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NCM136/RLE106 > Prefinal - Skin Integrity > Flashcards

Prefinal - Skin Integrity Flashcards

1
Q

is the body’s largest organ and is the primary defense against infection.

A

Skin

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2
Q

A disruption in the integrity of body tissue

A

Wound

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3
Q

Classification according to Wound Type:

A

Incised
Contusion
Punctured
Abrasions

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4
Q

Classification of Wounds Thickness

A

Superficial
Deep

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5
Q

Wounds that leave the deeper skin layers intact. These types of wounds are usually caused by friction rubbing against an abrasive surface.

A

Superficial (on the surface) wounds

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6
Q

Wounds that go through all the layers of the skin and into underlying tissue like muscle or bone.

A

Deep wounds

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7
Q

Factors Affecting Wound Healing

A

Age
Nutrition
Oxygenation
Smoking
Drug Therapy
Diabetes Miletus

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8
Q

this Factor Affecting Wound Healing means that Although the elderly can heal most wounds, they have a slower healing process, and all phases of wound healing are also affected.

A

Age

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9
Q

this Factor Affecting Wound Healing means that Optimal wound healing requires adequate nutrition. Nutrition deficiencies impede the normal processes that allow progression through stages of wound healing. Malnutrition has also been related to decreased wound tensile strength and increased infection rates.

A

Nutrition

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10
Q

this Factor Affecting Wound Healing means that Oxygen plays a very significant role in wound healing – it is needed for cellular function and can kill bacteria and cause resistance to infection. Oxygen stimulates the creation of new blood vessels and also aids growth factors to form new skin. Your red blood cells carry oxygen throughout the body.

A

Oxygenation

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11
Q

this Factor Affecting Wound Healing means that Nicotine is a vasoconstrictor that reduces nutritional blood flow to the skin, resulting in tissue ischemia and impaired healing of injured tissue.

A

Smoking

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12
Q

this Factor Affecting Wound Healing means that The medications most likely to impair wound healing and damage skin integrity include antibiotics, anticonvulsants, steroids, and nonsteroidal anti-inflammatory drugs.

A

Drug Therapy

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13
Q

this Factor Affecting Wound Healing means that Diabetes mellitus is one of the major contributors to chronic wound healing problems. When diabetic patients develop an ulcer, they become at high risk for major complications, including infection and amputation.



A

Diabetes Miletus

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14
Q

(persistent bleeding) is abnormal and may indicate a slipped surgical suture, dislodged clot, or erosion of a blood vessel.

A

Hemorrhage

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15
Q

Some bleeding from a wound is normal during and immediately after initial trauma and surgery.

A
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16
Q

wound contamination

A

Infection

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17
Q

Effects of Having a Wound



A

Dehiscence
Evisceration

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18
Q

is the partial or complete separation of the wound edges and the layers below the skin.

A

Dehiscence

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19
Q

occurs when the client’s viscera protrudes through the disrupted wound.

A

Evisceration

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20
Q

Nursing Process for Altered Skin Integrity

A

Assessment of Wounds
Health history
Allergies to tape, latex, medications, or other substances
Physical examination
Location of wound
Size of wound
General appearance and drainage
Pain
Laboratory data

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21
Q

ASSESSMENT TOOL:



A

A- anatomical location, Age of wound
S-size, Shape
S- sinus tract, Tunnelling, Undermining
E- exudate
S- sepsis (including odour)
S-surrounding skin
M-maceration
E-edge, Epithelialization
N-necrotic tissue
T-tissue bed, Tenderness (pain)
S-status- changes in condition, improvement

22
Q

Nursing Diagnoses

A

Impaired Tissue Integrity
Risk for Infection
Disturbed Body Image
Acute or Chronic Pain
Deficient Knowledge

23
Q

Outcome Identification and Planning

A

After my health teachings, the client will manifest positive receptivity/response to
health instructions
> wound begins to heal after a week
> gains weight at least 3 pounds a week
> bearable pain in the affected area

24
Q

Principles for Wound Dressing:

A

Use Standard Precautions at All Times
When using a swab or gauze to cleanse a wound, work from the clean area out toward the dirtier area.
When irrigating a wound, warm the solution to room temperature, preferably to body temperature, to prevent lowering of the tissue temperature.
Be sure to allow the irrigant to flow from the cleanest area to the contaminated area to avoid spreading pathogens.

25
Q

is the application of a hot agent, warmer than skin either in a moist or dry form on the surface of the body;

A

Hot application

26
Q

Purpose of Hot Application:



A

To relieve pain and congestion
To provide warmth
To promote suppuration
To promote healing
To decrease muscle tone
To soften the exudates

27
Q

is the application of a cold agent cooler than skin either in a moist or dry form, on the surface of the skin.

A

Cold application

28
Q

Purpose of Cold Application:

A

To reduce pain and body temperature,
To anesthetize an area
To control hemorrhage
To control the growth of bacteria
To prevent gangrene
To prevent edema
To reduce inflammation

29
Q

Local Dry Heat Examples:

A

Infrared Therapy
Shortwave diathermy
A heating pad
Heating lamps

30
Q

Local Moist Heat Examples:

A

Hot bath
A poultice
Stupes
A sitz bath
Aquathermia pads
A paraffin or wax bath

31
Q

to improve the healing of wounds, relieve pain, stiffness, and fatigue from rheumatoid arthritis

A

Infrared Therapy

32
Q

uses high-frequency electromagnetic energy to generate heat to treat pain from kidney stones, and PID.

A

Shortwave diathermy

33
Q

is used for the warming of parts of the body in order to manage pain

A

A heating pad

34
Q

increase blood circulation and hasten wound healing.

A

Heating lamps

35
Q

is for stress/ pain relief, muscle relaxation, improved sleep, and calorie burn.

A

Hot bath

36
Q

also called a cataplasm, is a paste made of herbs, plants, and other substances with healing properties.

A

A poultice

37
Q

is a hot, wet cloth or sponge with a medication for external application to lessen irritation/inflammation

A

Stupes

38
Q

is a warm water bath that helps to relieve pain from episiotomy wound (a surgical cut made between the vaginal opening and anus to aid in the delivery of the baby), hemorrhoids (painful and swollen blood vessels in the rectum or anus)

A

A sitz bath

39
Q

or blankets are useful in treating muscle sprains and for areas with mild inflammation or edema.

A

Aquathermia pads

40
Q

can also aid in healing problems with the skin.

A

A paraffin or wax bath

41
Q

General Dry Heat Examples:

A

Sunbathing
Electric cradle or incubator

42
Q

protects a person against inflammation & improves memory.

A

Sunbathing

43
Q

provides an environment that can be adjusted to provide the ideal temperature as well as the perfect amount of oxygen, humidity, and light.

A

Electric cradle or incubator

44
Q

General Moist Heat Examples

A

Steam baths
A whirlpool bath

45
Q

relieve tension, soothe nerve endings, relax muscles, and minimize joint pain, as well as minimize the pain of headaches due to the high-heat environment.

A

Steam baths

46
Q

reduces the amount of pain in the joints or muscles and improves body blood flow.

A

A whirlpool bath

47
Q

Local Dry Cold Examples

A

Ice bag
Ice collar
Ice pack (poultice)
Ice cradle
Chemical cold packs

48
Q

Local Moist Cold Examples

A

Ice to suck
Cold compress
Evaporating lotion

49
Q

General Dry Cold Example

A

Hypothermia

50
Q

General Moist Cold Examples

A

Cold sponging
Cold bath
Cold packs

51
Q

Other measures to relieve pain

A

> Contralateral stimulation

NCM136/RLE106 (27 decks)

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