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Fundamentals of Nursing Lec > Midterm_Skin Integrity and Wound Care > Flashcards

Midterm_Skin Integrity and Wound Care Flashcards

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1
Q

Any disruption in the integrity of the body tissue

A

WOUND

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2
Q

Result of TRAUMA or SURGERY.

A

Impaired skin integrity, such as wounds

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3
Q

refers to the presence of normal skin and skin layers uninterrupted by wounds.

A

INTACT SKIN

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4
Q

largest ORGAN and is the primary defense against infection.

A

Skin

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5
Q

Factors that affect skin integrity

A
  • Genetics and heredity
  • Age
  • Chronic illnesses and - their treatments
  • Medications (rashes)
  • Poor nutrition
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6
Q

Types of Wounds

A

Described according to:
- How they are acquired
- Likelihood and degree of contamination

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7
Q

Types of Wounds
- Likelihood and degree of contamination

A
  • Clean
  • Clean-contaminated
  • Contaminated
  • Dirty, infected
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8
Q

Types of Wounds

A
  1. Incision
  2. Contusion
  3. Abrasion
  4. Puncture
  5. Laceration
  6. Penetrating wound
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9
Q

Identify the Types of Wounds being described
- caused by Sharp instrument
- Open wound
- deep or shallow
- once the edges have been sealed together as a part of treatment or healing, it becomes a closed wound

A

Incision

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10
Q

Identify the Types of Wounds being described
- caused by Blow from a blunt instrument
- Closed wound, skin appears ecchymotic
(bruised) because of damaged blood vessels.

A

Contusion

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11
Q

Identify the Types of Wounds being described
- caused by Surface scrape, either unintentional or intentional
- Open wound involving the skin

A

Abrasion

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12
Q

Identify the Types of Wounds being described
- caused by Penetration of the skin and often the underlying tissues by a sharp instrument, either intentional or unintentional
- Open wound

A

Puncture

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13
Q

Identify the Types of Wounds being described
- caused by Tissues torn apart, often from accidents
- Open wound
- edges are often jagged

A

Laceration

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14
Q

Identify the Types of Wounds being described
- caused by Penetration of the skin and the underlying tissues and enters a tissue or a cavity
- Open wound

A

Penetrating
wound

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15
Q
  • Injury to skin and/or underlying tissue usually over a bony prominence
  • Preventable
A

Pressure Ulcers

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16
Q

Risk Factors of Pressure Ulcers

A
  • Friction and shearing
  • Immobility
  • Inadequate nutrition
  • Fecal and urinary incontinence
  • Maceration- Tissue softened by prolonged wetting
  • Excoriation (denuding)
  • Area of loss of superficial layers of skin
  • Decreased mental status
  • Diminished sensation
  • Excessive body heat
  • Advanced age
  • Chronic medical conditions
  • Poor lifting and transferring techniques
  • Incorrect positioning
  • Hard support surfaces
  • Incorrect application of pressure-relieving devices
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17
Q

Risk Assessment Tools

A
  • Braden Scale for Predicting Pressure Sore Risk
  • Norton’s Pressure Area Risk Assessment Form Scale
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18
Q

Stages of Pressure Ulcers
- nonblanchable erythema signaling potential ulceration.

A

Stage Ⅰ

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19
Q

Stages of Pressure Ulcers
- partial-thickness skin loss (abrasion, blister, or shallow crater) involving the epidermis and possibly the dermis.

A

Stage Ⅱ

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20
Q

Stages of Pressure Ulcers
- full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue.

A

Stage Ⅲ

21
Q

Stages of Pressure Ulcers
- full-thickness skin loss with tissue necrosis or damage to muscle, bone, or supporting structures, such as a tendon or joint capsule. Undermining and sinus tracts may also be present

A

Stage Ⅳ

22
Q

Stages of Pressure Ulcers
- full-thickness skin or tissue loss-depth unknown: Actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed.

A

Unstageable/unclassified

23
Q

Stages of Pressure Ulcers
- purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar.

A

Suspected deep tissue injury-depth unknown

24
Q

Phases of Wound Healing

A
  1. Inflammatory phase
  2. Proliferative phase
  3. Maturation phase
25
Q

Phases of Wound Healing
- Immediately after injury
- Lasts 3 to 6 days
- Hemostasis (process to prevent and stop bleeding)
- Phagocytosis (process by which a cell uses its plasma membrane to engulf a large particle, giving rise to an internal compartment called the phagosome)

A

Inflammatory phase

26
Q

its a process to prevent and stop bleeding

A

Hemostasis

27
Q

its process by which a cell uses its plasma membrane to engulf a large particle, giving rise to an internal compartment called the phagosome

A

Phagocytosis

28
Q

Phases of Wound Healing
- From post-injury day 3/4 until day 21
- Collagen synthesis
- Granulation tissue formation

A

Proliferative phase

29
Q

Phases of Wound Healing
- From day 21 until 1 or 2-years post injury
- Collagen organization
- Remodeling or contraction
- Scar stronger
- Keloid
- Hypertrophic scar with abnormal amount of collagen

A

Maturation phase

30
Q

Types of Wound Healing

A
  1. Primary intention healing
  2. Secondary intention healing
  3. Tertiary intention healing
31
Q

Types of Wound Healing
- Tissue surfaces approximated (closed)
- Minimal or no tissue loss
(e.g., clean surgical incision)
- Formulation of minimal granulation tissue & scarring
- Proliferative phase

A

Primary intention healing

32
Q

Types of Wound Healing
- Extensive tissue loss
- Edges cannot be approximated.
- Repair time is longer.
- Scarring is greater.
- Susceptibility to infection is greater

A

Secondary intention healing

33
Q

Types of Wound Healing
- Also known as delayed primary intention
- Initially left open 3-5 days
- Edema, infection to resolve, or exudate to drain
- Closed with sutures, staples, or adhesive skin closures

A

Tertiary intention healing

34
Q
  • Material (fluid, cells) escaped from blood vessels during inflammatory process
  • Deposited in tissue or on tissue surface
A

Exudate

35
Q

3 major Types of Wound Exudate

A
  1. Serous
  2. Purulent
  3. Sanguineous
36
Q

Types of Wound Exudate
- Mostly serum
- Derived from blood and serous membranes of the body
- Looks watery, few cells
- E . g., fluid in blister from a burn

A

Serous exudate

37
Q

Types of Wound Exudate
- Thicker
- Presence of pus
- Consists of leukocytes, liquefied dead tissue debris, dead and living bacteria
- Color varies with causative organism

A

Purulent exudate

38
Q

Types of Wound Exudate
- Large number of R B Cs
- Indicates severe damage to capillaries
- Frequently seen in open wounds

A

Sanguineous exudate

39
Q

Types of Wound Exudate
- Serosanguineous
- Purosanguineous

A

Mixed exudate

40
Q

Clear and blood-tinged drainage

A

Serosanguineous

41
Q

Pus and blood

A

Purosanguineous

42
Q

Complications of Wound Healing
- Massive bleeding
- Hematoma

A

Hemorrhage

43
Q

Localized collection of blood under skin
May appear as reddish blue bruise

A

Hematoma

44
Q

Complications of Wound Healing
- Contamination of a wound surface with microorganisms

A

Infection

45
Q

Complications of Wound Healing
- Partial or total rupturing of a sutured wound
- Protrusion of the internal viscera through an incision
- Sudden straining may precede dehiscence

A

Dehiscence with possible evisceration

46
Q

Separation or splitting open of layers of a surgical wound

A

Dehiscence

47
Q

Extrusion of viscera or intestine through a surgical wound

A

Evisceration

48
Q

Factors Affecting Wound Healing

A
  • Developmental considerations
  • Nutrition
  • Lifestyle
  • Medications
49
Q

How medications affect wound healing

A

impair wound healing and damage skin integrity include antibiotics, anticonvulsants, angiogenesis inhibitors, steroids, and nonsteroidal anti-inflammatory drugs. Conversely, drugs such as ferrous sulfate, insulin, thyroid hormones, and vitamins may facilitate wound healing.

Fundamentals of Nursing Lec (11 decks)

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