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FOUNDATIONS 310 > Skin > Flashcards

Skin Flashcards

1
Q

5 functions of skin

A
  1. protection
  2. thermoregulation
  3. sensation
  4. metabolism
  5. Communication
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2
Q

2 parts of skin that help with protection

A

melanin and sebum

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3
Q

How does skin help with metabolism?

A

synthesis of vitamin D

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4
Q

What is the most prevalent skin related issue in healthcare

A

pressure ulcer

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5
Q

Newborn and infant skin changes

A
  • reduced ability to thermoregulate

- more susceptible to rashes, blistering, chafing

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6
Q

Toddlers and preschooler skin changes

A
  • sunscreen

- playing causes injuries

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7
Q

School age and adolescent skin changes

A
  • lice/scabies/impetigo
  • acne
  • sunscreen
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8
Q

Adult and older adult skin changes

A
  • dry skin more common
  • wrinkling and poor skin turgor
  • slower healing
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9
Q

3 Mechanical forces that damage skin?

A

-pressure, friction, sheering

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10
Q

Wound type- injury such as knife, gunshot, burn, or surgical incision, heals within 6 months

A

acute

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11
Q

wound that persists beyond usual 6 month healing time or recurs with new injury to area

A

chronic

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12
Q

open wound

A

break present in the skin; tissue damage present

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13
Q

closed wound

A

no break seen in the skin, but soft tissue damage evident

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14
Q

clean surgical wound

A

closed surgical wound that did not enter GI/Resp/Genituourinary system
-low infection risk

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15
Q

clean/contaminated wound

A

wound entering GI/Resp/Genituourinary system

-infection risk

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16
Q

contaminated surgical wound

A

open, traumatic wound; surgical wound with break in asepsis

-high infection risk

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17
Q

infected surgical wound

A

wound site with pathogens present

-signs of infection

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18
Q

What is pressure?

A

localized damage to skin or underlying tissue over bony prominence as a result of pressure or pressure in combination with shear

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19
Q

Stage I Pressure Ulcer

A
  • skin intact
  • nonblanchable redness (stays red when you press it)
  • painful or different feel to rest of skin
  • will feel cool in temperature
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20
Q

Stage II pressure ulcer

A
  • shallow OPEN ulcer with PINK wound bed
  • no sloughing/no eschar
  • PARTIAL thickness loss of dermis
  • skin shear, tape burn, maceration, excoriation
  • will feel warm
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21
Q

Stage III pressure ulcer

A
  • FULL thickness tissue loss
  • may have slough or eschar
  • NO bone tendon muscle exposure
  • UNDERMINING or TUNNELING possible
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22
Q

Stage IV pressure ulcer

A
  • EXPOSED bone tendon muscle
  • may have slough or eschar
  • tunneling or undermining
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23
Q

tunneling

A

-narrow passageway in soft tissue of open wound going down

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24
Q

undermining

A

area of tissue deconstruction under the edge of wound opening

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25
Q

eschar

A

dea tissue, bacterial debris, dark in color

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26
Q

What is an unstageable pressure ulcer?

A
  • wound cannot be visualized

- base is covered in slough or eschar

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27
Q

Tool for pressure ulcer screening

A

Braden Scale

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28
Q

What is in protective creams to help healing and prevention?

A

-zinc, vitamin A,D,E

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29
Q

____ rather than ____ when repositioning patient in bed

A

lift, pull

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30
Q

small spot like freckle or petechia

-circumscribed, flat, non palpable changes in skin color

A

macule, primary lesion

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31
Q

larger than macule like vitiligo,flat, non palpable changes in skin color

A

patch, primary lesion

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32
Q

up to 0.5 cm like elevated nevus, palpable elevated solid mass

A

papule, primary

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33
Q

flat elevated surface larger then 0.5 cm, often formed by coalescence of papules

A

plaque, primary

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34
Q

larger than 0.5 cm, deeper and firmer than a paule, palpable elevated solid mass

A

nodule, primary

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35
Q

large nodule, palpable elevated solid mass

A

tumor, primary

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36
Q

somewhat irregular, relatively transient superficial area of localized skin edema like mosquito bite or hive

A

wheal, primary

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37
Q

up to 0.5 cm, filled with serous fluid, circumscribed superficial elevation of the skin formed by free fluid in cavity within skin layers

A

vesicle, primary

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38
Q

> 0.5 cm , filled with serous fluid, like 2nd degree burn

A

bulla, primary

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39
Q

filled with pus like acne or impetigo

A

pustule, primary

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40
Q

loss of the superficial epidermis, surface moist but does not bleed ex:moist area after rupture of vesicle from chicken pox

A

loss of skin surface,secondary

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41
Q

dried residue of serum, pus, blood

A

crust, secondary

42
Q

deeper loss of skin surface, may bleed and scar like from venous stasis or syphlitic chancre

A

ulcer, secondary

43
Q

think flake of exfoliated epidermis like dandruff, dry skin, psoriasis

A

scale, secondary

44
Q

linear crack in the skin like from athletes foot

A

fissure, secondary

45
Q

primary vs secondary skin lesion

A

primary-arise from normal skin

seconary-result from changes in primary lesion

46
Q

4 phases of wound healing in order

A
  1. hemostasis
  2. inflammatory
  3. proliferative
  4. maturation
47
Q

what happens in heomstasis part of wound healing?

A
  • vasoconstriction
  • platelet aggregation
  • clot formation
48
Q

timeline for phases of wound healing for full thickness wound

A
  1. hemostasis- immediate
  2. inflammatory- up to day 3
  3. proliferative-4-21 days
  4. maturation- 21 days to 2 years
49
Q

what happens in inflammatory phase

A
  • vasodilation

- phagocytosis

50
Q

when does shear occur?

A

skin stays in place but subq tissue beneath shifts

  • might not be visible break in skin
  • can result in breakage/stretching of blood vessels–> soft tissue ischemia
51
Q

the presence of _____ causes skin to be ______ resistant to damage from friction and shear

A

moisture, less

52
Q

granulation tissue, what phase of wound healing

A

bright red tissue that is a manifestation fo wound healing but is also prone to trauma

  • see in proliferative phase of wound healing
  • full thickness wound
53
Q

epithelialization tissue, what phase of wound healing

A

pink in color, temporary protection, begins at wounds edges and moves inwards

  • action promoted by moist environment
  • partial thickness wound
54
Q

what happens in the proliferative phase

A

partial thickness wound: epithelialization

full thickness wound: granulation tissue, contracture

55
Q

When does maturation phase of wound healing occur? what kind of wounds?

A

21 days to 2 years

-only happens with full thickness wounds

56
Q

timeline for phases of partial thickness wounds

A
  1. hemostasis- immediate
  2. inflammatory- up to day 3
  3. proliferative-4-21 days
57
Q

Primary Intention wound

A
  • clean incision
  • early suture
  • hairline scar
  • decreased infection and scarring
58
Q

Secondary Intention wound

A
  • gaping irregular wound
  • granulation
  • epithelium grow over scar
  • increase scarring and infection
59
Q

Tertiary Intention

A
  • wound
  • granulation
  • closure with wide scar
  • delayed closure
  • increase scarring, may already have an infection that has to be cleared in order to heal
60
Q

Adhesive strips that hold edges of wound together

A

steri-strip

61
Q

Thread or metal that holds edges of wound together

A

suture, staple, clips

62
Q

Used to close wound on parts of the body that do not experience tension or stretching

A

cyanoacrylte glue

63
Q

Protocol for elastic wraps/bandages/stretch netting

A
  • apply distal to proximal
  • ensure it is not too tight
  • check distal circulation
64
Q

Complications from wounds

A
  • hemorrhage or hematoma
  • infection
  • dehiscence
  • evisceration
  • fistula
65
Q

what is dehiscence?

A

partial or total reopening of a wounds edges

66
Q

what is evisceration?

A

protrusion of viscera thru wound opening

-insides go outside

67
Q

what is a fistula? how is it named?

A

passage b/w 2 body parts/areas that don’t normally connect

-named for location ex: entercutaneous- goes intestine to epidermis

68
Q

What do you assess on a wound?

A

type, location, size, classification, base

  • drainage
  • undermining or tunneling
  • infection or pain
  • check fxality of drainage system
69
Q

Bloody drainage =

A

sanginous

70
Q

pale yellow pink drainage =

A

serosangiunous

71
Q

pale yellow watery fluid drainage

A

serous

72
Q

Penrose drain

A
  • tube placed in wound

- no suction

73
Q

Hemovac

A
  • bloody cavity

- suction

74
Q

Jackson Pratt drain

A

-gently suction when bulb compressed

75
Q

2 types of drains with suction

A

hemovac and JP

76
Q

A wound is present, who should assess it first?

A

Wound, Ostomy, Continence Nurse

77
Q

Who assesses surgical wounds?

A
  • only surgeon removes the dressing

- surgeon will write orders on how to do the dressing change

78
Q

Alginate

A

Used for absorption for draining wounds

79
Q

Collagens used for what kind of wound?

A

partial and full thickness

80
Q

Composites

A

use multiple products

81
Q

Foams

A

hydrophilic polyurethane

-partial and full thickness with small to moderate drainage

82
Q

Hydrocolloids

A

water resistant gel like wafer dressing

83
Q

hydrofiber

A
  • sodium carboxymethylcellulose

- very absorptive

84
Q

Hydrogels

A

-assist in autolytic debridement of necrotic tissue in full thickness wounds

85
Q

Nonadherent dressing function

A

minimize disruption of new cells

86
Q

silver dressing

A
  • antimicrobial for infected wound

- need wound care of physician order

87
Q

Transparent film fx

A

cover the wound but be able to see it

88
Q

What is negative pressure wound therapy?

A

hydrophobic sponge fills a wound cavity

  • cover with transparent dressing
  • connect to machine providing negative pressure = no pressure on wound, not even gravity
89
Q

Surgical Debridement

A
  • not done by nurses

- use of sharp tools to remove debris

90
Q

Enzymatic debridement

A

-place chemical products on wound to break down debris

91
Q

Autolytic debridement

A
  • occlusive or hydrogel to soften eschar

- debris gets eroded then irrigated with saline

92
Q

wet to dry dressing is what kind of debridement

A

mechanical use:

-pulsating lavage

93
Q

4 types of debridement

A
  • surgical
  • enzymatic
  • autolytic
  • mechanical
94
Q

3 benefits of using heat therapy

A
  • promote healing and suppuration
  • decrease inflammation by accelerating inflam. response
  • decrease musculoskeletal discomfort
95
Q

When to use heat therapy

A
  • surgical/infected wounds, hemorrhoids, episiotomies
  • phlebitis and IV infiltration
  • low back pain, menstrual cramps, contractures, arthritis, muscle spasms
96
Q

3 benefits of cold therapy

A
  • controls bleeding
  • decrease edema
  • relieves pain
97
Q

When to use cold therapy

A
  • fractures, trauma, superficial lacerations, puncture wounds
  • sprains, muscle strains, sports injuries
  • arthritis, trauma, musculoskeletal injuries
98
Q

When not to use hot or cold therapy

A
  • acute appendicitis/abscess tooth
  • broken skin/deep wound
  • circulatory impairment
  • sensory deficit
  • mental status impairment
  • age extremes
  • metallic implants
99
Q

Diet for wound healing

A

high protein, vitamin A/C/E, zinc, water, arginine, carbohydrates, fats

100
Q

What are 2 medicationd that can impair wound healing

A
  • anticoag

- corticosteroids (decrease ability to fight off infection)

FOUNDATIONS 310 (28 decks)

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