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NRSG 100: Fundamentals > Exam 2 - Chapter 32 (Skin Intergity and Wound Care) > Flashcards

Exam 2 - Chapter 32 (Skin Intergity and Wound Care) Flashcards

1
Q

Functions of the Skin - Protection

A

Acts as a barrier to water. REquires intact skin and mucous membranes to defend against pathogens

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2
Q

Functions of the Skin - Temperature Regulation

A

Draws heat from the skin as perspiration occurs and evaporates

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3
Q

Functions of the Skin - Sensation

A

Provides sense of touch, pain, pressure, and temperature through million of nerve endings

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4
Q

Functions of the Skin - Vitamin D Production

A

Activated from UV rays from sun to produce Vitamin D

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5
Q

Functions of the Skin - Immunologic

A

Triggers immunologic repsonses when broken

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6
Q

Functions of the Skin - Absorption

A

Absorbs substances, such as medications, for local and systemic effects

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7
Q

Functions of the Skin - Elimination

A

Secretes small amounts of water, electrolytes, and nitrogenous wastes in sweat

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8
Q

All functions of skin?

A 
Protection
Body Temperature
Sensation
Vitamin D Production
Immunologic
Absorption
Elimination
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9
Q

Factors Affecting the Skin

A 
Mobility
Nutritional Status
Age
Illness
Circulation
Moisture
Incontinence
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10
Q

Wound

A

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

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11
Q

What are some different ways that wounds can be classified?

A

Intentional/Unintentional
Open/Closed
Acute/Chronic
Pressure Ulcers

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12
Q

Open Wounds

A

Can be intentional or unintentional; skin is broken

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13
Q

Closed Wounds

A

Intact Skin with soft tissue damage

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14
Q

Hematoma

A

Collection of blood outside the vessel

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15
Q

Ecchymosis

A

Bruising

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16
Q

Pressure Ulcers can be classified into what categories?

A

Partial Thickness
Full Thickness
Complex

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17
Q

Pressure Ulcers - Partial Thickness

A

All or a portion of the dermis is intact

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18
Q

Pressure Ulcers - Full Thickness

A

Entire dermis and sweat glands and hair follices are severed, which can expose bone, tendon, or muscle

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19
Q

Pressure Ulcers - Complex

A

A full-thickness loss the true depth cannot be determined

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20
Q

Incision

A

Cutting or shape instrument, wound edges in close approximation and aligned

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21
Q

Contusion

A

Blunt instrument,overlying skin remains intact

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22
Q

Abrasion

A

Friction; rubbing or scraing with top layer abraded

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23
Q

Laceration

A

Tearing of skin and tissue with blunt or irregular instrument

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24
Q

Puncture

A

Blunt or shape object puncturing the skin

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25
Q

Penetrating

A

Foreign object entering the skin or mucous membrane and lodging in underlying tissue

26
Q

Avulsion

A

Tearing a structure from normal anatomic position

27
Q

Chemical

A

Toxic agents such as drugs, acids

28
Q

Thermal

A

High or lowtemperatures

29
Q

Pressure Ulcers

A

Compromised circulatioon secondary to pressure or pressure combined with friction

30
Q

Venous Ulcers

A

Injury and poor venous return

31
Q

Arterial Ulcers

A

Injuries and underlying ischemia

32
Q

Diabetic Ulcers

A

Injury and underlying diabetic neuropathy

33
Q

Four Stages of wound healing?

A

Hemostasis, Inflammation, Proliferation, and Maturation

34
Q

Hemostasis occurs..

A

immediately after the initrial injury. Involved blood vessels constrict and blood clotting begins through platet activation and clustering

35
Q

How do pressure/edema affect wound healing?

A

Disrupt blood flow of oxygen and nutrients to the wound

36
Q

Local Factors Affecting Wound Healing - Desiccation

A

Cells dry and die , moist wound bed promotes epitheliazation

37
Q

Local Factors Affecting Wound Healing - Maceration

A

Cells burst due to overhydration

38
Q

Local Factors Affecting Wound Healing - Infection

A

Decreases available energy in the body for skin repair

39
Q

Local Factors Affecting Wound Healing - Necrosis (Slough)

A

Moist, yellow, stringy tissue

40
Q

Local Factors Affecting Wound Healing - Necrosis (Eschar)

A

Dry, black, leathery tisue

41
Q

Dehisence

A

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

42
Q

Evisceration

A

Is the most serious complication of dehisence. Abdominal wound completely separates, with protrusion of visceria through the incisional area

43
Q

Stage I Pressure Ulcer

A

Non-Blachable Erythema of intact skin

44
Q

Stage II Pressure Ulcer

A

Partial-Thickness Skin Loss

45
Q

Stage III Pressure Ulcer

A

Full-thickness skin loss; not involving underlying fascia

46
Q

STage IV Pressure Ulcer

A

Full-thickness skin loss with extensive destruction

47
Q

Unstageable Pressure Ulcer

A

Base of ulcer covered by slough and or eschar in wound bed

48
Q

Fistula

A

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

49
Q

Pressure Injury

A

Defined as localized damage to the skin and underlying tissue that usually occurs over a body prominence

50
Q

Open Would Classification - R

A

Red - Protect

51
Q

Open Would Classification - Y

A

Yellow - Cleanse

52
Q

Open Would Classification - B

A

Black - Debride

53
Q

Open Would Classification - Mixed Wound

A

Contains components of RY&B wounds

54
Q

What is the main purpose of wound dressings?

A

TO prevenet disease, and promote healing

55
Q

Serious Drainage

A

Composed primarily of the clear, serious portion of the blood and from serous membranes. Clear and Watery

56
Q

Sanguineous Drainage

A

Consists of large numbers of red blood cells, and look slike blood. Bright-red sanguineous draingage is indicative of fresh bleeding

57
Q

Serosanguineous Drainage

A

Mixture of serum and red blood cells. It is light pink to blood tinged

58
Q

Purulent Drainage

A

MAde up of white blood cells, liquefied dead tissue debris and both dead and live bacteria.

59
Q

Types of Wound Dressings?

A

Telfa
Gauze Dressing
TRansparent Dressing

60
Q

Topics for Home HEalth Care Teaching

A 
Supplies
Infection Prevention
Wound Healing
Appearance of the Skin/Recent Changes
Activity/Mobility
Nutrition
Pain
61
Q

Effects of Applying Heat?

A 
Dilates peripheral blood vessels
Increases tissue metabolism
Reduces blood viscosity
REduces muscle tension
Helps relieve pain
62
Q

Effects of Applying Cold?

A

Constricts peripheral blood vessels
Reduces muscle spasms
Promotes comfort

NRSG 100: Fundamentals (27 decks)

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