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Nursing 120 > Exam 2 - Wound and Integument > Flashcards

Exam 2 - Wound and Integument Flashcards

1
Q

what are the types of bacterial infection?

A 
folliculities
cellulitis
furnucle and carbuncles
erysipelas
impetigo
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2
Q

what are the types of viral infections?

A 
HSV 1
HSV 2
HERPES ZOSTER
VARICELLA
WARTS (HPV)
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3
Q

what nerves does shingles usually effect?

A

trigeminal and dorsal root ganglia

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4
Q

what are the types of fungal infections?

A

tinea

candidias

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5
Q

what are the types of parasitic infections?

A

scabies
bed bugs
pediculosis

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6
Q

what are the types of inflammation?

A

eczema

dermatitis

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7
Q

what are the 3 types of skin cancer?

A

basal cell
squamous cell
melanoma

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8
Q

what are the manifestations of a furnuncle?

A

boils
red
tender
many or just one

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9
Q

what is the manifestations of folliculitis?

A

single or groups
papules
pustules
little to no discomfort

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10
Q

what are the manifestations of cellulitis?

A 
redness
warmth
edema
tenderness
pain
fever
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11
Q

what are the clinical manifestations of impetigo?

A

red macules
thin walled vesicles
honey yellow crusts

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12
Q

how is impetigo caused?

A

group A beta hemolytic streptococcus

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13
Q

what are the clinical manifestations of HSV 1

A

Cold sore

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14
Q

what are the clinical manifestations of HSV 2

A

warts on genitals with pain and weeping

vesicles

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15
Q

what are the clinical manifestations of herpes zoster?

A 
intense pain
vesicles following nerve route
malaise
GI disturbances
never crosses mid line!!!
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16
Q

what might be a manifestation of tinea?

A 
circle (ring worm)
scaling
peeling
patches
itching
pain
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17
Q

what are some manifestations of candidias?

A

itching
discharge (white)
burning

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18
Q

what are the manifestations of pediculosis?

A

itching
brown and black mites
whitish nits

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19
Q

what are the manifestations of scabies?

A

itching worse at night

linear lesions

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20
Q

what are some manifestations of bed bugs?

A

itching

mosquito bite like sore

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21
Q

what are the types of inflammation skin conditions?

A

seborrhea
psoriasis
pruritus
contact dermatitis

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22
Q

what is seborrhea dermatitis

A

dandruff

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23
Q

what is seborrheic keratosis?

A

skin keeps growing on skin in a darker pigment than usual. usually in more of geriatrics

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24
Q

what is psoriasis

A

excessive turnover of epidermal cells

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25
Q

what is pruritus

A

severe itching of the skin

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26
Q

what is contact dermatitis

A

skin rash that comes with contact with an irritant

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27
Q

what are the manifestations of psoriasis

A 
plaques with distinct borders
dryness
red
white
scaly
come and go
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28
Q

what are the manifestations of seborrhea

A

itchy
dry
flaky

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29
Q

what are the manifestations of pruritus

A

itching
dry
red

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30
Q

contact dermatitis manifestations

A 
itching
burning
erythema
edema
papules
vesicles
oozing
weeping
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31
Q

what is the distribution of dermaphyotis or tinea infections?

A

anywhere

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32
Q

what is the distribution of candidias?

A

skin fold areas or mucous membranes

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33
Q

what is the distribution of folliculitis and furuncles?

A

hair bearing skin

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34
Q

what is the distribution of impetigo?

A

face

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35
Q

what is the distribution of cellulitis?

A

usually lower legs, and around wounds

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36
Q

what is the distribution of inflammatory skin disorders?

A

really anywhere

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37
Q

what is the distribution of viral skin conditions?

A

face, genitals, along nerve endings, posterior and anterior trunk.

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38
Q

what is the treatment for bacterial infections

A

antibiotics, washing, compress

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39
Q

what is the treatment for viral infections (hsv 1 and 2)

A

topical/oral antiviral, vaccines, sitz bath, pain meds, cold compress

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40
Q

what is the treatment for shingles?

A

anaglesics, corticoid steroids, oral antiviral

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41
Q

what is the treatment for warts?

A

topical salicylic acid or cryotherapy

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42
Q

what is the treatment for fungal infections

A

topical antifungals

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43
Q

what is the treatment for parasitic infections (8)

A 
wash clothes
dye hair
combing
pyrethin OTC
permethrin comp OTC
lindane
malathion
benzyle benzoate
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44
Q

what is the treatment for inflammatory skin conditions (5)

A 
avoid irritant
avoid heat
antihistamines
steroids
no cosmetics
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45
Q

what does not cure inflammatory skin conditions?

A

corticosteroids

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46
Q

what is malathion used for?

A

parasitic infectionsq

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47
Q

what is benzyl benzoate used for?

A

parasitic infections

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48
Q

what is pyrethrin used for?

A

parasitic infections

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49
Q

what exactly treats seborrhea?

A

sulfur or hydrocortisone treatments

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50
Q 
corticosteroids
nonsteroidals 
coal or wood tar products
intralesionsal therapy
anthralin
medicated shampoos
retinoids

all topically treat what?

A

psoriasis

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51
Q

what is PUVA

A

combo of psoralen and UV A rays

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52
Q

what does PUVA treat

A

psoriasis with photochemotherapy

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53
Q

methotrexate
cyclosporin
oral retoinds
gold salts

all treat what systemically?

A

psoriasis

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54
Q

what is cellulitis?

A

inflammation of skin and subcutaneous tissue

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55
Q

what are some nursing implications for treating cellulitis?

A

raise limbs
clean wounds
bed rest

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56
Q

where is MRSA found?

A

nose, perineum and skin

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57
Q

how to prevent spread of MRSA

A

use sterile technique
hand hygiene
use PPE
educate

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58
Q

malignant

A

cancerous

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59
Q

benign

A

not cancerous

60
Q

what are the 3 skin cancers?

A

basal cell
squamous cell
melanoma

61
Q

what are skin cancer risk factors?

A

light skin
uv rays
arsenic
some gamma and x rays

62
Q

what is the incidence of skin cancer

A

1 million per year

90% being basal cell or squamous

63
Q

what is the treatment for basal cell and squamous cell skin cancer?

A

excision, surgery, tissue destruction by heat, radiation, freezing

64
Q

what is the treatment for melanoma?

A

surgery to remove lymphnodes and deep excisions, vaccines sometimes

65
Q

what is the prognosis for basal and squamous cell?

A

virtually curable

66
Q

what is the prognosis for melanoma?

A

less than 5 years when metastasized

67
Q

pruitus

68
Q

uticaria

A

wheal; hives; welt
skin rash
may be allergic reaction

69
Q

what are the 3 phases of wound healing?

A

inflammative
proliferative
maturation

70
Q

describe the inflammation process of wound healing

A

first 3-5 days of injury
clot formation
plasma and wbc migrate into wound

71
Q

describe the proliferative process of wound healing

A 
4th day to 4 wks
fibrin creates scaffold
fibroblasts create collagen
capillaries become a new blood vessel
scar tissue
72
Q

describe the maturation process of wound healing

A

3 wks to 1 year
collagen reorganizes for more strength
scar thins and pales
scar becomes firm and nonelastic

73
Q

partial thickness

A

loss involving epidermis and sometimes dermis

74
Q

full thickness

A

destruction of epidermis, dermis and subcutaneous

75
Q

friction

A

rubbing against surface (just pressure)

76
Q

shear

A

sliding (pressure and gravity)

77
Q

what do you do in the event of venous insufficiency

A

blood pools, no ted hose, raise legs!

78
Q

who experiences arterial insufficiency?

A

diabetic and smokers

79
Q

primary wound

A

surgical straight edges

80
Q

secondary wound

A

not good edges, has to build new tissue

81
Q

tertiary wound

A

open, muscle bone layer, surgically close

82
Q

dehiscence

A

wound edges break apart

83
Q

evisceration

A

organs pertrude

84
Q

adhesions

A

scar tissue

85
Q

stenosis

A

narrowing around surgical wounds

86
Q

keloids

A

excessive scar

87
Q

excessive contractures

A

healing becomes too tight

88
Q

epibole

A

rolled edge and curled under

89
Q

peri wound

A

surrounding tissue

90
Q

indurated

A

firm or hard

91
Q

denunded

A

loss of epidermis caused by exposure to urine feces, body fluid, wound exudate, friction

92
Q

excoriated

93
Q

erosion

A

loss of epidermis

94
Q

tunneling

A

pathway that extends any direction from wound through subcutaneous tissue

95
Q

undermining

A

tissue destruction underlying intact skin

96
Q

what causes underminding

97
Q

slough tissue

A

yellow, green, gray, wet

98
Q

eschar

A

dark thick hard (scab)

99
Q

granulation tissue

A

new tissue that replaces dead, beefy red

100
Q

what is a scant wound

A

moist tissue that has no measurable drainage

101
Q

what does the braden scale consist of?

A 
moisture
sensory perception
activity
mobility
friction or shear
nutrition
102
Q

how does the braden scale work?

A

higher the number, the less risk they are

103
Q

deep tissue injury

A

pressure related injury to subcutaneous tissues underneath intact skin

104
Q

why is deep tissue injury important?

A

because it can turn into a stage 3 or 4 pressure ulcer

105
Q

what are the types of debridement

A

autolytic
mechanical
sharp
chemical

106
Q

what is autolytic debridement

A

natures way!

107
Q

what is mechanical debridement

A

scrubbing (wet to dry dressings)

108
Q

what is chemical debridement

109
Q

what is sharp debridement

A

scrape out

110
Q

how does physical therapy help with wounds

A

whirlpool treatments loosen debris

111
Q

how does drug therapy help wounds

A

control bacterial growth

112
Q

how does nutrition help wounds

A

proteins, vitamins and water help rebuild

113
Q

how does electrical simulation help wounds

A

increase granulation and blood vessel growth

114
Q

how does hyperbaric o2 treatment help wounds

A

increase abc and oxygen helps heal

115
Q

how does a wound vac help wounds

A

it drys out wound constantly

116
Q

what is the intervention of surgical debridemtn?

A

removing necrotic tissue and grafting

117
Q

what are indicators of infection for a wound?

A 
increase in wbc
increase in wound size and depth
positive blood culture
purulent or malodorous drainage
fever
118
Q

what should the nurse watch for to prevent infection

A

increase in pain
tenderness
redness
edema

119
Q

when should a wound management plan be reevaluated?

120
Q

what are the 4 categories of clean?

121
Q

what is stage 1 of clean

A

not infected operated wound, done sterile

122
Q

what is stage 2 of clean

A

clean but contaminated - infected part was operated on

123
Q

what is stage 3 of clean

A

contaminated - open fresh and unintentional

124
Q

what is stage 4 of clean

A

dirty infected - old traumatic or surgical would that is infected

125
Q

what is a macule

126
Q

what is a vesicle or bulla (bigger)

A

small fluid filled

bulla is more than 1 cm

127
Q

what is a pustule

A

solid elevated lesion that is less than 1 cm

128
Q

cyst

A

semi solid that can sometimes move and is surgically removed

129
Q

papule

A

sole elevated (mole)

130
Q

provides a moist surface that interacts with exudate in order to form a gelatinous mass and helps debridement. it also eliminates dead space

A

alginate dressing

131
Q

alters the wound bed and decreases risk of infection

A

antimicrobials

132
Q

assists with stopping bleeding and helps recruit cells into the wound and stimulate proliferation

133
Q

combine dressing physically for multi function

A

composities

134
Q

thin and non adherent that is placed on an open wound bed to protect tissue from direct contact

A

contact layer

135
Q

provide moist healing, doesn’t adhere to the skin, helps granulize and epithelialize wounds

136
Q

absorb exudate, produce a moist environment that helps healing, protect wound from contamination, foreign debris and prevents shearing. can stay in place for days

A

hydrocolloid

137
Q

liquefy necrotic tissue or slough. rehydrate the wound bed and fill dead space.

138
Q

minimize adherent to wound and manage exudate

A

specialty absorptive

139
Q

moist healing under the dressing and helps soften the necrotic tissue. helps with deep wounds and speeds up debridement

A

wound fillers

140
Q

provide protection against contamination, and friction. maintains a clean moist surface that facilitates cellular migration and allows for assessment

A

transparent

141
Q

wounds for superficial wounds

A

transparent

hydrocolloid

142
Q

wounds for eschar

A

hydrogel

enzymatic debridement

143
Q

exudative wound dressings

A

alginate
hydrofiber
foam

144
Q

granulating or epithelializing wounds

A

hydrocolloid

foams

145
Q

fibrinous wound beds or slough

Nursing 120 (21 decks)

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