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Test #4 > Skin > Flashcards

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
Q

What are the two types of drains?

A

Hemovac or Jackson, Pratt

26
Q

What are five types of exudates

A

Serous
Clear, Amber, yellow, thin, watery
Serosanguinous
Pink, thin, watery
Sanguineous
Bright red
Purulent
Thick, yellowish green
Bad odor
Hemorrhage
Read, thick

27
Q

What are the two types of debridement for wounds?

A

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
Q

Santiel ointment on wound

A

Is meant to eat dead tissue and will also eat away healthy tissue

29
Q

Hydrocolloid dressing

A

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
Q

Hydrogel dressing

A

Maintains a moist healing environment
Provides up to 72 hour where time
For partial and full thickness wound

31
Q

Transparent dressing

A

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
Q

How to clean wounds

A

Start in the middle of the wound and work your way out in a circular motion
Normally, saline or sterile water is used

33
Q

Exudate

A

Drainage

34
Q

Heat intervention

A

Increase circulation, improves blood flow, prevents, redness, prevents, localized tenderness, must place barrier to prevent heat burn

35
Q

Cold intervention

A

Decreases swelling/pain
Promotes coagulation
Caution should be used in length of application to avoid tissue ischemia

36
Q

Requirement on MD order

A

Site, type, frequency, duration
Example
Apply cold pack two left knee x 20 minutes three times a day.

37
Q

Safety key points do

A

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
Q

Safety key points do not

A

-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

Test #4 (6 decks)

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