SKIN INTEG & WOUND CARE Flashcards

1
Q

What is Skin?

A

Largest Organ of the Body 1/6 of TBW, Synthesize Vita D, Protects, Sensory Organ

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

Skin is Affected By?

A

Genetics, Age, Meds, Chronic Illness, Nutrition

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

2 Principal Layers of the Skin?

A

Epidermis and Dermis

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

Types of Wounds

A

Open, Close, Ulcer

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

Open Wounds

A

Abrasion, Laceration, Puncture, Avulsions

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

Abrasion is?

A

Skin rubbed on a rough surface with little to no bleeding

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

Laceration is?

A

Jagged cut caused by sharp objects with extensive bleeding that needs stitches and heavy cleaning

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

Puncture is?

A

Hole wound caused by objects such as gunshot and usually need tetanus or antibiotic shot

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

Avulsion is?

A

Partial or complete tear of the skin caused by explosions or accidents

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

Closed Wounds

A

Contusion, Blisters, Seroma, Hematoma, Crush Injury

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

Contusion is?

A

Medical term for bruise with black to blue color caused of BV breakdown

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

Blister is?

A

Bubble pops with fluid build up of clear water (serum)

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

Seroma is?

A

Clear fluid build up near an incision surgical site

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

Hematoma is?

A

Pool of clotted blood caused by BV breakdowns because of injury or trauma

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

Crush injury is?

A

Prolonged compression of torso or limbs

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

Ulcer wounds

A

Pressure, Venous, Arterial, Neuropathic

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

Pressure ulcer is also known as?

A

Decubitus Ulcer, Pressure Sore, Bed Sore

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

What is Ischemia?

A

Decreased blood supply to tissues

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

What is Reactive Hyperemia?

A

Red Flush in localized site of wound

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

What is Vasodilation?

A

Extra blood delivery to the impeded site of blood flow

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

How does ulcer affect cellular metabolism?

A

Impedes blood flow causing ischemia

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

Factors of pressure ulcer

A

Friction /Shearing, Poor Nutri, Incontinence (Maceration, Excoriation), Moisture, Activity, Immobility, Decreased LOC, Excessive Body Heat, Poor Lifting technique, incorrect pos

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

What is LOC?

A

Level of Consciousness

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

What is Maceration?

A

Too moist site making tissues soft

25
Q

What is Excoriation

A

Loss of Layers of the Skin

26
Q

Common sites of pressure ulcer of the back?

A

Heels, Tailbone, elbow, shoulder, back of the head

27
Q

Common site of pressure ulcer of the sides?

A

Ankle, Hips, knees, shoulder, ears

28
Q

Common site of pressure ulcer sitting?

A

Shoulder blade, buttocks, heels, ball of foot

29
Q

What is Stage 1 Pressure Ulcer?

A

Intact Skin, Non blanchable redness, pain, firm, warm/cool

30
Q

Stage 1 treatment?

A

Offload pressure, transparent film dressing, hydrocolloid dressing, moisture barrier

31
Q

What is Stage 2 Pressure Ulcer?

A

Partial Thickness loss of skin, superficial present/abrasion, bleeding, higher scarring, higher susceptibility

32
Q

Stage 2 treatment?

A

Hydrocolloid dressing, Absorptive dressing, Draining wound, Hydrogel Healing Wound

33
Q

What is Stage 3 Pressure Ulcer?

A

Full thickness loss of skin, deep crater

34
Q

Stage 3 treatment?

A

Draining: Absorptive Dressing, Neuropathic: Debridement, Granulation: Hydrogel Healing wound

35
Q

What is Stage 4 Pressure Ulcer?

A

Visible bone or palpable, full thickness loss of skin

36
Q

What is unstageable wound?

A

True depth is not determined due to slough or eschar

37
Q

Slough color?

A

Tan, Yellowish, Stringy

38
Q

Eschar Color?

A

Brown, Black

39
Q

Deep tissue injury?

A

Starts inside showing maroon or purple color above the localized site

40
Q

Risk assessment tools for pressure ulcer?

A

Norton Scale, Gosnell Scale, Braden Scale

41
Q

Braden scale subscales are?

A

Sensory percep, moisture, activity, mobility, nutrition, friction/shearing

42
Q

What is Primary Intention?

A

little to no loss of skin tissues, approximated

43
Q

What is Secondary Intention?

A

Excessive skin tissue loss, edges cannot be approximated, bleeding, higher scarring and susceptibility

44
Q

What is Tertiary Intention?

A

Also known as delayed primary intention, 3-5 days opened and closed by staples, sutures

45
Q

Phases of wound healing?

A

Inflammatory, Proliferative, Maturation

46
Q

Inflammatory phase?

A

3-6 days after injury, hemostasis, phagocytosis happens

47
Q

What is Hemostasis?

A

Bleeding is stopped

48
Q

What is Phagocytosis?

A

Defense is build up

49
Q

What is Proliferative phase?

A

3-21st day post injury, collagen synthesize, granulation of tissue occurs

50
Q

What is Maturation phase?

A

21st day to 2 years, collagen organize, remodeling, scarring present, keloid too

51
Q

What is Kelloid?

A

Hypertrophic scarring caused by collagen build up

52
Q

What is Hemorrhage?

A

Massive bleeding

53
Q

What is Infection?

A

Contaminated wound site during healing

54
Q

What is Dehiscence with possible evisceration?

A

Rupture of suture wound with protruding viscera

55
Q

What is Serous Exudate?

A

Serum build up with few watery cell

56
Q

What is Purulent exudate?

A

Puss filled build up

57
Q

What is Sanguineous exudate?

A

High number of RBC build up

58
Q

What is Serosanguineous exudate?

A

Blood clear build up

59
Q

What is Purosanguineous exudate?

A

Puss and blood build up