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Anatomy > Skin and wound > Flashcards

Skin and wound Flashcards

1
Q

Skin is the bodies ___ organ

A

Largest

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2
Q

What are the functions of skin

A

Protective barrier against disease-causing organisms
Sensory organ for pain, temp, and touch
Can synthesize vitamin D
Contributes to self-esteem
Can absorb medications
Loss of water, electrolytes, & nitrogenous wastes in sweat

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3
Q

Epidermis-
Dermis-
Subcutaneous tissue-

A

Epidermis- top layer
Dermis- inner layer; contains collagen, __blood and lymph___ vessels, & nerves
Subcutaneous tissue- contains _____ & lymph vessels, nerves, & fat cells
Collagen- tough, fibrous protein

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4
Q

Collagen-

A

Collagen- tough, fibrous protein

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5
Q

types of wounds

Incision-

A

Incision- cutting sharp instrument wound

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6
Q

types of wounds

Contusion-

A

Contusion- blunt wound skin intact

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7
Q

types of wounds

Abrasion-

A

Abrasion- friction rubbing or scraping

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8
Q

types of wounds

Laceration-

A

Laceration- tearing of the skin not aligned cut

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9
Q

types of wounds

Puncture-

A

Puncture- enters the skin

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10
Q

types of wounds

Penetrating-

A

Penetrating- puncturing and loging in tissue possible scattering inside skin

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11
Q

types of wounds

Avulsion-

A

Avulsion- tearing from natural anatomical position damage to blood nerves and other structures

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12
Q

types of wounds

Irradiation-

A

Irradiation-ultraviolet or radiation exposure

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13
Q

types of wounds

Pressure ulcers-

A

Pressure ulcers- compromised circulation caseing preasure

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14
Q

types of wounds

Venous ulcers-

A

Venous ulcers- injury related to poor venus return due to underlying obstruction

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15
Q

types of wounds

Arterial ulcers-

A

Arterial ulcers- underlying ischemia from thrombosis

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16
Q

types of wounds

Diabetic ulcers-

A

Diabetic ulcers- caused by diebetic condition or

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17
Q

Wound Classification

Intentional & unintentional

A

Intentional-(planned therapy or treatment)

& unintentional-(unexpected trauma)

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18
Q

Wound Classification

Open & closed

A

Open-(skin surface is broken)

& closed(internal injury like hemmorigeing)

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19
Q

Wound Classification

Acute & chronic

A

Acute(low risk of infection healing proccess is normal)

& chronic(infection risk is high wound does not heal normally)

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20
Q

4 stages of wound healing?

A

Hemostats
Inflammation
proliferation
maturation

21
Q

Hemostasis

A

blood vessels constrict clotting begins Exudate is released causing swelling and pain

22
Q

Inflammation

A

Inflammatory phase- follows hemostasis & lasts 4-6 days. WBC mainly luekocytes move to the wound. Macrophages arrive about 24 hours after injury to ingest debris & release growth factors. The patient will have pain, heat, redness & swelling at the site. A mildly elevated temp,

23
Q

proliferation

A

Proliferation phase- lasts for several days; filling of the wound with granulation tissue primarily thru the action of fibroblasts. Highly vascular, red, & bleeds easily. If healing by primary intention, epidermal cells seal the wound within 24-48 hours. Collagen synthesis and accumulation continue. Depending on the size of the wound can take several weeks to years. By the end of the second week the majority of WBC have left the wound area & the wound is lighter in color.

24
Q

maturation

A

Maturation phase- Begins about 3 weeks after the injury. A scar forms- an avascular tissue that does not sweat, grow hair, or tan in sunlight. It is less elastic than uninjured tissue. Wounds that heal by secondary intention take longer to remodel.

25
Q

Primary intention-

A

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

26
Q

Secondary intention(open wound)-

A

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

27
Q

Tertiary or delayed primary-

A

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)

28
Q

Exudate

A

The accumulation of exudate causes swelling and pain.

29
Q

What local factors effect healing?

A 
LOCAL FACTORS:
Pressure(longer to heal)
Desiccation( extreme dryness)
Maceration
Trauma
Edema
Infection
Excessive _Bleeding_
Necrosis(dead tissue in the way)
Biofilm
30
Q

What systemic factors effect healing?

A 
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
31
Q

desiccation

A

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

32
Q

maceration

A

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

33
Q

necrosis

A

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

34
Q

biofilm

A

result of wound bacteria growing in clumps and weaking resistances

35
Q

Dehiscence

A

Dehiscence(wound opened back up)

36
Q

Evisceration

A

Evisceration(organs intestines comeing out of the wound)

37
Q

Fistulas

A

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

38
Q

CLASSIFICATION OF PRESSURE ULCERS

STAGE I

A

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

39
Q

CLASSIFICATION OF PRESSURE ULCERS

STAGE II

A

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

40
Q

CLASSIFICATION OF PRESSURE ULCERS

STAGE III

A

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

41
Q

CLASSIFICATION OF PRESSURE ULCERS

UNSTAGEABLE PRESSURE INJURY

A

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.

42
Q

CLASSIFICATION OF PRESSURE ULCERS

STAGE IV

A

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

43
Q

abcess

A

infected fluid that has not drained

44
Q

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

A

“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

45
Q

FACTORS WHICH INFLUENCE PRESSSURE ULCER FORMATION

A 
Nutrition
Tissue perfusion
Infection
Age 
Psychosocial impact
46
Q

Discuss nursing assessment of skin integrity and wound healing.

A

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
47
Q

What are some wound related nurseing diagnosis?

A

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

48
Q

debidement

A

(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

Anatomy (28 decks)

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