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fundamentals test four skin integrity > defined the role > Flashcards

defined the role Flashcards

1
Q

defined the role of nurse

reduced infection rate in military hospitals during Crimean

A

Florence Nightingale

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2
Q

factors that influence skin breakdown

A

age, mobility, nutrition, hydration, diminished sensation, impaired circulation, medications, moisture on skin, fever, lifestyle

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3
Q

another name for liver spots (age spots)

A

solar lentigo

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4
Q

variations of aging

A

decreased sweat/oil glands
senile lentigines
skin tags
decreased hair and nail growth
decreased skin elasticity (wrinkles, sagging, turgor)
hair grays due to reduction in melanocytes
nails thicken, yellow and peel

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5
Q

healthy person moves/changes position when experiencing pressure or discomfort

A

mobility

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6
Q

protein needed to maintain skin, repairs min defects, edema decreases elasticity

A

nutrition and hydration

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7
Q

leads to loss of feeling pressure, heat and cold

A

diminished tactile sensation

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8
Q

to low cholesterol can impair

A

wound healing

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9
Q

decreased oxygenation/decreased venous and arterial flow

A

impaired circulation

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10
Q

NSAID’s and steroids, ibuprofen (more easily to bruising),

coumadin

A

inhibit would healing

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11
Q

exposure to maceration (softening of skin), incontinence and fever( most common in bed ridden patients), bowel incontinence

A

moisture on skin causing skin breakdown

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12
Q

temperature >101
leads to sweating
sign of infection
triggers immune response which uses calories and nutrients

A

fever

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13
Q

multiple daily baths lead to

A

poor skin turgor

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14
Q

body’s largest organ

primary defense against infection

A

skin

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15
Q

disruption in the integrity of body tissue

A

wound

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16
Q 
intentional (surgery)/unintentional (getting stabbed)
open/closed
partial/full thickness (how deep)
acute/chronic
pressure ulcer stages : 1-4
R-Y-B: red, yellow, black 
types of wounds
A

classification of wounds

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17
Q

slowing healing

had more than two months

A

chronic wound

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18
Q 
primary intention
secondary intention
tertiary intention (delayed primary)
A

types of wound healing

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19
Q

wound with little tissue loss
edges are approximated
heals rapidly with minimal scarring
healing occurs in 4 stages

A

primary intention

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20
Q 
wound with loss of tissue
edges widely separated
healing occurs by granulation
large scar
increased potential for infection
healing time longer 
heals form the bottom up
A

secondary intention

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21
Q

also called delayed primary healing
widely separated wound is later brought together with some type of closure material (may need skin graft)
usually fairly deep
lots of draining

A

tertiary intention

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22
Q

vascular response/inflammation
proliferation/regeneration
maturation/remolding

A

physiology of wound healing

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23
Q

hemostasis and inflammation being in minutes and last 3- 6 days
blood vessels constricts, blood clots
vasodilation bring nutrients and WBC’s
blood flow reestablished after epithelial cells began to grow
phagocytosis
slight fever

A

vascular response/inflammation

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24
Q

day 3 or 4 to day 21
macrophages clear are of debris
begins with appearance of new blood vessels
fills wound with connective or granulation tissue
top is closed by epithelialization
fibroblasts synthesize collagen closes wound
scar is pink and raised

A

proliferation/regeneration

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25
Q

layer of pink, pebbly, tissue

layer gets thicker, becomes beefy read

A

granulation tissue

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26
Q

grows from edges and cover over the granulation (new skin or scar)
is never as strong as original skin

A

epithelialization (epithelia tissue)

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27
Q

starts 3rd week/day 21 and can go long periods
collagen scar gains strength
scar remodels, resumes normal appearance
take months/years to complete

A

maturation/remodeling

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28
Q

serous
sanguinous
serosanguinous
purulent

A

drainage/exudate

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29
Q

clear, watery plasma

A

serous

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30
Q

fresh bleeding

A

sanguinous

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31
Q

pale more watery, combination of plasma

A

serosanguinous

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32
Q

forming pus
thick yellow, green, brown
indicates presence of dead or living organism and white blood cells

A

purulent

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33
Q 
infection
hemorrhage
dehiscence
evisceration
fistulas
A

complication of healing

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34
Q

wound opens partially, can happen when sutures/staples are removed

A

dehiscence

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35
Q

medical emergency
wound keeps going through
mostly seen in stomach and gut will protrude out
cover with sterile 4x4 gauge or sterile towel, do not pack
call doctor

A

evisceration

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36
Q

prevention of tissue dehydration and cell death
accelerated angiogenesis
increased breakdown of tissue and fibrin
reduced pain

A

keeping moist wound beds

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37
Q

normal saline only solution for wound care

recommended by Agency of Health care

A

prevent injury to healing tissue

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38
Q 
normal saline: best isotonic
hydrogen-peroxide: delays healing
Dakin's solution: delays healing (bleach solution)
Acetic acid slows healing (vinegar)
commercial products
betadine (povidine-iodine)
A

topical agents used in wounds

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39
Q

a major no-no to use in wounds

removes moisture from wound bed

A

betadine

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40
Q

keep wound bed moist and surrounding skin dry

A

protect periwound skin

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41
Q 
electrical stimulation and ultrasound
hyperbaric oxygen
negative pressure wound treatment
heat and cold
debridement
dressings
A

wound care treatment

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42
Q

intermittent current to wound bed
stimulates granulation
inhibits bacterial growth
limited clinical use

A

electrical stimulation

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43
Q

oxygen delivered at increased atmospheric pressure
improves blood capacity to carry O2 to increase tissure oxygenation
ask patient is they are Claust phobic

A

hyperbaric oxygen

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44
Q

sponge inside wound covered with dressing and connected to negative pressure machine
low suction
works well on wound with excessive drainage
can’t use on dry wounds, needs to have exaudates

A

negative pressure wound treatment

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45
Q

acute wounds in inflammatory phase

A

cold therapy

46
Q

chronic wounds
better for backs
contradicted in arterial insufficiency

A

heat therapy

47
Q

if deficiency in feet or legs

could get vasoconstriction

A

alternate heat and cold

48
Q

very young, older adults with thin skin
open wounds/broken skin where subcutaneous tissue is sensitive
areas of edema or scar information where there is reduced sensation
peripheral vascular disease such as diabetes where body extremities are less sensitive
confusion where there is reduced perception of sensory
spinal cord injury

A

conditions that increase risk for injury form heat and cold application

49
Q 
improve blood flow to injured body part
promote delivery of nutrients
removal of wastes
improve delivery of leukocytes to wound site
promote muscle relaxation
reduce pain from spasm or stiffness
increase blood flow
provide local warmth
promote movement of waste products
A

heat therapy

50
Q 
reduce blood flow to injured site
preventing edema
reduce inflammation
reduce localized pain
reduce oxygen needs of tissues
promote blood coagulation at injury site
A

cold therapy

51
Q

support cut muscles
snug but not restrictive
several types: straight abdominal and Montgomery straps
an example could be an arm sling

A

binders

52
Q

for abdominal wounds that have to change daily or often

A

Montgomery straps

53
Q

mechanical, enzymatic, autolytic, sharp

A

debridement (clean up a wound)

54
Q

scrub, rub, wet/dry damp dressing, irrigation, whirlpool, maggots

A

mechanical

55
Q

topical medication, collagenase ezymes

A

enzymatic

56
Q

body does it to itself

dressings that contain moisture make use of the body’s enzymes to break down necrotic tissue

A

autolytic

57
Q

use of scalpel/scissors

requires special training

A

sharp

58
Q

localized injury to the skin and/or underlying tissue usually over bone prominence
result of pressure
result of pressure in combination with shear and/or friction
can form in any person in constant maintained postions(standing, lying, sitting)
pressure from shoe/clothing
constant unchanging pressure
primary cause is pressure

A

pressure ulcer

59
Q

individuals need not be lying down, or bedridden

A

to develop tissue ulcerations related to pressure

60
Q

90% of hospital stays involving treatment of pressure ulcers were for conditions other than ones for admission

A

septicemia, pneumonia UTI, CHF, aspiration pneumonia

61
Q

hospitals stays principally for pressure ulcers

A

paralysis, SCI, stroke, MS

62
Q

coccyx-sacral area, heels, elbows most susceptible

heals are worse area

A

pressure wounds

63
Q

when subcutaneous tissue is compressed between a bony prominence and an external surface for a prolonged peiod

A

pressure ulcer

64
Q

pressure ulcer sites

A

see page 1072

65
Q 
prolonged pressure (lying in bed long periods, unrelieved pressure)
shearing force
friction
moisture
nutrition
infection
impaired peripheral circulation
obesity 
age
A

contributing factors for pressure ulcers

66
Q

when patients slide in bed

A

shearing force

67
Q

two surfaces rubbing against each other
heels and elbows most vulnerable
injury is shallow and without necrosis
limited to the epidermis

A

friction

68
Q

reduces skin’s resistance to pressure and shearing

A

moisture

69
Q

causes atrophy and decreased subcutaneous tissue
less tissue to pad bones
poor nutrition often overlooked if obese
fluid/electrolyte imbalance
anemia: reduced O2 available
cachexia: person is skin and bones, lost of all adipose

A

poor nutritional status

70
Q

results in diaphoresis and increased skin moisture

A

fever

71
Q

without decreased circulation, tissue become hypoxic

decreased sensation leads to loss of feeling of pressure and limited moment

A

peripheral circulation

72
Q

adipose tissue had poor vascularity
skin breaks down easier
prone to ischemic changes

A

obesity

73
Q

lean body mass loss
epidermis thins
changes in collagen (skin looses elasticity)
decreased oil production (skin dryness)
pain perception decreased
peripheral circulation and oxygenation compromised
cells regenerate slower, cause delayed healing

A

age

74
Q

classified in stages based on depth of tissue destroyed

four stages

A

pressure ulcer wounds

75
Q

nonblanchable erythema of the intact skin when you push on it
only the epidermis is involved
reversible if pressure romoved

A

stage 1 pressure ulcer

76
Q

partial thickness skin loss involving epidermis and/or dermis
skin tears
superficial
presents as an abrasion, blister or shallow crater
may be swollen and painful
more painful that stage IV
wounds are usually open

A

stage 2 pressure ulcer

77
Q

full thickness skin loss with damage or necrosis of subcutaneous tissue that may extend to but not through, the underlying fascia
presents as deep crater with/without undermining
may have foul-smelling drainage
wound not into muscle

A

stage 3 pressure ulcer

78
Q

full thickness skin loss with extensive destruction
tissue necrosis or damage to muscle, bone or supporting structures
undermining/tunneling may be present
tendon will be exposed

A

stage 4 pressure ulcer

79
Q

localized area of purple/maroon discoloration

red and puffy

A

suspected deep tissue injury

80
Q

can’t see bottom of wound bed
can’t tell what stage it is
base of ulcer is covered by slough and/or eschar

A

unstageable

81
Q

cannot be graded/staged

depth of wound and tissue type cannont be visualized

A

necrotic ulcer

82
Q

when scab apprears
is not appropriate designation
physiology impossible for full thickness wounds such as stage 3 and 4 to regenerate

A

reverse staging

83
Q
  1. relieve pressure: frequent turning, pressure relieving, keep wound clean and dry
  2. moist healing environment: saline or occlusive dressing
  3. debride with wet to dry
  4. non-adherant dressing, skin grafts
A

stage related treatments

84
Q

risk assessment
skin care and early treatment
mechanical loading and support surfaces
education

A

pressure ulcer prevention

85
Q

consider all who are bed/chair bound or whose ability to reposition themselves is impaired
use Braden, PUSH, Norton
assess regularly: admission and regular intervals
identify: individual risk factors
implement specific preventions modalities

A

risk assessment

86
Q

the higher the number the better the
22 is the maximum number to get
assesses pressure ulcers
sensory, moisture, activity, mobility, nutrition, friction, shear

A

Braden scale

87
Q

predictive instruments are used for at-risk patients for

A

increased early detection

88
Q 
physical condition
mental condition
activity
mobility
continence
A

Norton Scale

89
Q

enter through direct contact, inhalation, ingestion, insect/animal bite

A

pathogens

90
Q

primary and secondary

A

defenses against infection

91
Q 
skin and normal flora
mucous membranes
sneeze, cough, tearing reflexes
elimination and acidic environments
circulatory system
A

primary defenses

92
Q

first line of defense

A

skin

93
Q

physical barrier
inhibits growth
traps infection

A

mucous membranes

94
Q

trap and propel mucous from lung

A

cilia

95
Q

physical expulsion

A

sneeze/cough

96
Q

flushing mechanism

A

tears

97
Q

acidic urine: inhibits growth, cleanse bladder neck

A

elimination

98
Q

essential to inflammatory and immune response
blood carries components of immunity
removes waste products for tissue

A

circulatory system

99
Q

increase WBC (lymphocytes) destroy/react to cells the body decides are harmful

A

inflammatory response stage 1

100
Q

white blood cells
second line of defense
ingest and destroy microbes
normal range < 10,000

A

leukocytes

101
Q

increased blood flow to the inflamed area

produces the characteristic signs of redness and increased warmth

A

stage 2 inflammatory response

102
Q

increased capillary permeability with leakage of large quantities of plasma
infection is walled off
non-pitting edema occurs

A

stage 3 inflammatory response

103
Q

damaged tissue invaded by leukocytes that engulf bacteria and necrotic tissue
produces purulent

A

stage 4 inflammatory response

104
Q

destroyed tissue cells replaced by similar cells
promotes tissue healing or formation of scar
functional capacity of tissue may be reduced

A

stage 5 inflammatory response

105
Q

redness: blood accumulation in dilated capillaries
warmth: heat of the blood
swelling: fluid accumulation
pain: pressure or injury to local nerves

A

signs and symptoms of inflammation

106
Q

does not equal infection

is a normal response

A

inflammation

107
Q

when the body’s defenses are overwhelmed

A

infection

108
Q

surgical wounds
urinary tract
respiratory tract

A

common sites of infections

109
Q

major cause of hospital morbidity
accounts for 60% extra hospital days
pathogens enter wound at time of surgery
infection rates double for each hour patient is in surgery

A

surgical wounds

110
Q

most common nosocomial infection
medicare will not for this hospital problem
catheters major causative agents
by-pass cleansing of bladder neck by urine
poor technique
long-term use
improper/poor perineal care

A

urinary tract

111
Q

second most common site and associated with most deaths
aspiration most common mechanism
stasis of respiratory secretions cause by immobility
decreased cough

A

respiratory tract

fundamentals test four skin integrity (1 decks)

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