Brainscape's Knowledge GenomeTM


Top Flashcards (Certified)
All Flashcards

nurs222 > skin integ and wound care > Flashcards

skin integ and wound care Flashcards

1
Q

RN’s role in skin integrity

A

2-hr turns
skin assessments
provide wound care

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Patients at risk for altered skin integrity

A

Bed bound
Less mobile
Post-surgery
Older adults
Body piercings (hole)
Dehydration/malnourishment
Reduced sensation (quadriplegic)
Diabetics/immunocompromised (delayed wound healing)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Connective tissue

A

stores fat for energy
cushioning (protective layer)
heat/insulator
blood lymph vessels, nerves, fat cells

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

What is one function of the skin related to protection?

A

Coughing and sneezing mechanisms

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

How does the skin help regulate body temperature?

A

Perspiration and evaporation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

What psychosocial function does the skin serve?

A

External appearance

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

What sensory function does the skin provide?

A

Nerve endings that detect hot vs cold

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

What does vitamin D do for the body?

A

healthy bone density

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

What immunologic function does the skin provide?

A

immune system response triggered in presence of infection

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

What absorption function does the skin provide?

A

absorbing medications

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

What elimination function does the skin provide?

A

excretions through sweat

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

What helps defend against harmful agents related to the skin?

A

Unbroken, healthy skin and mucous membranes

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Adequate circulation is necessary to maintain ___

A

cell life

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Jaundice

A

yellow, itchy skin (liver problems)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Intentional wound (surgical)

A

a wound that is the result of a planned surgical or medical intervention

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Unintentional wound

A

are accidental; occur from unexpected trauma

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Neuropathic wound

A

Aka “diabetic” foot ulcers
Various neuropathic (sensory, motor, autonomic) contribute to changes in the foot which can lead to ulceration
Typically found on the plantar surface of the foot

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Vascular wound

A

Occurs with poor venous return, typically in leg

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Pressure related wounds

A

bed sores

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

open wounds

A

skin surface broken (portal of entry for bacteria)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Closed wound

A

force or trauma (soft tissue damage)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

acute wound

A

surgical, approximated wound edges, decreased infection rate, heals in days-weeks

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

chronic wound

A

healing is impeded, decreased quality of life (pain, restricted mobility)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

Partial thickness

A

all or a portion of the dermis is intact

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
full thickness
the entire dermis and sweat glands and hair follicles are severed
26
complex wound
the dermis and underlying subcutaneous fat tissue are damaged or destroyed
27
incision
a cut made in order to get inside something
28
contusion
bruise
29
abrasion
friction
30
laceration
tearing of skin
31
puncture
blunt sharp
32
penetrating
lodging
33
avulsion
tearing away
34
thermal wound
hot or cold
35
irradiation
UV radiation, light
36
pressure ulcers
4 stages 2 unstageable
37
venus ulcers
poor circulation
38
arterial ulcers
underlying ischemic (decreased tissue perfusion)
39
Wound healing depends on
first intention, second intention, third intention
40
first intention
healing of wound where wound edges are directly next to each other (mostly surgical- small scaring, well approximated)
41
second intention
wound edges are widely separated- takes longer to heal- larger scaring [burns, traumas, often contaminated]
42
third intention
edges widely separated- then brought together by a type of closure material
43
phases of wound healing
1. inflammatory phase 2. proliferation or reconstruction phase 3. maturation or remodeling phase
44
hemostasis
as soon as injury occurs; stops bleeding/activates WBC; coagulation/clotting
45
inflammation phase
immediately-4 days - immediate constriction of blood vessels to limit blood loss - dilates to damaged tissues so plasma and blood components can leak out and forms exudate - platelets aggression, formation of fibrin-> clot formation - macrophages come and ingest debris and growth factors
46
S/S inflammatory phase
- swelling or edema -erythema (increased blood supply) - heat/increased temp - pain from pressure on nerve receptors - possible loss of functioning (weakness/malaise) -leukocytosis (increased WBC)
47
new tissue
granulation tissue (very fragile) ; increased vascularity, very red, bleeds easily
48
proliferation stage
2-3 weeks - macrophages clear debris -fibroblasts synthesized collagen - new capillary networks form and begin to supply nutrients to support collagen - wound contracts and decreased in size - increase in endothelial cells
49
maturation stage
3 weeks-1 year - collagen is lysed (broken down) and resynthesizes by the macrophages -produces strong scar tissue [does not have same elasticity, bony area = decreased movement]
50
local factors affecting wound healing
pressure [disrupts blood supply] , desiccation [dehydration = dry], maceration [over hydration] , trauma, edema, infection [increased stress on body], excessive bleeding [large clots, hematomas] , necrosis [eschar tissue] , biofilm
51
Pathogenesis of pressure injuries
pressure intensity, tissue ischemia, blanching, pressure duration, tissue tolerance
52
Deep tissue pressure injury (DTPI)
deep bruise
53
slough
yellow tissue
54
eschar
black (you cannot properly stage a wound with eschar)
55
serous exudate
clear plasma
56
sanguineous exudate
bloody, red
57
serous-sanguineous
pink-tinged
58
purulent
thick, milky discharge that comes out of a wound and is a sign of infection. It may vary in color (grayish, yellow, green, or brown) and often has an unpleasant smell.
59
blanching
early sign, white skin
60
hemorrhage
-can result from slipped suture or dislodged clot - Q8 patients post-op - internal may lead to hypovolemic shock -external may include sanguineous drainage
61
S/S of hemorrhage
decreased bp, increased pulse, increased RR, restlessness, diaphoresis (sweating)
62
fistulas
abnormal passage from internal organ or vessel to outside of body
63
infection
immune system failure
64
Wound infection
- traumatic wounds higher risk -localized infection is called an abscess
65
abscess
accumulation of pus from debris as a result of phagocytosis
66
Dehiscence
- spontaneous opening of an incision - when an incision fails to heal properly [usually underlying disease]
67
S/S of dehiscence
increased flow of serosanguineous, pain, redness, swelling, increased temp, increased WBC
68
Evisceration
MEDICAL EMERGENCY NPO, supine position - protrusion of an internal organ through an incision
69
Health Promotion of Skin Integrity
-prevention of pressure ulcers - topical skin care, and incontinence management -positioning support surfaces
70
Debridement
the process of removing necrotic tissue from a wound so that healing can occur
71
Sharp method of debridement
necrotic tissue removed with sterile scissors or scalpel
72
Chemical method of debridement
use of topical substances to break down wound debris [NOT infected wounds & risk for complication] ex. elase
73
Autolytic method of debridement
process that allows the body's enzymes to soften and debride itsself - takes awhile to heal -wound kept moist with occlusive dressing -small wounds without infection ex. hydrogel
74
Mechanical method of debridement
physical removal of debris -surgically laser, wound irrigation -ex. hydrotherapy
75
purpose of dressings
protect wounds, aids in hemostasis, promotes healing, absorbs, supports and splints wounds, most environment
76
Drains and devices
tubes that provide a means for removing blood or drainage from a wound
77
open drain
(passive) drains by gravity ; not sutured in place [penrose drain, soft flexible, no collection device]
78
closed drain
(active) use negative pressure to drain wound; sutured in place,b built in reservoir [JPD, hemovacs]
79
Effects of heat application
vasodilation, reduced blood viscosity, reduced muscle tension, increased tissue metabolism, increased capillary permeability
80
Effects of cold application
vasoconstrictor, local anesthesia, reduced cell metabolism, increased blood viscosity, decreased muscle tension
81
Documentation of wound care
Size Presence of any drainage (amount and color) Odor Actual wound care given and how it was redressed How patient tolerated procedure

nurs222 (4 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2025 Bold Learning Solutions. Terms and Conditions