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Funds > Skin and Wounds > Flashcards

Skin and Wounds Flashcards

1
Q

Epiderms

A

superficial layer

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2
Q

Dermis

A

gives skin elecastisity

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3
Q

Subcutaneous Tissue

A

reserve calories

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4
Q

Older Patients

A

thinner, weaker, dryer

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5
Q

Intrinsic Factors for Ulcers

A

aging, nutrition, stroke, decreased mobility

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6
Q

Extrinsic Factor for Ulcers

A

friction, shearing, moisture, hygiene and positioning

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7
Q

Braden Scale

A

pressure injury risk; < 18- risk for pressure injury

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8
Q

Braden Scale Catergories

A

Sensory/Perception
Moisture
Activity
Mobility
Nutrition
Shear and Friction

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9
Q

Closed Wound

A

no break in the skin such as bruised over a closed fracture

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10
Q

Open Surgical Wound

A

a break in the skin

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11
Q

Acute Wound

A

can be surgical incision, goes through 3 stages of healing in short time without complication

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12
Q

Chronic Wound

A

when natural healing process is slower with healing occurring from inside out

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13
Q

Clean Wound

A

uninfected wound that has minimal inflammation, can be open or closed

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14
Q

Clean Contaminated Wound

A

an incision that is higher risk of infection, might require antibiotics
ex ostomy

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15
Q

Contaminated Wound

A

traumatic or surgical wound where there is a break in sterility

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16
Q

Infected Wound

A

overgrowth of microorganisms

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17
Q

Colonized Wound

A

Presence of proliferating bacteria without a host response

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18
Q

Infection

A

invasion of proliferated microorganisms into surrounding tissue causing a host response

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19
Q

Superficial Thickness

A

just involving epidermis, can be due to friction

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20
Q

Partial Thickness

A

through epidermis but not through dermis

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21
Q

Full Thickness

A

through dermis and maybe into subq tissue

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22
Q

Penetrating

A

when a foreign body has pierced through the skin damaging underlying tissue

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23
Q

Abrasion

A

superficial scrape

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24
Q

Abscess

A

collection of puss or drainage: pocket of infection

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25
Q

Contusion

A

bruising or localized infection; “goose egg”

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26
Q

Crushing

A

heavy object falling onto someone

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27
Q

Incision

A

intentional opening

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28
Q

Laceration

A

where skin is cut or torn

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29
Q

Puncture

A

foreign object has punctured the skin

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30
Q

Tunnel

A

area inside the wound where a specific area has extended

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31
Q

Undermining

A

where skin surrounding opening remains intact but underlying tissue is eroded

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32
Q

Stage 1 Ulcer

A

area of redness that doesn’t blanch

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33
Q

Stage 2 Ulcer

A

Small break in skin, partial thickness into epidermis or dermis; appears pinkish red, may have yellow slough over it

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34
Q

Stage 3 Ulcer

A

down to subq tissue and can see the fat, can be down to muscle but not through muscle

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35
Q

Stage 4 Ulcer

A

Full thickness into muscle, may be able to see tendon or bone

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36
Q

Unstagable

A

full thickness, covered in slough or eschar so you cant see it

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37
Q

Granulation Tissue

A

pink to red, beefy red, looks like raw sugar, good sign of healing

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38
Q

Epithelial Tissue

A

healthy pink to pearly white tissue

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39
Q

Clean Non-Granulating Tissue

A

pink shiny moist tissue which is healthy

40
Q

Eschar

A

necrotic tissue which is leathery and could be brown, black or gray

41
Q

Slough

A

dead tissue which looks white yellow or tan; common in tan wounds

42
Q

Maceration

A

when moisture causes the skin to become pale and wrinkled, can be caused by wet dressings left on skin for too long

43
Q

Blistering

A

small bubble on skin filled with serum

44
Q

Erythema

45
Q

Epiboly

A

wound with rolled or curled under edges that may be dry or calloused

46
Q

Adhesive Strips/Steri-strips

A

used for low tension small wounds, such as skin tear, fall off on their own

47
Q

Sutures

48
Q

Absorbant Stitches

A

internal, deeper layers

49
Q

Nonabsorbent Stitches

A

external, superficial; nurse removes these every other

50
Q

Retention Sutures

A

heavy, nonabsorbent plastic, usually tied over a buttress for skin

51
Q

Staples

A

used on legs, arms and head, leaves a scar so not used on a face

52
Q

Dermabond

A

used on face and for smaller wounds

53
Q

Serous Drainage

A

straw-colored, from serum portion of blood

54
Q

Sanguineous

A

bloody drainage, new is bright red, and old is brownish red

55
Q

Seroussanguineous

A

mixture of serous and sanguineous

56
Q

Purulent

A

thick, yellow white or green puss

57
Q

Purosanguineous

A

Purulent with some blood

58
Q

Penrose Drain

A

looks like a straw and is flexible

59
Q

Jackson-Pratt Drain

A

bulb drain where suction is applied by emptying the cap and compressing the bulb; seen after masectomy or abdominal surgery

60
Q

Hemovac

A

use suction via a spring; we empty the drain and them compress it to restart suction

61
Q

Primary Intention

A

surgical incision that is closed and well approximated; will heal quick

62
Q

Secondary Intention

A

cannot be closed and must heal from inside out ex pressure injury

63
Q

Tertiary Intention

A

closing the wound at a different date

64
Q

Intermediate Phase

A

cleansing/clotting, days 1-5, PEST

65
Q

Proliferative Phase

A

granulation, 5-21 days, when collagen is starting to build

66
Q

Maturation

A

epithelialization, 6 months, where cartilage is remodeling and scar tissue is building

67
Q

Fistula

A

passage between 2 body cavities that doesn’t belong, common is between vagina and anus

68
Q

Hemorrhage

A

massive blood loss; biggest risk is 24-48 hours after surgery

69
Q

Internal Bleeding

A

you cant see it, decreased BP, Increased HR

70
Q

External Bleeding

A

you can see it, can be in drain

71
Q

Dehiscence

A

when the wound ruptures; obese patients are more at risk

72
Q

Evisceration

A

when internal organs pop out; cover with sterile dressing and call MD

73
Q

Negative Pressure Wound Therapy

A

woundvac, stimulates granulation and decreases edema

74
Q

Hyperbaric Oxygen Therapy

A

stimulate blood vessels and white cells to promote healing; used in osteomyelitis

75
Q

Debridement

A

removal or dead tissue

76
Q

Graft or Flap

A

skin graft are used in burns, flap grafts are used in mastectomies or when large amount of tissue is lost

77
Q

Sharp

A

where surgery is performed to remove dead tissue

78
Q

Wet to Dry

A

pulling out dry gauze that takes daed tissue with it

79
Q

Hydrotherapy

A

“powerwashing” to remove dead tissue

80
Q

Enzymatic

A

gel that dissolves dead tissue

81
Q

Autolysis

A

our body naturally dissolves dead tissue, band aids help this

82
Q

Biotherapy

A

done with maggots or leeches

83
Q

Primary Dressing

A

covering the wound

84
Q

Secondary Dressing

A

placed over primary dressing

85
Q

Taping

A

can be irritating

86
Q

Absorbant Dressings

A

made of cotton

87
Q

Alginates

A

absorbable dressing, allows autolytic debridement

88
Q

Antimicrobial

A

cream or dressing ex; silver dressing

89
Q

Foam

A

used in wound vac

90
Q

Gauze

A

used for wet to dry

91
Q

Hydrocolloids

A

duoderm, serves as an extra skin layer, used in stage 2 pressure ulcers, change every 48-72 hours

92
Q

Hydrogels

A

adds moisture to wounds

93
Q

Transparent Films

A

tegaderm, seen over IV sites

94
Q

Prealbumin

A

most accurate indicator, if low indicates poor wound healing

95
Q

ESR

A

if high it can indicate inflammatory reaction

96
Q

PT, PTT, INR

A

if high there will be increased bleeding

97
Q

Wound Culture

A

dont touch Q tip to drainage

Funds (10 decks)

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