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Fundamental Exam 3 > Module 7b > Flashcards

Module 7b Flashcards

1
Q

Functions of the Skin

A 
Protection
Body temperature regulation
Psychosocial
Sensation
Vitamin D production
Immunologic
Absorption
Elimination
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2
Q

Factors Affecting the Skin

A

Unbroken and healthy skin and mucous membranes
defend against harmful agents.
Resistance to injury is affected by age, amount of
underlying tissues, and illness.
Adequately nourished and hydrated body cells are
resistant to injury.
Adequate circulation is necessary to maintain cell life.

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3
Q

Developmental Considerations

A

In children younger than 2 years, the skin is thinner and
weaker than it is in adults.
An infant’s skin and mucous membranes are easily
injured and subject to infection; a child’s skin becomes
increasingly resistant to injury and infection.
The structure of the skin changes as a person ages; the
maturation of epidermal cells is prolonged, leading to
thin, easily damaged skin.
Circulation and collagen formation are impaired, leading
to decreased elasticity and increased risk for tissue
damage from pressure.

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4
Q

Causes of Skin Alterations

A

Very thin and very obese people are more susceptible to
skin injury.
o Fluid loss during illness causes dehydration.
o Skin appears loose and flabby.
Excessive perspiration during illness predisposes skin to
breakdown.
Jaundice causes yellowish, itchy skin.
Diseases of the skin, such as eczema and psoriasis, may
cause lesions that require special care.

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5
Q

Types of Wounds

A

Intentional or unintentional
Open or closed
Acute or chronic
Partial thickness, full thickness, complex

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6
Q

Principles of Wound Healing #1

A

Intact skin is the first line of defense against
microorganisms.
Careful hand hygiene is used in caring for a wound.
The body responds systematically to trauma of any of its
parts.
An adequate blood supply is essential for normal body
response to injury.
Normal healing is promoted when the wound is free of
foreign material.

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7
Q

Principles of Wound Healing #2

A

The extent of damage and the person’s state of health
affect wound healing.
Response to wound is more effective if proper nutrition is
maintained.

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8
Q

Phases of Wound Healing

A

Hemostasis
Inflammatory
Proliferation
Maturation

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9
Q

Hemostasis

A

Occurs immediately after initial injury
Involved blood vessels constrict and blood clotting
begins.
Exudate is formed, causing swelling and pain.
Increased perfusion results in heat and redness.
Platelets stimulate other cells to migrate to the injury to
participate in other phases of healing.

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10
Q

Inflammatory Phase

A

Follows hemostasis and lasts about 2 to 3 days
White blood cells, predominantly leukocytes and
macrophages, move to the wound .
Macrophages enter the wound area and remain for an
extended period.
They ingest debris and release growth factors that attract
fibroblasts to fill in the wound.
The patient has a generalized body response.

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11
Q

Proliferation Phase

A

Lasts for several weeks.
New tissue is built to fill the wound space through the
action of fibroblasts.
Capillaries grow across the wound.
A thin layer of epithelial cells forms across the wound.
Granulation tissue forms a foundation for scar tissue
development.

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12
Q

Maturation Phase

A

Final stage of healing; begins about 3 weeks after the
injury, possibly continuing for months or years.
Collagen is remodeled.
New collagen tissue is deposited.
Scar becomes a flat, thin, white line.

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13
Q

Local Factors Affecting Wound Healing

A 
Pressure
Desiccation (dehydration)
Maceration (overhydration)
Trauma
Edema
Infection
Excessive bleeding
Necrosis (death of tissue)
Presence of biofilm (thick grouping of microorganisms)
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14
Q

Systemic Factors Affecting Wound Healing

A

Age: children and healthy adults heal more rapidly
Circulation and oxygenation: adequate blood flow is
essential
Nutritional status: healing requires adequate nutrition
Wound etiology: specific condition of the wound affects
healing
Health status: corticosteroid drugs and postoperative
radiation therapy delay healing
Immunosuppression
Medication use
Adherence to treatment plan

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15
Q

Wound Complications

A

Infection
Hemorrhage
Dehiscence and evisceration
Fistula formation

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16
Q

Psychological Effects of Wounds

A 
Pain
Anxiety
Fear
Impact on activities of daily living
Change in body image
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17
Q

Factors Affecting Pressure

injury Development

A 
Aging skin
Chronic illnesses
Immobility
Malnutrition
Fecal and urinary incontinence
Altered level of consciousness
Spinal cord and brain injuries
Neuromuscular disorders
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18
Q

Mechanisms in Pressure

A

Injury Development
External pressure compressing blood vessels
Friction or shearing forces tearing or injuring blood
vessels

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19
Q

Stages of Pressure injuries

A

Stage 1: nonblanchable erythema of intact skin
Stage 2: partial-thickness skin loss with exposed dermis
Stage 3: full-thickness skin loss; not involving underlying
fascia
Stage 4: full-thickness skin and tissue loss
Unstageable: obscured full-thickness skin and tissue loss
Deep tissue pressure injury: persistent nonblanchable
deep red, maroon, or purple discoloration

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20
Q

Measurement of a Pressure injury

A

Size of wound
Depth of wound
Presence of undermining, tunneling, or sinus tract

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21
Q

Cleaning a Pressure Injury/Wound

A

Clean with each dressing change.
Use new gauze for each wipe and clean from top to
bottom and/or from the center to the outside.
Use 0.9% normal saline solution to irrigate and clean the
injury.
Once the wound is cleaned, dry the area using a gauze
sponge in the same manner
Report any drainage or necrotic tissue.

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22
Q

Assessment of Wound Drainage

A

Serous
Sanguineous
Serosanguineous
Purulent

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23
Q

Wound Assessment

A 
Inspection for sight and smell
Palpation for appearance, drainage, and pain
o Serous drainage
o Sanguineous drainage
o Serosanguineous drainage
o Purulent drainage
Sutures, drains or tubes, and manifestation of
complications
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24
Q

Purposes of Wound Dressings

A

Provide physical, psychological, and aesthetic comfort
Prevent, eliminate, or control infection
Absorb drainage
Maintain moisture balance of the wound
Protect the wound from further injury
Protect the skin surrounding the wound
Debride (remove damaged/necrotic tissue), if appropriate
Stimulate and/or optimize the healing response
Consider ease of use and cost-effectiveness

25
Q

Presence of Infection

A

Wound is swollen.
Wound is deep red in color.
Wound feels hot on palpation.
Drainage is increased and possibly purulent.
Foul odor may be noted.
Wound edges may be separated, with dehiscence
present.

26
Q

Types of Wound Dressings

A

Telfa
Gauze dressings
Transparent dressings

27
Q

Types of Bandages

A

Roller bandages
Circular turn
Spiral turn
Figure-of-eight turn

28
Q

Types of Binders

A

Slings
Abdominal binders
Chest binders
T-binders

29
Q

Type of Drainage Systems

A 
Open systems
o Penrose drain
Closed systems
o Jackson-Pratt drain
o Hemovac drain
30
Q

Pressure injury Assessment

A 
Risk assessment
Mobility
Nutritional status
Moisture and incontinence
Appearance of existing pressure injury
Pain assessment
31
Q

Topics for Home Health Care Teaching

A 
Supplies
Infection prevention
Wound healing
Appearance of the skin/recent changes
Activity/mobility
Nutrition
Pain
Elimination
32
Q

Factors Affecting the Response

to Hot and Cold Treatments

A

Method and duration of application
Degree of heat and cold applied
Patient’s age and physical condition
Amount of body surface covered by the application

33
Q

Effects of Applying Heat

A 
Dilates peripheral blood vessels
Increases tissue metabolism
Reduces blood viscosity and increases capillary
permeability
Reduces muscle tension
Helps relieve pain
34
Q

Effects of Applying Cold

A

Constricts peripheral blood vessels
Reduces muscle spasms
Promotes comfort

35
Q

Devices to Apply Heat

A 
Hot water bags
Electric heating pads
Aquathermia pads
Hot packs
Warm, moist compresses
Sitz baths
Warm soaks
36
Q

Devices to Apply Cold

A

Ice bags
Cold packs
Hypothermia blankets
Cold compresses to apply moist cold

37
Q

Some developmental

considerations:

A

> In children younger than 2 years, the skin is thinner and weaker than it
is in adults.
An infant’s skin and mucous membranes are easily injured and subject
to infection; a child’s skin becomes increasingly resistant to injury and
infection.
The structure of the skin changes as a person ages; the maturation of
epidermal cells is prolonged, leading to thin, easily damaged skin.
Older age: Circulation and collagen formation are impaired, leading to
decreased elasticity and increased risk for tissue damage from
pressure.

38
Q

Some causes of skin alterations:

A

• Very thin and very obese people are more susceptible to skin injury.
-Fluid loss during illness causes dehydration.
-Skin appears loose and flabby.
• Excessive perspiration during illness predisposes skin to breakdown.
• Jaundice causes yellowish, itchy skin.
• Diseases of the skin, such as eczema and psoriasis, may cause lesions
that require special care.

39
Q

Factors placing a person at risk for
skin alterations
•

A

-Age
• Lifestyle variables (homosexuality, history of multiple partners, IV drug use)
• Occupation or activity that gives prolonged exposure to the sun
• Body Piercings
• Changes in health state (dehydration, malnutrition)
• Reduced sensation (paralysis, local nerve damage, circulatory insufficiency)
• Illness (diabetes)
• Therapeutic measures (bed rest, cast, medications, radiation therapy)

40
Q

The Nurses major role:

A

• -Identifying risk factors that predispose a patient to a break in
integrity
• -Intervening to prevent or reduce a patient’s risk for impaired skin
integrity
• -Providing specific wound care when breaks in integrity arise
• Measuring wounds
• Obtaining wound specimens

41
Q

Wound Healing Process Phases

A
  • Hemostasis
  • Inflammation
  • Proliferation
  • Maturation
42
Q

Hemostasis

A

• Occurs immediately after initial injury
• Involved blood vessels constrict and blood clotting begins.
• Exudate is formed, causing swelling and pain.
• Increased perfusion results in heat and redness.
• Platelets stimulate other cells to migrate to the injury to participate in
other phases of healing.

43
Q

Inflammatory Phase

A

• Follows hemostasis and lasts about 2 to 3 days
• White blood cells, predominantly leukocytes and macrophages, move
to the wound.
• Macrophages enter the wound area and remain for an extended
period.
• They ingest debris and release growth factors that attract fibroblasts
to fill in the wound.
• The patient has a generalized body response

44
Q

Proliferation Phase

A

• Lasts for several weeks.
• New tissue is built to fill the wound space through the action of
fibroblasts.
• Capillaries grow across the wound.
• A thin layer of epithelial cells forms across the wound.
• Granulation tissue forms a foundation for scar tissue development.

45
Q

Maturation Phase

A 
• Final stage of healing; begins about 3 weeks after the injury, possibly
continuing for months or years.
• Collagen is remodeled.
• New collagen tissue is deposited.
• Scar becomes a flat, thin, white line.
46
Q

Wound Complication

A 
• Infection
• Hemorrhage
• Dehiscence and Evisceration
• Fistula Formation
fistula: an abnormal passage from an internal organ to the skin or from
one internal organ to another
47
Q

Pressure Injuries

A

• Pressure injuries are staged based on their depth, exudate, and/or
eschar development.
• A pressure injury is defined as localized damage to the skin and
underlying tissue that usually occurs over a bony prominence or is
related to the use of a (medical or other) device.
• Most pressure injuries develop when soft tissue is compressed
between a bony prominence and an external surface for a prolonged
period of time, or when soft tissue undergoes pressure in
combination with shear and/or friction.

48
Q

Stages of pressure injuries

A

• Stage 1: non-blanchable erythema of intact skin
• Stage 2: partial-thickness skin loss with exposed dermis
• Stage 3: full-thickness skin loss; not involving underlying fascia
• Stage 4: full-thickness skin and tissue loss
• Unstageable: obscured full-thickness skin and tissue loss
• Deep tissue pressure injury: persistent non-blanchable deep red,
maroon, or purple discoloration

49
Q

How to measure a pressure injury:

A
  • Size of wound
  • Depth of wound
  • Presence of undermining, tunneling, or sinus tract
50
Q

Measuring wounds & Obtaining

specimens

A

• Measuring (length, width, and diameter)
• Wound specimens are best obtained from the center of the wound
site with live tissue. Collecting the specimen from the suspected
source of infection ensures that neighboring microbes do not
contaminate the specimen. Collecting from dead tissue or tissue
outside the wound with give inaccurate results.

51
Q

What are some signs and symptoms of wound infection?

A
  • Wound is swollen.
  • Wound is deep red in color.
  • Wound feels hot on palpation.
  • Drainage is increased and possibly purulent.
  • Foul odor may be noted.
  • Wound edges may be separated, with dehiscence present.
  • Fever
  • Pain
52
Q

Types of drainage symptoms:

A 
• Open systems
-Penrose drain
• Closed systems
- Jackson-Pratt drain
- Hemovac drain
53
Q

Pressure injury assessment consist

of:

A
  • Risk assessment
  • Mobility
  • Nutritional status
  • Moisture and incontinence
  • Appearance of existing pressure injury
  • Pain assessment
54
Q

Psychological Considerations

Actual and potential emotional stressors related to wounds include:

A
  • pain
  • Anxiety
  • Fear
  • activities of daily living
  • changes in body image
55
Q

Wound treatment

Affects of applying heat:

A

• Dilates peripheral blood vessels

Affects of applying heat:

• Increases tissue metabolism
• Reduces blood viscosity and
increases capillary permeability
• Reduces muscle tension
• Helps relieve pain
Affects of applying cold:
• Constricts peripheral blood
vessels
• Reduces muscle spasms
• Promotes comfort
56
Q

Pressure Ulcer Care Plan

• Pathophysiology

A

Pressure ulcers are also called decubitus ulcers or bedsores. These are
injuries to the skin and underlying tissues that develop after prolonged
pressure in a particular area. Bedsores are common on the heels,
sacrum and over bony prominences such as the elbows and shoulder
blades. Pressure ulcers can develop and progress very quickly, but are
preventable and treatable.

57
Q

Etiology

• Pressure ulcers are caused by three main factors.

A

• Pressure: Constant or prolonged pressure that restricts blood flow to any
part of the body. If blood is restricted to an area, nutrition, oxygenation
and tissue perfusion cannot take place. Without these essentials, the skin
and nearby tissue is damaged and may eventually become necrotic.
• Friction: As skin rubs against clothing or bedding, it can make weakened
areas in the skin that are vulnerable to injury. This occurs often if the skin
is consistently moist.
• Shear: When skin slides against a surface, such as sliding down in the
bed when the head only is elevated or transferring or positioning a
patient by allowing the skin to move across the bedding. Fragile skin is
easily ripped or torn this way.

58
Q

Desire outcome/goal with pressure wound

A 
Patient will experience healing of current pressure wounds, prevention of further skin
injury and maintain optimal skin integrity
Subjective Data Outcome
• Tender areas of skin
• Pain, burning of skin
• Itching
Objective Data
• Changes in skin color or texture
• Swelling
• Drainage from wounds
• Stage 1 – non-blanchable redness
• Stage 2 – open skin, pink/red, blister
• Stage 3 – Exposed subcutaneous tissue
• Stage 4 – Exposed muscle/bone
 Assess skin for signs of hydration pressure injury, and note areas of increased risk
• Monitor for signs of infection (plan)
Interventions:
Note odor and appearance of exudate
Fever
Warmth to touch
Obtain wound cultures as needed
Monitor white blood count (WBC)
Administer antibiotics as required
• Provide appropriate wound care (plan)
Interventions:
Cleaning
Debridement
Dressings
Emollients
Skin barriers
Negative pressure wound therapy
• Promote nutrition and education (plan)
Interventions:
Consult dietitian
Offer high-protein, high-calorie diet
Encourage hydratio

Fundamental Exam 3 (8 decks)

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