Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Assessment Final > Skin > Flashcards

Skin Flashcards

1
Q

What are the structures of the skin

A

skin
hair
nails
scalp

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Skin makes up ___% of total body weight

A

15

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Melanin

A

gives color to skin

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Epidermis

A

pH4.5-5.5

slightly acidic to protect from bacteria and fungus

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Dermis

A

secondary layer of skin

made up of collagen (tensile strength) and elastin (recoil)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

What is a pressure ulcer

A

an area of local tissue damage usual developing where soft tissue is compressed between a bony prominence and any external surface for prolonged time periods. It is a sign of local tissue necrosis and death

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

What are some risk factors for pressure ulcers

A 
excessive exposure and moisture from bodily secretions
impaired metal status
impaired nutritional status
immobility
mechanical forces
shearing and friction
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

What is the difference between shearing and friction

A

Friction causes removal of the stratum corneum and damage to underlying layers of the skin
Shearing occurs when friction hold the skin in place but gravity pulls the axial skeleton down which results in the pulling of the dermal layers of the skin

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Hyperemia

A

occurs when pressure is applied for <30 minutes and resolves in 1 hour

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Ischemia

A

Condition in which there is insufficient blood flow to the part of the body

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Necrosis

A

death of body tissue. not enough blood going to tissies

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Ulceration

A

breakdown of the skin

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

What are the 4 things you should think about with regard to ulcerations

A

Surface selection
Keep turning
Incontinence management
Nutrition

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

What is the first indication that a pressure ulcer may be developing

A

blanching of the skin (becoming pale and white)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Braden Scale

A

Scores sensory, perception, moisture nutrition, friction and shear, activity, and mobility.

Lower the score, the higher the risk for a pressure ulcer (score of <18)

Needs to be done consistently and updated frequently

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

What are facts that affect pressure ulcer development

A 
Wrinkled sheets
Pull of pt over linen surfaces
Immobility
Malnutrution and dehydration
moisture on skin
mental status and sense of recovery
Age
Heep HOB at 30 degrees or less to reduce pressure/fricton or shearing
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Stage I pressure ulcer

A

non blanchable erythema
may contain changes in skin temp tissue consistency (firm or boggy feeling), itching (sensation)
may be red, blue, or even purple hues

*It is reversible if pressure is relieived

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

What re pressure ulcer relieving mechanisms

A

frequent turning
pressure-relieving devices
positioning

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Stage II pressure ulcer

A

partial thickness and skin loss
looks like an abrasion, blister or shallow crater

Maintenance of moist healing environment with saline and occlusive dressing (promotes natural healing but prevents the formation of scar)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Stage III pressure ulcer

A

full thickness/loss of skin
damage/necrosis of subcutaneous tissue that can extend as far down as the fascia
may have fowl smelling drainage if it is infected and usually takes months to heal after the pressure is relieved

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Stage IV pressure ulcer

A

full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone or supporting structures. Wound may appear small on surface but can have extensive tunneling

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

What are often associated with Stage IV pressure ulcers

A

Sinus tracts

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

Eschar

A

thick leathery scab or dry crust that is necrotic and must be removed from a pressure ulcer in order to determine what stage the ulcer is in

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

Unstageable pressure ulcers

A

full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, grey) and or/eschar in the wound bed

**True depth and stage cannot be determined until eschar is removed

25
Q

What are things to assess/document when measuring pressure ulcers

A

location
stage
drainage
types of tissue present
Document: size of wound, side - side, top to bottom and depth
Determine presence of undermining, tunneling or sinus tracts

26
Q

How do you clean a pressure ulcer

A

use a dressing change (careful and gentle motion)
avoid harmful cleaners
use 0.9% NaCl solution to irrigate/clean area
use a catheter tip syringe and 35ml/20ml/water pic at lowest setting

27
Q

When dressing an ulcer what do you want to make sure to use

A

Use dressing that keep the wound moist
Wet to Dry dressing are for debridement ONLY
make sure dressing absorbs exudate
pack the wound cavities loosely - overpacking could increase wound pressure

28
Q

What are some ways to debride a wound

A

surgically - use scalpel to cut the necrotic skin or eschar from the wound
mechanically - wet to dry dressing
enzymatically - using a chemical agent that degrades eschar
autolytically - covering the pressure ulcer with a gel or hydro colloid allowing the bodes moisture and enzymes to soft the eschar

29
Q

debridement

A

removal of the devitalized tissue and foreign material so the wound can heal

30
Q

What are the different types of drainage

A

serous
sanguineous
serosanguineous
purulent

31
Q

Serous drainage

A

clear and watery

32
Q

Sanguineous drainage

A

large numbers of RBCs and looks like blood

Indicative of fresh bleeding

33
Q

Serosanguineous drainage

A

mixture of serum and RBCs (light pink)

34
Q

Purulent

A

WBCs, liquefied dead tissue debris, dead and live bacteria

thick, musty/foul odor and can be yelled or green

35
Q

What are the 4 things to assess for with a wound

A

COCA

Color Odor Amount Consistency

36
Q

Intentional wound

A

result of planned invasive therapy or tx
Ex. IV, surgery wound etc.

Usually done under sterile conditions so risk for infection is decreased

37
Q

Unintentional wound

A

accidental and usually caused by trauma, forcible injury (stabbing, gunshot etc.), or burns.
Contamination is likely since it occurred in a unsterile environment
Bleeding often uncontrolled and would edges are jagged

38
Q

Acute wounds

A

usually heal within days to weeks and wound edges are well approximated: edges meet closely
Risk for infection is lessened

39
Q

Chronic wounds

A

healing is impeded; wound edges are not well approximated, and increased risk of infection.
They remain in the inflammatory stage of wound healing

Ex. venous/arterial wounds and pressure ulcers

40
Q

Before treating a wound what is it important to know

A

the etiology : venous, arterial, surgical, or trauma

41
Q

Abrasions

A

superficial injury caused by rubbing or scraping of skiing against another surface

42
Q

Laceration

A

open would with jagged edges

43
Q

Contusions

A

closed wound; swollen, discolored and painful

44
Q

What are the phases of wound healing?

A

Hemostasis
Inflammatory Stage
Proliferative Stage
Remodeling

45
Q

Hemostasis phase

A

tissue injury initiates clotting process which leads to platelet aggregation. This leads to fibrin clot formation which prevents excessive blood loss and body fluids

46
Q

Inflammatory phase

A

phagocytois occurs; increase of WBC to the area of wound; erythma, edema warmth, increase in temp, general malaise (approx 4-6 days after onset)

47
Q

Proliferative phase

A

new tissue is built to fill the wound space days after the injury. Granulation tissue (new tissue) forms

Starts after 5-7 days

48
Q

Remodeling (maturation) phase

A

starts about 3 weeks after injury and can continue for months to years. new collagen continues to be formed - leads to scar

49
Q

What are common sites for the development of pressure ulcers

A 
occipital bone
scapula
vertebra
sacrum
coccyx
calcaneus
ribs (side lying) iliac crest (side lying) greater trocanter (side lyings) lateral knee, malleolus and medial malleolus (side lying
50
Q

Primary intention wound healing

A

would with little tissue loss, edges approximated. heals rapidly with minimal scarring, low risk of infections
healing occurs by direct union of granulating surfaces

51
Q

Secondary intention wound healing

A

wounds involving loss of tissue, wound edges widely separated, healing occurs by granulation, large scar increases likelihood of infection, longer healing time
EX burns, pressure ulcers

52
Q

Tertiary intention would healing

A

deep wound and is likely to contain extensive drainage and tissue debris. High risk of infection

53
Q

wound dehiscence

A

surgical wound that tears open along the closure of the wound

54
Q

When changing a dressing for a draining wound

A

promote comfort
maintain skin integrity
prevent infection
promote healing

55
Q

NPWT - vacuum assisted closure therapy

A

used for recalcitrant wounds, acute and chronic wounds, pressure ulcers, surgical wounds, skin graft etc.

The negative pressure on the wound bed results in mechanical tension on the wound tissues, stimulating cell proliferation, blood flow to the wounds and the growth of new blood vessels

56
Q

Growth factors

A

applied to the wound bed to bind to cells to promote granulation, cell proliferation and cell migration.

Used during the proliferative phase of wound healing in pts with chronic non-healing wounds

57
Q

HBOT (hyperbaric oxygen tx)

A

placing patients in a pressurized chamber, where they breathe 100% to. Promotes cell proliferation, increased blood flow to wounds and promotes angiogenesis (growth of new blood cells)

58
Q

When is VAC contraindicated

A

necrosis, malignancy, fistula, or if arteries or veins are exposed in the wound

59
Q

Heat and Cold Therapy

A

heat accelerates the inflammatory response to promote healing
cold constricts blood vessels, reduces muscle spasms, and promotes comfort

Assessment Final (7 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions