SKIN INTEG & WOUND CARE Flashcards
What is Skin?
Largest Organ of the Body 1/6 of TBW, Synthesize Vita D, Protects, Sensory Organ
Skin is Affected By?
Genetics, Age, Meds, Chronic Illness, Nutrition
2 Principal Layers of the Skin?
Epidermis and Dermis
Types of Wounds
Open, Close, Ulcer
Open Wounds
Abrasion, Laceration, Puncture, Avulsions
Abrasion is?
Skin rubbed on a rough surface with little to no bleeding
Laceration is?
Jagged cut caused by sharp objects with extensive bleeding that needs stitches and heavy cleaning
Puncture is?
Hole wound caused by objects such as gunshot and usually need tetanus or antibiotic shot
Avulsion is?
Partial or complete tear of the skin caused by explosions or accidents
Closed Wounds
Contusion, Blisters, Seroma, Hematoma, Crush Injury
Contusion is?
Medical term for bruise with black to blue color caused of BV breakdown
Blister is?
Bubble pops with fluid build up of clear water (serum)
Seroma is?
Clear fluid build up near an incision surgical site
Hematoma is?
Pool of clotted blood caused by BV breakdowns because of injury or trauma
Crush injury is?
Prolonged compression of torso or limbs
Ulcer wounds
Pressure, Venous, Arterial, Neuropathic
Pressure ulcer is also known as?
Decubitus Ulcer, Pressure Sore, Bed Sore
What is Ischemia?
Decreased blood supply to tissues
What is Reactive Hyperemia?
Red Flush in localized site of wound
What is Vasodilation?
Extra blood delivery to the impeded site of blood flow
How does ulcer affect cellular metabolism?
Impedes blood flow causing ischemia
Factors of pressure ulcer
Friction /Shearing, Poor Nutri, Incontinence (Maceration, Excoriation), Moisture, Activity, Immobility, Decreased LOC, Excessive Body Heat, Poor Lifting technique, incorrect pos
What is LOC?
Level of Consciousness
What is Maceration?
Too moist site making tissues soft
What is Excoriation
Loss of Layers of the Skin
Common sites of pressure ulcer of the back?
Heels, Tailbone, elbow, shoulder, back of the head
Common site of pressure ulcer of the sides?
Ankle, Hips, knees, shoulder, ears
Common site of pressure ulcer sitting?
Shoulder blade, buttocks, heels, ball of foot
What is Stage 1 Pressure Ulcer?
Intact Skin, Non blanchable redness, pain, firm, warm/cool
Stage 1 treatment?
Offload pressure, transparent film dressing, hydrocolloid dressing, moisture barrier
What is Stage 2 Pressure Ulcer?
Partial Thickness loss of skin, superficial present/abrasion, bleeding, higher scarring, higher susceptibility
Stage 2 treatment?
Hydrocolloid dressing, Absorptive dressing, Draining wound, Hydrogel Healing Wound
What is Stage 3 Pressure Ulcer?
Full thickness loss of skin, deep crater
Stage 3 treatment?
Draining: Absorptive Dressing, Neuropathic: Debridement, Granulation: Hydrogel Healing wound
What is Stage 4 Pressure Ulcer?
Visible bone or palpable, full thickness loss of skin
What is unstageable wound?
True depth is not determined due to slough or eschar
Slough color?
Tan, Yellowish, Stringy
Eschar Color?
Brown, Black
Deep tissue injury?
Starts inside showing maroon or purple color above the localized site
Risk assessment tools for pressure ulcer?
Norton Scale, Gosnell Scale, Braden Scale
Braden scale subscales are?
Sensory percep, moisture, activity, mobility, nutrition, friction/shearing
What is Primary Intention?
little to no loss of skin tissues, approximated
What is Secondary Intention?
Excessive skin tissue loss, edges cannot be approximated, bleeding, higher scarring and susceptibility
What is Tertiary Intention?
Also known as delayed primary intention, 3-5 days opened and closed by staples, sutures
Phases of wound healing?
Inflammatory, Proliferative, Maturation
Inflammatory phase?
3-6 days after injury, hemostasis, phagocytosis happens
What is Hemostasis?
Bleeding is stopped
What is Phagocytosis?
Defense is build up
What is Proliferative phase?
3-21st day post injury, collagen synthesize, granulation of tissue occurs
What is Maturation phase?
21st day to 2 years, collagen organize, remodeling, scarring present, keloid too
What is Kelloid?
Hypertrophic scarring caused by collagen build up
What is Hemorrhage?
Massive bleeding
What is Infection?
Contaminated wound site during healing
What is Dehiscence with possible evisceration?
Rupture of suture wound with protruding viscera
What is Serous Exudate?
Serum build up with few watery cell
What is Purulent exudate?
Puss filled build up
What is Sanguineous exudate?
High number of RBC build up
What is Serosanguineous exudate?
Blood clear build up
What is Purosanguineous exudate?
Puss and blood build up