Integumentary Flashcards

1
Q

Risk factors for impaired skin integrity

A
nutrition
age
mobility
hydration
sensory perception
moisture
vascular integrity
disease
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Reduce risk for impaired skin integrity

A
proper nutrition and hydration
hygiene
turning q2h
proper lifting
special mattress
pillows
protect bony prominence
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Stage I pressure ulcer

A

intact, nonblistered skin

nonblanchable erythema

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

Stage II pressure ulcer

A

partial thickness wound
does not extend deeper than dermis
shallow, superficial with pink wound bed

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

Stage III pressure ulcer

A

full thickness wound
extends into SQ tissue but not deeper
undermining or tunneling may be present

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

Stage IV pressure ulcer

A

Exposure of muscle, bone, connective tissue

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

Unstageable pressure ulcer

A

full thickness wound

amount of necrotic tissue makes it impossible to assess depth and underlying structures

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

Dehiscence

A

partial or complete separation of tissue layers during healing process

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

Evisceration

A

Total separation of tissue layers allowing protrusion of visceral organs

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

factors affecting wound healing

A

age
nutrition
disease process
infection

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

nursing interventions to prevent dehiscence or evisceration

A

splinting or using binder while coughing, deep breathing, movement

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

What do you do if dehiscence or evisceration occurs?

A

cover wound with gauze moistened with normal saline and notify dr

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

Diet for wound healing

A

high protein, carbs, vitamins with moderate fat intake
30-35 kcal/kg/day
1.25–1.5 g protein/kg/day

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

What size needle/syringe do you need to get enough pressure to debride wound?

A

19g

30 mL syringe

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

Primary intention

A

ends are approximated
heals quickly
minimal scarring
ex: paper cut or surgical incision

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

Primary intention healing phases

A

Initial: approximated edges, clot forms, plt release GF
Granulation: migration of fibroblast, secretion of collagen, wound is fragile; wound is pink and vascular
Maturation: remodeling of collagen and strengthening of scar

17
Q

Secondary intention

A

Heal upward from bottom and inward from sides
cannot be approximated
much larger scar d/t more granulation tissue

18
Q

Tertiary intention

A

occurs when contaminated wound is left open and closed after control of infection
results in larger and deeper scar

19
Q

3 phases of wound healing

A

Inflammatory
Proliferative
Maturation

20
Q

What happens during inflammatory phase?

A

bleeding, coagulation
release of GF and cytokines
increase of pain, redness, warmth, swelling
Macrophages and neutrophils at site

21
Q

What happens during the proliferative phase?

A
angiogenesis
fibroblasts produce GF, synthesize collagen
fills bed with granulation tissue
resurface wound with skin
bleeds easily
bumpy appearance
22
Q

What happens during the maturation phase?

A

remodeling phase

scar tissue forms and strengthens

23
Q

Documentation of a wound

A
color of wound bed and periwound
COCA of drainage
type of tissue in wound (granulation, eschar, slough, SQ)
s/sx infection
width, length, depth, undermining depth
24
Q

Film dressing

A

used as a secondary dressing for autolytic debridement
adheres to the damaged skin
barrier to fluid and bacteria
allows wound to breathe; O2 can pass through
promotes moist environment

25
Q

What dressing would you use if wound has excessive exudate?

A

transparent film or hydrocolloid

26
Q

What type of dressing would you use for a clean stage I pressure ulcer?

A

transparent film to protect from shear/friction

hydrocolloid

27
Q

What type of dressing would you use for a clean stage II pressure ulcer?

A

composite film
hydrocolloid
hyrdrogel

28
Q

What type of dressing would you use for a clean stage III pressure ulcer?

A

hydrocolloid
hydrogel covered with foam dressing
calcium alginate
gauze with normal saline

29
Q

What type of dressing would you use for a clean stage IV pressure ulcer?

A

hydrogel covered with foam dressing
calcium alginate
gauze with normal saline

30
Q

What type of dressing would you use for an unstageable pressure ulcer covered in eschar?

A

adherent film (softens eschar)
gauze with ordered solution
enzymes