Exam 3 part 2 Flashcards

1
Q

what is the order of the skin from top to inside?

A

epidermis and dermis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

what does skin do?

A

protects from infection
locks in moisture
protects from uv
vitamin d production
absorbs medication

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

how does skin change with age?

A

as you get older you
decrease in collagen production
decresed circulation
dehydration
slower cell replication

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

what factors affect skin integrity

A

occupation….healt status…diabetes…circulation issues…decreased oil production….immuno comprimised

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

what is a wound?

A

any break in the skin

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

what promotes faster wound healing?

A

nutrition…hand hygeine…blood supply

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

what are some local factors that can affect healing?

A

location….desacation….masceration…repeated trauma…edema..infection…bleeding..necrosis…eschar

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

what is desecation?

A

drying up of skin

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

what is masceration?

A

overhydration

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

what are some systemic factors that affect healing?

A

circulation problems…smoking….nutrition….meds….anemic… radiation…chemo meds…prolonged antibiotics…

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

how long does it take for infection to set in a wound?

A

2-7 days

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

what are signs and symptoms of infection?

A

increased temp….increased WBC…increased drainage…increased pain

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

what is hemorrhaging wound mean?

A

can be caused by stich opening up or infection

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

what does dehissence mean?

A

wound has opened up and muscle tissues is visiable

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

what does visceration mean?

A

muscle and oragns are visible

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

what should you do when dehiscence and evisceration occur?

A

put on sterile saline and call provider?

17
Q

which one calls for immediate surgery dehiscence and evisceration?

A

evisceration

18
Q

what are you looking for in wound assessment?

A

apperance….size…depth…drain…sutures, staples, glue..drainage color/smell

19
Q

what is serous fluid?

A

clear fluid

20
Q

what is sangionus fluid?

A

bloody fluid

21
Q

what is serosanguinous fluid?

A

mix of blood and clear

22
Q

what is purulent fluid?

A

infection….green

23
Q

what does malodorous mean?

24
Q

what is a pressure injury?

A

bed sore caused by pressure….pressure leads to less ciruclation

25
what is friction?
the force of rubbing two surfaces against one another.
26
what is shearing?
pressure from and object
27
who is at risk for pressure injury/
immobile...bed rest...poor nutrition...overly hydrated....dehydrated...altered LOC...coma
28
what are the characteristics of a stage 1 pressure injury?
localized redness.....non blanch-able skin
29
what are the characteristics of a stage 2 pressure injury?
partial skin broken...blisters
30
what does non blanchable mean?
if pressed wont turn white when pressed
31
what are the characteristics of a stage 3 pressure injury?
broken skin...could have tunneling...
32
what are the characteristics of a stage 4?
bone and tendon showing....tunnnleing
33
what is the braden scale?
assesses fall risk in patients
34
what is the braden scale ranges
Risk 18 and belwo No Risk: Total Score 19-23.
35
what braden scale number calls for intervention?
18 and below