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Exam 3 > Skin and Wounds > Flashcards

Skin and Wounds Flashcards

1
Q

-Outermost layer of skin
-regenerates every 4-6 weeks

A

Epidermis

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2
Q

outermost layer of the epidermis
-provides protection
-regulates fluids and electrolytes

A

Stratum corneum

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3
Q

-Inner layer of epidermis
-new cells are produced
-keratin, melanin, and langer cells are found

A

Stratum Germanium

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4
Q

-1-5 cells thick
-reduced friction and shearing

A

Stratum Lucidum, Granulosum, and spinosum

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5
Q

-provide skin strength
-Flexibility
-Repair

A

Keratin

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6
Q

-Skin color
-UV protection

A

Melanin

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7
Q

-Digest bacteria
- Immune response

A

Langer cells

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8
Q

-Layer between epidermis and subcutaneous layer
-Contains sebaceous glands, sweat glands, hair/nail follicles, nerves, and lymphatics

A

Dermis

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9
Q

-Anchors the epidermis and dermis together
-Prevents friction/shearing

A

Papillary Dermis (Rete Ridge)

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10
Q

-Layer of adipose tissue
-attaches dermis to muscle and bone
-blood supply to dermis
-Provide insulation and cushion

A

Subcutaneous tissue

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11
Q

-Disruption in skin integrity
- lead to loss of normal skin function

A

Wound

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12
Q

Break in the skin surface

A

Open wound

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13
Q

skin intact and seen with bruising

A

Closed wound

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14
Q

clean wound that is at greater risk of infection

A

clean contaminated wound

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15
Q

wound with bacteria present from trauma, break in sterile technique, or spillage of bacteria latent material (stomach contents) during surgery

A

contaminated wound

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16
Q

wound that shows clinical signs of infection

A

Infected wound

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17
Q

one or more organisms are present on the surface of wound but no other overt sign of infection below the surface

A

Colonized wound

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18
Q

wound that progresses through the phases of wound healing in a rapid and uncomplicated manner

A

acute wound

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19
Q

edges of wounds can be brought together

A

approximated

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20
Q

-fast wound healing
-no to minimal scaring
-edges are approximated

A

Primary intention

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21
Q

-new granulated tissue forms to bottom and sides of wound till wound bed is filled
-open wound
-Scarring
-Takes 6-12 weeks

A

Secondary Intention

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22
Q

-Fails to progress to healing in a timely
-remain open for a long period of time

A

chronic wound

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23
Q

-delay of 4-6 days to begin healing
-scaring
-deep and open wound
-possible necrotic tissue

A

Tertiary Intention

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24
Q

-Healing begins
- first 3-5 days
-Increase of pain, redness, warmth, and swelling
-bleeding is formed into clots (coagulation cascade)

A

Inflammatory phase

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25
Q
  • Last several weeks (depends on intention)
    -Wound bed fills with granulation tissue
    -new blood vessels develop
A

Proliferative phase

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26
Q
  • Remodeling
  • Collagen continues to be deposited and remodeled
    -last up to a year
    -scar tissue is formed and strengthened
A

Maturation phase

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27
Q

new beefy red tissue created to fill wound bed

A

granulation tissue

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28
Q

avascular mass of collagen that gives strength to repaired wound

A

scar tissue

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29
Q

connection with surgical incisions becomes separated during healing process

A

dehiscence

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30
Q

total separation of all tissue layers causing organ protrusion

A

evisceration

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31
Q

indicative of new collagen growth being layed down in the wound

A

healing ridge

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32
Q

abnormal connection between two internal organs or from organ to skin

A

fistula

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33
Q

damage to skin in an area that includes soft tissue damage and usually found over boney prominences

A

pressure injury

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34
Q

minimum pressure required to collapse a capillary

A

capillary closing pressure

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35
Q

injuries resulting from use of medical devices (tubing, sensors, trach ties)

A

medical device related pressure injury

36
Q

two surfaces rubbing together

A

friction

37
Q

skin sticks to surface and is forcefully pulled off

A

shear

38
Q

inflammation or skin erosion caused by prolonged exposure to a source of moisture

A

moisture associated skin damage

39
Q

condition in which excessive moisture cause softening of the skin

A

maturation

40
Q

-perineal inflammation and dermatitis caused by contact with urine or feces
-damage from moisture is confined to more superficial layers

A

incontinence related dermatitis

41
Q

redness due to excessive vasodilation caused by pressure

A

abnormal reactive hypermia

42
Q

area of tissue loss present under intact skin forming a lip around wound

A

undermining

43
Q

narrower passageway extending outward from edge or the wound

A

tunneling

44
Q

necrotic tissue

A

eschar

45
Q

clear, watery drainage from wound

A

serous

46
Q

pink to pale red drainage that is mix of serous fluid and blood

A

serosanguineous

47
Q

bleeding drainage

A

sanguineous

48
Q

removal of necrotic tissue

A

debridement

49
Q

bacterial load

A

bioburden

50
Q

closed drainage system in which a soft drain is attached to a bulb like suction device

A

JP drain

51
Q

open drain that is a flexible piece of tubing that is not sutured into place

A

penrose drain

52
Q

spring like drainage system

A

hemovac

53
Q

threads used to bring the edges of a wound together in order to speed wound healing and reduces scar formation

A

suture

54
Q

What are the factors that affect skin integrity?

A

-wounds
-vascular disease
-diabetes
-malnutrition
-age

55
Q

-superficial layers of skin are removed by medical adhesive
-lasts longer than 30 minutes
-causes pain, increases infection and wound size, slows healing

A

medical adhesive related skin injury

56
Q

What factors affect wound healing?

A

-oxygen and tissue perfusion
-diabetes
-nutrition
-age
-infection

57
Q

injuries caused by electricity, chemicals, radiation, extreme cold, friction

A

burns

58
Q

-damages on the epidermis
-pain and redness

A

superficial burn

59
Q

-damages epidermis and dermis
- pain and blisters

A

partial thickness burn

60
Q

-damages all layers of skin
-white, brown, or charred
-no sensation
-requires surgery

A

full thickness burn

61
Q

What factors can lead to pressure injury?

A

-friction/shear
-sensory loss/ immobility
-moisture
-nutrition

62
Q

-non blanchable
-intact skin
-painful
- differs in temp and firmness
-abnormal reactive hypermia

A

stage 1

63
Q

-partial thickness skin loss
-exposed dermis
-intact or open blisters
-shallow and superficial

A

stage 2

64
Q
  • full thickness skin loss but not muscle, bone, connective tissue
    -undermining and tunneling
A

stage 3

65
Q
  • full thickness skin and tissue loss
    -see bone, cartilage, muscle
A

stage 4

66
Q

-obscured full thickness skin and tissue loss
-cannot be assessed till eschar is removed

A

unstageable

67
Q
  • nonblanchable
  • deep red, maroon, or purple
    -skin intact
A

deep tissue

68
Q

-uses a scalpel, curette, or scissors
-underlying infection, or large amount that needs fast removal
-premedicate and caution with bleeding disorders

A

sharp debridement

69
Q

-remove necrotic tissue but also disturbs viable tissue
-wet to dry
-whirlepools
-painful, harmful to viable tissue, and bleeding

A

mechanical debridement

70
Q

-topical agents containing enzymes that break down fibrin, collagen, or elastin present in devitalized tissue
-slow but effective

A

enzymatic debridement

71
Q

wounds have innate ability to clean itself of debris and necrotic tissue

A

autolytic

72
Q

-autolytic
-requires moist environment
-slowest but most comfortable

A

occlusive debridement

73
Q

-sterile, medical larvae
-secrete enzymes that break down necrotic tissue
-most effective

A

biologic debridement

74
Q

-used to pack all wounds
-cover dressings
-absorbant for heavy wound drainage

A

gauze dressing

75
Q

-used for wounds with minimal to no drainage
-promotes autolytic debridement
-prevents bacteria and fluids

A

transparent film

76
Q

-Used on clean, uninfected wounds
-promotes autolytic debridement

A

hydrocolloids

77
Q

-used for wounds that are producing moderate to heavy amounts of drainage

A

foams

78
Q

-used for bleeding and draining wounds

A

alginates

79
Q

–used for wounds with minimal to no drainage
-promotes autolytic debridement
-adds moisture to wound

A

gels

80
Q

drainage that is thick, yellowish green, and four odor

A

purluent

81
Q

What are the 5 ps of circulation?

A
  • pain
    -pallor
    -puleslessness
    -paresthesia
    -paralysis
82
Q

culture that is available on the surface of the wound

A

aerobic

83
Q

culture that is available deeper in the wound

A

anaerobic

84
Q

dressing that begins at distal portion of a limb and is wrapped around twice

A

circular wrap

85
Q

wraps for extremities

A

spiral/reverse spiral

86
Q

wraps for joints

A

figure eight

87
Q

wraps for head or amputated limbs

A

recurrent wraps

Exam 3 (2 decks)

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