Exam 3 - integumentary system and wounds Flashcards
1
Q
pallor
A
- loss of color, in black skin tones can change to a grey color
- look particularly in the mucous membranes
- indication: anemia, shock, lack of blood flow
2
Q
cyanosis
A
- bluish discoloration, in brown skin tones can turn yellow-brown or grey
- nail beds, lips, mucosa
- indication: hypoxia, impaired venous return
3
Q
jaundice
A
- yellow discoloration
- sclera, skin, mucous membranes
- indication: liver dysfunction (RBC destruction)
4
Q
erythema
A
- redness, difficult to see in darker skin tones, palpate skin as well to look for warmth and texture changes
- face, skin, pressure prone areas
- indication: inflammation, vasodilation, sun exposure, elevated body temperature
5
Q
shear
A
- sliding movement of skin and subcutaneous tissue when muscle and bone are not moving
6
Q
friction
A
- two surfaces moving across one another
7
Q
moisture
A
- duration and amount of moisture determine risk
8
Q
pressure injuries
A
- impaired skin integrity related to unrelieved, prolonged pressure
9
Q
factors involved in pressure injury development
A
- pressure intensity
- pressure duration
- tissue tolerance
10
Q
blanchable
A
- turns lighter when pressed and then erythema returns
- there is hope with this
- may overcome ischemia
11
Q
non-blanchable
A
- does not turn lighter in color when pressed; remains erythematous
- deep tissue damage
12
Q
stage 1 pressure injury
A
- intact skin with a localized area of nonblanchable erythema
- may appear differently in darkly pigmented skin
13
Q
stage 2 pressure injury
A
- partial-thickness skin loss with exposed dermis
14
Q
stage 3 pressure injury
A
- full-thickness loss of skin, in which adipose tissue is visible in the ulcer and granulation tissue and epibole are often present
15
Q
stage 4 pressure injury
A
- full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage and bone in the ulcer
16
Q
deep tissue injury
A
- persistent non-blanch able deep red, maroon, or purple discoloration
- cannot tell what layers are involved
17
Q
unstageable pressure injury
A
- obscured by infection or dying skin (slough/eschar), cannot determine involvement
18
Q
incontinence related skin damage
A
- prolonged exposure to urine or stool
19
Q
intertriginous skin damage
A
- inflammatory dermatitis related to moist skin on rubbing against each other
20
Q
periwound/peristomal skin damage
A
- associated with wound or stomas and enzyme breakdown associated with the exudate
21
Q
wound
A
- disruption of the integrity and function of the tissues
- pressure injuries can be wounds
22
Q
acute wounds
A
- proceeds through normal/timely repair process
- results in return to normal/sustained function and anatomical integrity
- example: trauma/surgical incision
23
Q
chronic wounds
A
- wound that fails to proceed through normal healing process
- does not return to normal function/anatomical integrity
- example: pressure ulcer, vascular insufficiency wound
24
Q
labs associated with skin and wound healing
A
serum albumin and pre-albumin
25
Q
nutrition involved with skin and wound healing
A
- deficiencies result in delayed healing
- protein, vitamin A & C, zinc, copper are critical for healing
- adequate caloric intake necessary
26
Q
tissue perfusion
A
- ability to perfuse tissues with oxygenated blood crucial to wound healing
- diabetes/peripheral vascular disease are at risk for poor tissue perfusion
27
Q
infection
A
- prolongs the inflammation and delays healing
- purulent drainage, changes in color/volume/redness around the tissue, fever or pain
- low WBC b/c of inability to fight infection
28
Q
age wound healing
A
- affects all aspects of wound healing
- delayed inflammatory responses, delayed collagen synthesis, and slower epithelization
29
Q
wound drainage
A
- result of the healing process: can be normal or abnormal
- accumulates during the inflammatory and proliferative phases of healing
30
Q
serous exudate
A
- portion of blood (serum) that is watery and clear or slightly yellow in appearance
31
Q
sanguineous exudate
A
- serum and red blood cells, thick and appears reddish
- brighter indicates active bleeding
- darker indicates older bleeding
32
Q
serosanguinous exudate
A
- contains serum and blood, watery, looks pale/pink
33
Q
purulent exudate
A
- result of infection
- thick, contains WBCs, tissue debris, and bacteria
- yellow, tan, green, brown
34
Q
wet to dry wound dressing
A
- used to mechanically debride a wound until granulation tissue starts to form
35
Q
hydrocolloid wound dressing
A
- occlusive dressing that swells in the presence of exudate
- example: duoderm
36
Q
hydrogel wound dressing
A
- mostly water, gels after contact with exudate, promotes autolytic debridement, rehydrates and fills dead space
- not for wounds that are draining a lot
- for infected, deep wounds or necrotic tissue
37
Q
alginates wound dressing
A
- nonadherent dressing that conform to wound shape and absorb exudate
38
Q
collagen wound dressing
A
- powders
- pastes
- granules
- gels
39
Q
wound vacs
A
- use of foam strips into the wound bed with occlusive dressing - creates negative pressure to occur once the tubing is connected
- helps with tissue generation, decrease swelling, and enhance healing in moist, protective environment
40
Q
hemorrhage wound problem
A
- greatest risk 24-48 hours after surgery
- clot dislodgment, slipped suture, or blood vessel damage
- can be an emergency
- apply pressure dressing, notify provider, monitor vital signs
41
Q
dehiscence
A
- partial or total rupture (separation) of a sutured wound, usually with a separation of underlying skin layers
42
Q
evisceration
A
- a dehiscence that involves that protrusion of visceral organs through wound opening
