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NURSING EXAM 3 > SKIN and WOUNDS > Flashcards

SKIN and WOUNDS Flashcards

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1
Q

how does circulation affect the integumentary function

A

Maintain cell life. Lead to abnormal color, texture, thickness or moisture of skin

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2
Q

how does nutrition affect the integumentary function

A

well-nourished skin cells are less likely to get injured or diseases

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3
Q

condition of epidermis

A

Outer wrapping
Epidermis avascular, no blood vessels, relies on underlying dermis for nutrition
The epidermis replace itself every 15-48 days

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4
Q

how does allergy affect the integumentary function

A

Rash, hives, and swellings stimulated by histamine release

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5
Q

how does infection affect the integumentary function

A

too many natural flora and portal of entry is opened can cause an infection
Ex. antibiotics gets rid of good and bad bacteria

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6
Q

how does abnormal growth rate affect the integumentary function

A

Psoriasis (infected on elbows, knees, scalpe, and soles of feet. Red raised patches with white scales due to systemic inflammation.

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7
Q

systemic diseases

A

Peripheral vascular disease / diabetes (slower healing)
renal failure/ hepatic failure. (itchy, hepatic is jaundice

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8
Q

intentional

A

break in skin integrity for a therapeutic purpose.
Surgery

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9
Q

unintentional

A

not done on purpose more prone to infection; therefore, a longer healing time.
Abrasions: hard surface
Lacerations: tearing up skin and tissue with a blunt or irregular instrument
Puncture wound: penetrates the skin

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10
Q

open or closed

A

Closed: soft tissue damaged but skin is still intact
Open: skin is broken

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11
Q

acute or chronic

A

Acute: heals in days to week. Normal healing process
Chronic: do not progress through the normal healing process and remina in the inflammatory stage of wound healing. More susceptible to infection.

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12
Q

healing process of children younger than 2 years old

A

Skin is thinner and weaker
An infant’s skin and mucous membranes are easily injured and subject to infection
Becomes increasingly resistant to injury and infection

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13
Q

healing process of elderly

A

Maturation of epidermal cells is prolonged, leading to thin, easily damaged skin
Circulation and collagen formation are impaired, leading to decreased elasticity and increased risk for tissue damage from pressure.
- Pressure injuries/ Bedsore
- Decubitus ulcers
- Bedsores

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14
Q

pressure intensity

A

restriction of blood flow leading to low supply of O2 and nutrients leading to ischemia

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15
Q

risks of pressure injuries

A

Impaired tissue tolerance

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16
Q

nutrition

A

not enough vitamin c leading to poor circulation

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17
Q

moisture

A

more moisture, more chance of pressure injury.
Incontinence

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18
Q

age

A

older skin

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19
Q

friction

A

two surfaces rubbing together cause skin break down

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20
Q

shear

A

one layer of skin is sliding over another layer causing damage to the skin
- boosting in bed. sliding instead of lifting

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21
Q

comorbid conditions

A

Altered level of consciousness
Sensory impairment
Impaired mobility

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22
Q

common sites for pressure injury

A

scapula
sacrum
coccyx
patella
sole, heel, calcaneus

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23
Q

stage 1 Pressure injury

A

non- blanchable erythema of intact skin
Clear area, barrier cream or foam dressing to prevent from getting worse

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24
Q

stage 2 pressure injury

A

partial-thickness skin loss. Presents as an abrasion or blister
Similar interventions to stage I. Relieve pressure, barrier cream, foam dressing

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25
Q

stage 3 pressure injury

A

full-thickness skin loss with damage or necrosis of SQ tissue. Presents as a deep craters
Undermining (sterile Qtip in shelf or lip of wound) and tunneling (hole in wound, stick sterile Qtip through)
Slough can be present but does not obscure the depth of woundChange dressings twice a day, waffle mattress, nutrition consult

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26
Q

stage 4 pressure injury

A

full-thickness skin loss with extensive destruction, necrosis, or damage to muscle, bone, or tendons
Osteomyelitis (infection of bone)
Takes months to years to heal. Same interventions of stage III

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27
Q

slough

A

Yellow, tan, gray, brown,
Non-viable tissue

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28
Q

eschar

A

Dark brown or black
crust-like , non viable tissue

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29
Q

unstageable

A

Full thickness tissue damage
Base of the wound is covered by slough or eschar

30
Q

susceptible deep tissue injury (SDTI)

A

Purple or maroon localized area of intact skin

31
Q

autolytic debridement

A

Use of hydrocolloid or foam dressings
Bodys own enzymes and defensive mechanisms to loosen and liquefy necrotic tissue

32
Q

bio-surgical debridement

A

Use of surgical grade/ sterile fly larvae
Larvae secrete enzyme that liquifies necrotic tissue, then larvae consumes liquid and infections material in the wound

33
Q

enzymatic debridment

A

Application of commercially prepared enzymes
Enzymes are prescribed treatments by a provider

34
Q

mechanical debridement

A

Use of an external physical force (irrigating a wound)
Painful method of debridement

35
Q

sharp/ surgical debridement

A

Use of scalpel
Performed by physicians and advanced practice nurses

36
Q

wound healing: hemostasis

A

Vasoconstriction: shut down to slow bleeding
Exudate production
Clot formation –> 48 hours of bleeding

37
Q

wound healing: inflammatory

A

Vasodilation: after platelets are there to allow more fluid to get to wound
Phagocytosis: ingestion of bacteria
Localized inflammatory response: looks like an infection
- Lasts 4-6 days.
- Wbc surround the tissue and take care of any debri
- Redness, warmth, swelling, tenderness

38
Q

proliferative

A

Lasts 3-24 days
Fibroblasts and Growth Factor create collagen and blood vessels
Granulation tissue formation
- Very vascular. Gentle and support to prevent from causing harm
new tissue built to fill the wound space, primarily through the action of fibroblasts.

39
Q

maturation

A

Can take up to 2 years
Collagen matures
Scar tissue is created by collagen as it cures.
- Never regains full strength after healed. About 70-80% of previous strength

40
Q

primary wound healing

A

Sacring is minimal
Risk of infection is less
Skin is still intact

41
Q

secondary wound healing

A

Pressure injuries or deep
Edges of skin are not next to each other.
Heal from bottom up
Scaring is more obvious and infections are more common

42
Q

tertiary wound healing

A

Delayed closer
Wound is intentionally left opened for a certain time to view bleeding or cant close site

43
Q

how does age effect wound healing

A

Older: diminished circulation → prolonged healing
Young: poor adherence of dermis and epidermis → more trauma from smaller action but heal quicker

44
Q

how does nutrition affect wound healing

A

Protein,
Vitamins A & C,
Zinc

45
Q

how does health status affect wound healing

A

Diabetes
Shock
Immunosuppression
Obesity

46
Q

how does moisture affect wound healing

A

Desiccation: dry and crusty
Maceration: excessive moisture or prolonged exposure to moisture
caused by overhydration related to urinary and fecal incontinence?

47
Q

necrosis

A

healing with not occur if there is dead tissue

48
Q

biofilm

A

thick sticky collection of bacteria and their habit.
Protect from antibiotics, wound care, tubes, plaque on teeth
Can make a wound more difficult to threat

49
Q

attachment of biofilm

A

bacteria fasten onto a variety of surfaces using specialized tall-like structures. this can occur in pipes and water fibers, in the human intestine, and on implants such as heart valves

50
Q

expansion of biofilm

A

the cells grow and divide forming dense matmary layers thick. the bacteria communicate with each other using specific signals. at this stage, the biofilm is still too thin to be seen.

51
Q

maturation of biofilm

A

when there are enough bacteria in the developing biofilm the microbes secrete a surgery glue and form mushroom-shaped structures that look like futuristic cities

52
Q

resistance biofilm

A

the glue protects the bacteria in the biofilm from the harsh environment outside, shielding them from antibiotics, toxic chemicals, and the body’s immune system.

53
Q

hemorrhage: hematoma

A

collection of blood under intact skin. Usually looks like a bruise, warm to the touch
- Ice packs can help
- HBG/HCT: will be low

54
Q

dehiscence

A

wound edges separated because of infection

55
Q

evisceration

A

organs push through incision

56
Q

infection

A

7 days after the wound occurs because of the inflammation stage.
HAI → osteomyelitis, sepsis,

57
Q

fistula

A

abnormal passageway or connection of two adjacent organs/ vessels that do not normally connect.
r/t: cancer, treatments of cancer, infection

58
Q

5 signs of localized infection

A

Redness
Heat
Edema —> Purulent : white puss, stinky
Pain
Altered Function

59
Q

implementation: health promotion

A

Being aware medications can cause sensitivity to skin
Wear sunscreen, looking for moles, wear glasses so they don’t fall

60
Q

implementation: prevent pressure injuries

A

Positioning & skin care
Pressure reducing surfaces

61
Q

implementation: patient teaching

A

Hygiene and Handwashing
Pressure injury prevention
Symptoms of infection

62
Q

implementation: prevent and manage wounds

A

Remove nonviable tissue
Manage wound exudate

63
Q

evaluate and revise interventions

A

New interventions include: apply skin barrier to bilateral heels BID; utilize boot to suspend both heels off the bed surface at all times

64
Q

ways of thinking: remember

A

recall facts and basic concepts
ex. The use of sharp tools to remove devitalized tissue is called Surgical debridemen

65
Q

ways of thinking: understand

A

explain ideas or concepts
ex.Assessing a wound on a foot, the nurse finds tissue destruction down to the bone. The nurse would correctly classify this wound as which of the following? Stage 4 Pressure Injury

66
Q

ways of thinking: apply

A

use information in new situations
ex.Which statement best describes the healing process for a surgical wound that was closed with sutures? The edges of the wound are approximated

67
Q

ways of thinking: analyze

A

draw connections among ideas
ex.Which patient is at highest risk for impaired wound healing?
72 year old with diabetes and cardiovascular disease who had surgical repair of a broken hip

68
Q

ways of thinking: evaluate

A

justify a stand or decision

69
Q

ways of thinking: create

A

produce new or original work

70
Q

why is a protein needed for our skin?

A

Protein needed for regeneration and healing of wounds

71
Q

characteristics of the dermis

A

Provides support and nutrition to epidermis, nerve ending, blood vessels, lymphatic vessel
Dermis for nutrition and shred and regrow every 27-45 days.
Dermis is the thickest of skin composed of connective tissue

72
Q

characteristics of the subcutaneous tissue

A

Underlies skin contains fat and connective tissue to support and cushion the skin (different than adipose tissue)

NURSING EXAM 3 (6 decks)

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