Skin Flashcards

1
Q

What does the skin do?

A

Regulates body temperature
Protects the body
Infection control

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2
Q

Decubitus ulcers

A

Are bedsores
They cut off blood supply and tissue dies

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3
Q

Malleolus

A

Ankle

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4
Q

Impaired sensory perception (cannot feel pressure)

A

Neuropathy
Spinal cord injury
Stroke
Patients that have these impairments, or at higher risk for decubitus ulcers (bedsores)

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5
Q

What are some examples of patients with impaired nutrition?

A

Impaired nutrition also put the patient at risk for bedsores
Lack of proteins
Patience with feeding tubes
Financially unable to afford good food
Patient that cannot swallow

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6
Q

Friction and shear

A

Body goes one way to skin goes the other way

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7
Q

What does moisture, fecal, or urinary incontinence do to patient’s

A

They cost breakdown of skin & massuration when the skin is moist for long periods of time, —-prolong moisture

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8
Q

What is the Braden scale?

A

The Braden scale is a number that measures the likelihood for the cutest ulcers
^ the higher, the number, the lower the risk
The lower, the number, the higher, the risk

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9
Q

Stage one pressure ulcer

A

The skin is intact
Redness
Non-blanchable

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10
Q

Stage two pressure ulcer

A

Partial Dash thickness, loss involving the epidermis, dermis, or both

A stage two pressure ulcer resembles a popped blister/superficial
It can be pink in color

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11
Q

Stage three pressure ulcer

A

Full thickness, tissue loss with visible fat(adipose)
Is bright red with drainage

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12
Q

Stage four pressure ulcer

A

Full thickness, tissue, loss with exposed muscle, tendon, bone

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13
Q

Unstageable pressure ulcer

A

Full thickness, loss, but the actual depth of the ulcer is obscured by sloth or eschar

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14
Q

Deep tissue injury(DTI)

A

Localized area of discolor, intact, skin, or blood filled blister caused by damage of underlying soft tissue from pressure or sheer
This can usually be caused by things that are left under the patient

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15
Q

Eschar

A

Can be black or brown when this is present, the wound is unstageable once the eschar leaves, the wound can be staged

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16
Q

Slough

A

Green or yellow in color

17
Q

What labs do we look at with wounds?

A

Albumin
Protein
White blood count

18
Q

Primary intention

A

A closed wound that heals quickly on its own
Staples, stitches

19
Q

Secondary intention

A

Balloon is left open in order to heal from inside out

20
Q

Tertiary intention

A

The wound is left open until risk of infection has passed usually within a 24 to 48 hour window. Then the wound is sealed.

21
Q

Factors that influence wound healing

A

Nutrition
Tissue perfusion (blood circulation)
Infection
Age
Psychosocial impact of wounds: how it makes the patient feel, may give a different body image, may cause pain

22
Q

Dehiscence

A

Separation of splitting open of layers of surgical wound
This can be due to pressure, straining
I can occur 3 to 12 days after procedure
Obese, patient or most at risk due to deeper adipose tissue

23
Q

Evisceration

A

Extrusion of viscera or intestine through a surgical wound (guts spilling out)

24
Q

When assessing wounds remember taco

A

T= type of drainage
A= amount of drainage(in centimeters)
C= color
O= odor

25
What are the two types of drains?
Hemovac or Jackson, Pratt
26
What are five types of exudates
Serous Clear, Amber, yellow, thin, watery Serosanguinous Pink, thin, watery Sanguineous Bright red Purulent Thick, yellowish green Bad odor Hemorrhage Read, thick
27
What are the two types of debridement for wounds?
Chemical and mechanical Chemical : use of ointment or gel that softens or get rid of dead tissue Mechanical: can be wet to dry dressings, scrubbing, scraping the tissue can also remove healthy tissue Both types of debridement remove dead tissue
28
Santiel ointment on wound
Is meant to eat dead tissue and will also eat away healthy tissue
29
Hydrocolloid dressing
Is moldable Impermeable to liquids and bacteria Absorbs wound fluids Swells and forms a gel that covers the one bed Maintains moisture and protects newly formed tissue from dressing changes Can be worn for 3 to 7 days
30
Hydrogel dressing
Maintains a moist healing environment Provides up to 72 hour where time For partial and full thickness wound
31
Transparent dressing
Allows visualization of site Impermeable to liquids and bacteria Do not use in wounds with excess of moisture Can be worn for 3-7 days Are usually placed on IVs
32
How to clean wounds
Start in the middle of the wound and work your way out in a circular motion Normally, saline or sterile water is used
33
Exudate
Drainage
34
Heat intervention
Increase circulation, improves blood flow, prevents, redness, prevents, localized tenderness, must place barrier to prevent heat burn
35
Cold intervention
Decreases swelling/pain Promotes coagulation Caution should be used in length of application to avoid tissue ischemia
36
Requirement on MD order
Site, type, frequency, duration Example Apply cold pack two left knee x 20 minutes three times a day.
37
Safety key points do
Do: Explain the patient what they may feel during application (this may feel warm/cold) Protect skin (towel, pillowcase) Instruct patient to report changes in sensation Check the patient frequently
38
Safety key points do not
-Do not allow patient to adjust temperature settings -Do not place patient in a position that does not allow them to move away from temperature source -Do not leave patient unattended if they are unable to since change, or move away from source