Skin and wound Flashcards

Question

Primary intention-

Answer 1

Primary intention- healing occurs by epithelialization; heals _Quickly(skin is connected still) with minimal scar formation

Answer 2

Secondary intention(open wound)- wound heals by granulation _tissue_ formation, wound contraction, and epithelialization

Answer 3

Tertiary or delayed primary- closure of wound is delayed until risk of infection is resolved(we open the wound to try to get dangerous infection out)

Answer 4

The accumulation of exudate causes swelling and pain.

Answer 5

``` LOCAL FACTORS: Pressure(longer to heal) Desiccation( extreme dryness) Maceration Trauma Edema Infection Excessive _Bleeding_ Necrosis(dead tissue in the way) Biofilm ```

Answer 6

``` SYSTEMIC FACTORS: _Age_ Circulation to & oxygenation of tissues Nutritional status(don’t eat protein slower heal) Wound etiology(what caused wound?) Health status(diabetic) Immunosuppression Medications Adherence to treatment plan ```

Answer 7

the process of drying up delays healing wound should be kept moist(not wet)

Answer 8

over-hydration breakdown of skin to over hydration likely from incontinence

Answer 9

death of tissue appearance of eschar dry black dead tissue wound will not heal with dead tissue present

Answer 10

result of wound bacteria growing in clumps and weaking resistances

Answer 11

Dehiscence(wound opened back up)

Answer 12

Evisceration(organs intestines comeing out of the wound)

Answer 13

an abnormal passage from an internal organ to the outside of the body

Answer 14

Intact Change in skin _turgor_, tissue consistency, and/or sensation Defined area of persistent redness- light pigment Persistent red, blue, or purple hues- darker skin tones

Answer 15

Partial thickness _skin_ loss involving epidermis and/ or dermis Superficial Abrasion, blister, or shallow crater

Answer 16

Full-thickness __skin__ loss involving damage or necrosis of subcutaneous tissue Does not extend thru underlying fascia Deep crater w/ or w/o undermining of adjacent tissue

Answer 17

Full-thickness skin and tissue loss in which the extent of the tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a stage 3 or 4 pressure ulcer will be revealed. Stable eschar on the heel or ischemic limb should not be softened or removed.

Answer 18

STAGE IV Full- thickness __skin__ loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures May have undermining & sinus tracks

Answer 19

infected fluid that has not drained

Answer 20

“Pressure Ulcers increase hospital costs significantly. In the US, pressure ulcer care is estimated to approach $11 billion (USD) annually, with a cost of between $500 (USD) and $70,000 (USD) per individual pressure

Answer 21

``` Nutrition Tissue perfusion Infection Age Psychosocial impact ```

Answer 22

Identify the client’s __risk__ for developing impaired skin integrity Identify signs and symptoms associated with impaired skin integrity or __poor__ wound healing Examine client’s skin for actual impairment in skin integrity Skin Pressure ulcers- _predicted measures_ measures; mobility, nutritional status, body fluids, & pain. Wounds- emergency setting(control bleeding) vs. stable setting(prevent infection) ``` others Wound appearance Character of wound drainage Drains Wound closures Palpation of wound Wound cultures Client expectations ```

Answer 23

Risk for _infection_ Acute or chronic pain Impaired skin integrity Risk for impaired skin integrity Imbalanced nutrition- less than body requirements Impaired physical mobility Ineffective tissue _perfusion_

Answer 24

(removal) devitalized tissue removal Necessary to rid the ulcer of a source of infection Enable visualization of the wound bed Provide a clean base necessary for healing “heel ulcers w/ dry eschar need not be debrided if they do not have edema, erythema, fluctuance, or drainage.” May observe an increase in wound exudate, odor, and ____ Manage pain