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NURSING EXAM 3 > SKIN and WOUNDS > Flashcards

SKIN and WOUNDS Flashcards

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
stage 3 pressure injury
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
26
stage 4 pressure injury
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
27
slough
Yellow, tan, gray, brown, Non-viable tissue
28
eschar
Dark brown or black crust-like , non viable tissue
29
unstageable
Full thickness tissue damage Base of the wound is covered by slough or eschar
30
susceptible deep tissue injury (SDTI)
Purple or maroon localized area of intact skin
31
autolytic debridement
Use of hydrocolloid or foam dressings Bodys own enzymes and defensive mechanisms to loosen and liquefy necrotic tissue
32
bio-surgical debridement
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
enzymatic debridment
Application of commercially prepared enzymes Enzymes are prescribed treatments by a provider
34
mechanical debridement
Use of an external physical force (irrigating a wound) Painful method of debridement
35
sharp/ surgical debridement
Use of scalpel Performed by physicians and advanced practice nurses
36
wound healing: hemostasis
Vasoconstriction: shut down to slow bleeding Exudate production Clot formation --> 48 hours of bleeding
37
wound healing: inflammatory
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
proliferative
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
maturation
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
primary wound healing
Sacring is minimal Risk of infection is less Skin is still intact
41
secondary wound healing
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
tertiary wound healing
Delayed closer Wound is intentionally left opened for a certain time to view bleeding or cant close site
43
how does age effect wound healing
Older: diminished circulation → prolonged healing Young: poor adherence of dermis and epidermis → more trauma from smaller action but heal quicker
44
how does nutrition affect wound healing
Protein, Vitamins A & C, Zinc
45
how does health status affect wound healing
Diabetes Shock Immunosuppression Obesity
46
how does moisture affect wound healing
Desiccation: dry and crusty Maceration: excessive moisture or prolonged exposure to moisture caused by overhydration related to urinary and fecal incontinence?
47
necrosis
healing with not occur if there is dead tissue
48
biofilm
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
attachment of biofilm
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
expansion of biofilm
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
maturation of biofilm
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
resistance biofilm
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
hemorrhage: hematoma
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
dehiscence
wound edges separated because of infection
55
evisceration
organs push through incision
56
infection
7 days after the wound occurs because of the inflammation stage. HAI → osteomyelitis, sepsis,
57
fistula
abnormal passageway or connection of two adjacent organs/ vessels that do not normally connect. r/t: cancer, treatments of cancer, infection
58
5 signs of localized infection
Redness Heat Edema ---> Purulent : white puss, stinky Pain Altered Function
59
implementation: health promotion
Being aware medications can cause sensitivity to skin Wear sunscreen, looking for moles, wear glasses so they don't fall
60
implementation: prevent pressure injuries
Positioning & skin care Pressure reducing surfaces
61
implementation: patient teaching
Hygiene and Handwashing Pressure injury prevention Symptoms of infection
62
implementation: prevent and manage wounds
Remove nonviable tissue Manage wound exudate
63
evaluate and revise interventions
New interventions include: apply skin barrier to bilateral heels BID; utilize boot to suspend both heels off the bed surface at all times
64
ways of thinking: remember
recall facts and basic concepts ex. The use of sharp tools to remove devitalized tissue is called Surgical debridemen
65
ways of thinking: understand
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
ways of thinking: apply
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
ways of thinking: analyze
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
ways of thinking: evaluate
justify a stand or decision
69
ways of thinking: create
produce new or original work
70
why is a protein needed for our skin?
Protein needed for regeneration and healing of wounds
71
characteristics of the dermis
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
characteristics of the subcutaneous tissue
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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