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NSG 102 > Integumentary Alterations > Flashcards

Integumentary Alterations Flashcards

1
Q

What would you use between skin folds & why?

A

Interdry; it will get rid of the moisture

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2
Q

Intertriginous dermatitis

A

inflammation of skin where 2 surfaces rub together

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3
Q

what 4 main things contribute to pressure injuries?

A

pressure, shear, friction, moisture, & nutrition

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4
Q

Tissue ischemia

A

decreased blood flow to tissues

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5
Q

How does moisture put you at risk of pressure injury?

A

it softens the skin, reducing resistance to pressure or shearing

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6
Q

Shearing

A

Force exerted against skin

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7
Q

Friction injury

A

surface damaged caused by skin rubbing against another surface (elbows & heels rubbing against sheets)

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8
Q

how does protein deficiency increase risk of breakdown?

A
  • It causes edema, which contributes to less oxygen & nutrients
  • need protein to heal
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9
Q

what lab value tells you a patient may have malnutrition?

A

Albumin (3.5-5)

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10
Q

Stage 1 pressure injury

A

Skin is intact, but has an non-blanchable red area

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11
Q

Hyperemia

A

Increased blood flow to the area

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12
Q

Stage 2 pressure injury

A
  • Dermis is exposed, partial thickness skin loss
  • may also appear as an intact or ruptured blister
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13
Q

Stage 3 pressure injury

A
  • Full thickness lost, adipose tissue visible
  • granulation tissue, slough, eschar, epibole, undermining & tunneling are present
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14
Q

Granulation tissue

A

Red, shiny, moist tissue part in base of wound that helps the healing process

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15
Q

Slough

A

Stringy white, yellow, brown, or green material attached to tissue that is part of an inflammatory process
(looks like ligaments)

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16
Q

Stable Eschar

A

Dry gangrene from lack of blood flow that causes skin to be black/green (necrotic tissue)

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17
Q

Why is it so important to move a patient q2h when they have a wound?

A

Wounds need blood supply!!!

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18
Q

How do you treat eschar?

A

Gently trim the edges, keep dry & redistribute pressure
(DO NOT remove the black, it is a protectant covering)

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19
Q

Epibole

A

Closed or rolled wound edges; usually light in color, raised, round, & hard

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20
Q

When will epibole not heal?

A

When it is dry & looks like a callus

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21
Q

Undermining

A

Pocket underneath the wound’s edge due to tissue erosion

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22
Q

Tunneling

A

A tunnel through the muscle or subc tissue (can be more than 1)

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23
Q

Stage 4 pressure injury

A

Full thickness of skin is lost; Fascia, muscle, ligament, cartilage & bone exposed (also has the same characteristics of stage 3)

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24
Q

Why does having a stage 4 pressure injury put you at risk for osteomyelitis?

A

Because the infection may spread to the bone

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25
Q

Deep tissue pressure injury

A
  • Looks like a big bruise (don’t mistake with normal bruises!)
  • Persistent, non blanchable, deep red/maroon/purple discoloration
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26
Q

What does it mean when the skin is non blanchable?

A

The capillaries are damaged :(

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27
Q

Unstageable pressure injury

A

Full thickness & tissue lost; Completely covered by slough or eschar

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28
Q

How does an altered microclimate contribute to mechanical device pressure injuries?

A

Heat & humidity develops between the device and the skin which makes it more prone to breakdown

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29
Q

What signs of healing are normal?

A

Slight redness & edema

30
Q

What is the inflammatory response of partial thickness wound repair?

A
  • brief, lasts about 24 hours
  • erythema & edema present
  • WBC come together at the incision site to continue the healing process, then the epidermis gets thicker (will look pink)
  • may form scab if the exudate dries (cells, proteins)
31
Q

What is the homeostasis phase of full thickness wound repair?

A

clot forms to stop bleeding and start healing

32
Q

You have a patient who just had an appendectomy. You check their labs, and their WBC count is 13,000. Why is infection not a concern at this moment?

A

WBC count will be high after a surgery, because it means the wound is trying to heal.

33
Q

In order for tissue to be strong for healing, you need collagen. What would you increase in diet in order to bring in the collagen?

A

PROTEIN!!!!!!!!!!

34
Q

Nurses should never change the initial surgical dressing, but it is crucial to…

A

Reinforce it by applying more pads, gauze, & taping them on as tight as possible to put pressure and keep the clot intact.

35
Q

Internal Hemorrhage s/s

A

can cause hypovolemic shock
swelling of affected area, decreased BP, increased HR, might feel firm or have a swelling/mass depending on severity

36
Q

S/S of an infected wound

A
  • green, yellow, or brown foul-smelling drainage
  • elevated WBC
  • fever, malaise
  • painful to the touch
  • swelling & redness beyond wound edges
37
Q

what does a wound need in order to heal?

A

blood supply, oxygen, WBC

38
Q

What would you do if you suspect an infection & are waiting for a drainage culture?

A

Administer broad spectrum antibiotics until results are back, get temp q4h

39
Q

What are findings for a traumatic wound infection?

A
  • very high WBC count
  • foul odor, purulent drainage
40
Q

Dehiscence

A
  • edges are not together, held by retention sutures
  • partial or total separation of layers of skin in a wound
  • most often in abdominal surgical wounds after sudden strain (coughing, vomiting, sitting up)
41
Q

Mike just had surgery on his abdomen and the physician used retention sutures. He has has had a cough for a couple of days. What is an intervention to decrease his risk of dehiscence?

A

cough pillow, put hands on incision, abdominal binder, incentive spirometer

42
Q

What type of drainage from a wound shows a huge risk of dehiscence?

A

Serosanguineous drainage
(pink = not good!!!)

43
Q

What are some foods to ensure proper nutrition?

A

foods high in protein: eggs, chicken, fish, beef, nuts, whole grains, beans, chickpeas, ensure shakes

44
Q

How to prevent pressure injuries

A
  • turn & reposition every q1-2h
  • use lift sheets and devices to prevent rubbing
  • raise HOB no more than 30 degrees or at lowest tolerated level to prevent sliding & shearing
  • use overlay pads
45
Q

What do you do 30 mins prior to a dressing change?

A

Administer analgesics

46
Q

Serous drainage

A

yellow clear, watery plasma

47
Q

Sanguineous drainage

A

fresh bleeding (could be hemorrhage)

48
Q

Purulent drainage

A
  • thick yellow, green, or brown
  • indicates dead or living organisms & WBC
  • WBC will prob be around 20,000
49
Q

Penrose drain

A

goes in between layer of gauze, very soft & pliable tubing

50
Q

Jackson Pratt

A

Has a squeezable bulb that hangs outside the body. Squeezing it creates pressure which pulls out fluid.

51
Q

What if a drain stops suddenly? What is this a sign of & what should you do?

A

Could be blocked from a clot; look at I&O

52
Q

Hemovac

A

Round cylinder that has tubing going into the wound. The spring in it expands when emptying.

53
Q

How would you assess a sutured wound?

A
  • inspect staples and sutures for irritation
  • make sure edges are approximated
  • is there any drainage?
  • look for continued swelling (could mean the sutures are too tight)
54
Q

Sutures

A

Thread or wires that sew body tissue together

55
Q

Why do you get 2 different wound cultures?

A

some bacteria grows without oxygen (anaerobic) and some grow with (aerobic)

56
Q

How do you promote wound healing?

A

debridement - only on dead tissue; make sure they are eating enough protein

57
Q

Pressure dressing

A

exerts localized downward pressure over an actual or potential bleeding site

58
Q

Dry dressing

A

promotes healing by allowing wound to heal by primary intention and absorb minimal oozing

59
Q

Moist dressing

A

lightly packed into wound, fosters normal healing, acts like a sponge absorbing excessive drainage while maintaining a moist environment. (best for wound healing by secondary intention)

60
Q

Wet to Dry

A
  • keeps wound moist so cells grow
  • damp gauze placed on a wound and removed after the dressing dries
61
Q

How do you cleanse a wound?

A
  • Go from least contaminated to most, then side to side
  • Use a different 4x4 for each stroke
  • Clean incision first, then the drain (circle out)
  • Always use sterile glove when packing
62
Q

Wound irrigation

A

Fill syringe with water and apply GENTLE pressure

63
Q

What are signs of an infection when you have a rash?

A

Fever, cough, enlarged lymph nodes

63
Q

Contact dermatitis

A
  • itchy rash caused by exposure to allergen, chemical, or mechanical irritation
63
Q

Treatment for contact dermatitis

A
  • Avoid scratching
  • Wash with mild soap
  • Apply cool, damp compress
  • Oatmeal bath
  • Meds if severe
64
Q

Hydrocortisone (topical)

A

anti-inflammatory med
apply to intact skin only - do not apply to infected or open wounds

65
Q

Prednisone (systemic & oral)

A
  • patient must stay on it
  • makes skin paper thin
  • increases risk of infection
66
Q

Diphenhydramine (Benadryl) - Topical or systemic oral

A
  • relives redness, edema, pruritis
  • may make patient drowsy
  • can cause urinary retention
67
Q

Yeast infection

A

Caused by overgrowth of fungus, usually in genitals, mouth, skin
potential side effect of antibiotics

68
Q

What side effects happen from taking too many antibiotics?

A

Thrush & vaginal yeast infection from normal bacteria being killed

69
Q

Melanoma

A

very severe skin cancer - travels all throughout body
not associated with sun exposure

NSG 102 (11 decks)

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