood accumulation in dilated capillaries
Warmth - the heat of the blood
Swelling - fluid accumulation
Pain - pressure or injury to local nerves

58
Q

Does inflammation equal infection

A

No

59
Q

Is inflammation a normal response

A

Yes

60
Q

When the body’s defenses are overwhelmed

A

Infection

61
Q

Setting up for trouble in individuals

A 
Breaks in skin and mucous membranes 
Invasive devices
Stasis of body fluids
Inadequate nutrition
Stress
Immune system dysfunction
62
Q

Common sites of infection

A

Surgical wounds
Urinary tract
Respiratory tract

63
Q

Major cause for hospital morbidity which accounts for 60% of extra hospital days

A

Surgical wounds

64
Q

Most common nosocomial infection

UTI
Respiratory

A

Urinary tract

65
Q

Second most common site and associated with most deaths

A

Respiratory tract

66
Q

Does wound infection double or triple for each hour a patient is in surgery

A

Doubles

67
Q

Most common mechanism of respiratory infection

A

Aspiration

68
Q

Major causative agent of a UTI

Caths
Wounds

A

Catheters

69
Q

Very little tissue loss

Primary
Secondary
Tertiary

A

Primary

70
Q

Delayed primary

Secondary
Tertiary

A

Tertiary

71
Q

A wound that just happened

Acute
Chronic

A

Acute

72
Q

A wound that has been there for two months or longer

A

Chronic

73
Q

Granulating healing wound

Red
Yellow
Black

A

Red

74
Q

Pus

Yellow
Red
Black

A

Yellow

75
Q

Necrosis

Brown
Black

A

Black

76
Q

What are the four stages of healing

A

Hemostasis
Inflammatory
Proliferate
Remodeling

77
Q

Also called delayed primary healing
A widely separated wound is later brought together with some type of closure material
Usually fairly deep
Often contains extensive drainage and tissue debris

A

Tertiary

78
Q

Physiology of wound healing

A

Vascular response/inflammation (hemostasis and inflammatory)
Proliferation/regeneration
Maturation/remodeling

79
Q 
Reaction phase
Begins in minutes and lasts about 3-6 days
Hemostasis
Slight fever
Inflammation

Proliferation
Vascular response
Remodeling

A

Vascular response

80
Q

Proliferation/regeneration

A

Day 3-4 to day 21
Macrophage clears area of debris
Begins with appearance of new blood vessels
Fills wound with connective or granulation tissue and top is closed with epithelialization
Fibroblasts synthesize collagen which closes wound (forms scar)
Scar is pink and raised

81
Q

Grows from edges and covers over the granulation

New skin/scar

A

Epithelial tissue

82
Q

Maturation/remodeling

A 
Starts day 21 and can go long periods
Collagen scar gains strength
Scar remodels resuming normal appearance
Scar becomes smaller, flatter and whiter
Takes months to years to complete
83
Q

Types of exudates

A

Serous
Sanguinous
Serosanguinous
Purulent

84
Q

Act of forming pus

A

Suppuration

85
Q

Complications of healing

A 
Infection
Hemorrhage
Dehiscence
Evisceration
Fistulas
86
Q

Used in clean and granulating wounds

A

Wet to moist

87
Q

Only solution for wound care recommended by Agency for Health Care Policy Research

A

Normal saline

88
Q

Best agent to use for wound and isotonic

A

Normal saline

89
Q

Solutions that delay healing

A

Hydrogen peroxide

Dakin’s solution (bleach solution)

90
Q

Solution that slow healing

A

Acetic acid (vinegar solution)

91
Q

Major no no, removes moisture from wound bed

A

Betadine

92
Q 
Intermittent current to wound bed
Stimulates migration of cells involved in repair
Stimulates granulation
Inhibits bacterial growth 
Limited clinical use
A

Electrical stimulation

93
Q

Oxygen delivered at increased atmospheric pressure
Stimulates fibroblasts, collagen synthesis and epitheliumtunica
Improves blood capacity to carry O2 thus leading to increased oxygenation

A

Hyperbaric oxygen

94
Q

Sponge inside wound covered with occlusive dressing and connected to negative pressure machine
Eliminates excess exudates
Good for large/deep wounds, heavy exudates and nonhealing wounds

A

Negative pressure wound treatment

95
Q

Acute wounds in inflammatory phase

Cold or heat

A

Cold

96
Q

Chronic wound - direct heat contraindicated in arterial insufficiency

A

Heat

97
Q

Scrub, rub, wet to dry damp dressing, irrigation, whirlpool, maggots

What kind of debridement
Mechanical
Enzymatic
Automatic
Sharp
A

Mechanical

98
Q

Topical medication, collagenase are enzymes

A

Enzymatic

99
Q

Body does it to itself
Dressings that contain moisture that make use of the body’s enzymes to break down necrotic tissue

What kind of debridement
Mechanical
Enzymatic
Autolytic
Sharp
A

Autolytic

100
Q

Use of scalpel/scissors
Requires special training

What kind of debridement

Mechanical
Enzymatic
Autolytic
Sharp

A

Sharp

101
Q

What are some common misconceptions of pressure ulcers

A 
Develop because of poor nursing care
Are preventable
Are caused from pressure alone
Massaging reddened tissue helps prevent
Use of specialty equipment will prevent ulcers indefinitely and independently
102
Q

What would you use with a wound with a lot of drainage

A

Collagen

103
Q

Does a wound vac limit ambulation

A

Yes

104
Q

What are the most susceptible areas for a pressure ulcer

A

Coccyx-sacral area
Heels
Elbows

105
Q

Contributing factors leading to pressure ulcer

A 
Prolonged pressure
Shearing force
Friction
Moisture
Nutrition
Infection 
Impaired peripheral circulation 
Obesity
Age
106
Q

Abrasion
Two surfaces rubbing against each other
Injury is shallow and without necrosis
Limited to the epidermis (skinned knee, road rash)

A

Friction

107
Q

Most vulnerable areas with a friction injury

A

Heels and elbows

108
Q

Suspects deep tissue injury - localized area of purple/maroon discoloration
Intact skin or a blood filled blister that is due to damage of underlying soft tissue from pressure and/or shear
Tissue that is painful, firm, mushy, boggy, or warm/cool in comparison to adjacent tissue

A

Suspected deep tissue injury

109
Q

Base of the ulcer is covered by slough and/or eschar
A necrotic ulcer, or one with eschar, cannot be graded or staged - depth of wound and tissue type cannot be visualized
Cannot see bottom of wound bed, can’t tell stage

A

Unstageable

110
Q

Which stage related treatment

Relieve pressure

A

Stage 1

111
Q

Stage related treatment

Moist healing environment

A

Stage 2

112
Q

Which Stage related treatment

Debride

A

3

113
Q

Which stage related treatment

Non adherent dressing, skin grafts

A

4

114
Q

Head of bed position to prevent a pressure ulcer

A

Lowest possible level

115
Q

Hemostasis and inflammatory

A 
Reaction phase
Begins in mins and lasts about 3-6 days
Blood vessels constrict providing a clot
Vasodilation brings nutrients and WBCs
Blood flow reestablishedafter epithelial cells begin to grow

Phagocytosis
Slight fever less than 101. Normal and product of inflammation. Not infection

116
Q

Day 3 to 4 and lasts 21 days
Macrophages clear area of debris
Begins with appearance of new blood vessels
Fills wound with connective or granulation tissue and top is closed by epithelialization
Fibroblasts synthesize collagen which closes
Scar is pink and raised

A

Proliferation/regeneration

117
Q

Starts around three week mark and can go on for long periods
Collagen scar gains strength
Scar remodels resuming normal appearance
Scar becomes smaller, flatter and whiter
Takes months/years to complete

A

Maturation/remodeling

118
Q

Clear water plasma

A

Serous

119
Q

Sanguinuous

A

Fresh bleeding

120
Q

Pale, more watery, combination of plasma and red cells, blood streaked

A

Serosanginuous

121
Q

Thick, yellow, green, brown indicating presence of dead or living organisms and white blood cells

A

Purulent

122
Q

Complications of wound healing

A 
Infection 
Hemorrhage 
Dehiscence 
Evisceration
Fistulas
123
Q

Reduces skins resistance to pressure and shearing
Originates from
Wound drainage, perspiration, incontinence, vomitus, condensation from equipment

A

Moisture

124
Q 
Causes atrophy and lose subcu tissue
Less tissue present to pad bones
Poor nutrition Often overlooked because of obesity
Fluid/electrolyte imbalance
Anemia: reduced amount 02
A

Poor nutritional status

Nursing (10 decks)

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