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NS371—Fundamentals of Nursing > Skin Integrity > Flashcards

Skin Integrity Flashcards

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1
Q

clean wounds

A

closed, intact, not infected

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2
Q

clean-contaminated wounds

A

surgical wounds - no infection

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3
Q

contaminated wounds

A

open, accidental or surgical - involves major break in sterile technique

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4
Q

dirty & infected wounds

A

show evidence of infection

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5
Q

partial thickness wounds

A

dermis & epidermis healing by regeneration (on its own)

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6
Q

full thickness wounds

A

all 3 layers of tissue - possible muscle & bone - requires tissue repair

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7
Q

etiology of pressure wounds

A

ischemia

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8
Q

reactive hyperemia

A

blanchable bright red flush to skin when pressure removed - results from vasodilation

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9
Q

pressure ulcer risk factors

A 
friction & shearing
Immobility
Inadequate nutrition
Incontinence - can cause maceration
Decreased mental status
Diminished sensation
Excessive body heat
Advanced age
Chronic medical conditions
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10
Q

stages of pressure ulcers

A

Stage 1—Nonblanchable erythema
Stage 2—Partial-thickness skin loss - to dermis - open or closed ulcer
Stage 3—Full-thickness skin loss - SQ visible
Stage 4—Full-thickness skin loss c necrosis - muscle, tendon, ligament, bone visible

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11
Q

epibole

A

edges of ulcer roll under & damage to skin extends beneath roll

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12
Q

slough and eschar prevent us from…

A

assessing depth

staging injury

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13
Q

Deep tissue pressure injury

A

Purple or black intact skin - blackish blistered area - heavy or spongy at palpation

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14
Q

prevention of pressure ulcers

A

Assess pt’s risk factors q shift - Braden Scale
Keep skin dry & clean
Use barrier creams
Wrinkle-free linens
Turn q 2 hrs
Watch friction & shear
Special air beds & devices for pts c high risk

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15
Q

components of braden scale

A 
sensory perception
moisture
activitiy
mobility
nutrition
friction & shear
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16
Q

braden scale explain scores

A

the higher the score, the less risk for an ulcer

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17
Q

Primary intention healing

A

tissue surfaces approximate - minimal/no tissue loss - minimal granulation tissue & scarring

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18
Q

secondary intention healing

A

extensive tissue loss - no approximation - repair time longer - scarring greater - susceptibility to infection

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19
Q

tertiary intention healing

A

leave wound open for 3-5 days until edema/drainage is gone - closed with sutures, staples, adhesives

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20
Q

phases of healing

A

inflammation
proliferative
maturation

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21
Q

dehisence

A

rupture of sutured wound - partial or total - usually involves abdominal wound c layers beneath skin also separating

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22
Q

evisceration

what do you do?

A

4-5 days post op - protrusion of internal organ through incision - emergency situation - organ is exposed - immediately put on sterile wet dressing, then call physician

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23
Q

risk factors for dehisence, evisceration

A

obesity, poor nutrition, multiple trauma, failure of suturing, excessive coughing, vomiting, dehydration

24
Q

assess pressure ulcers for…

A

location related to bony prominence, undermining or sinus tracts, stage, color of wound bed, location of necrosis or eschar, condition of margins, integrity of surrounding skin, signs of infection

25
Q

minimal drainage

A

stains dressing - give size of stain

26
Q

moderate drainage

A

saturates dressing but does not leak out - notify physician

27
Q

maximal drainage

A

overflow dressing - emergency

28
Q

support wound healing

A 
Clean & dress injury using surgical asepsis
Do not use alcohol or hydrogen peroxide
Obtain C&S if infected
Teach pt to move often
Provide active or passive ROM exercise
RYB color code (color of wound)
29
Q

RYB

A

red - protect
yellow - cleanse
black - debride

30
Q

4 types of debriding

A

Sharp - scissors, scalpel to debride wound
Mechanical - scrubbing
Chemical - enzymes, etc
Autolytic - hydrocolloid dressing

31
Q

off loading

A

devices to prevent ulcers

32
Q

masd

A

moisture associated skin damage

33
Q

function of wound drains

A

prevent abscess

34
Q

penrose drain

A

little tube - drains surgical wounds

35
Q

jackson pratt drain

A

bulb - squeeze before closing lid - slowly opens and pulls drainage into it

36
Q

hemovac drain

A

same concept as JP drain, but holds more drainage

37
Q

wound irrigation pressure

A

4-15 psi

38
Q

type of dressing depends on…

A

Depends on location, size, type of wound, amount of exudate, whether it requires debridement, is infected, frequency of change, cost, difficulty of application

39
Q

3 types of dressings & what they are used for

A

Transparent - ulcerations, burns
Hydrocolloid - pressure injuries
Secure - ensure dressing covers entire wound & doesn’t become dislodged

40
Q

bandage turns & description

A

Circular - anchor bandages & terminate them - not applied directly to wound
Spiral - part of body uniform in circumference
Recurrent - cover distal parts of body
Figure 8 - elbow, knee, ankle - allow some movement

41
Q

applying arm sling

A

80º angle arm - thumb facing upward or inward toward body

42
Q

heat causes _______ after 20-30 mins

A

vasodilation

43
Q

heat increases…

cold decreases…

A

vasodilation
cap permeability
inflammation
cellular metabolism

44
Q

heat no longer than ___ mins

A

30

45
Q

heat indications

A

muscle spasm
inflammation
pain
joint stiffness

46
Q

heat has no effect on

A

traumatic injuries

47
Q

do not use heat…

A 
First 24 hours after traumatic injury
Active hemorrhage
Noninflammatory edema
Skin disorder that causes blister
Longer than 30 mins
48
Q

maximum cold vasoconstriction

A

60º

49
Q

lewis hunting effect

A

alternation of vasodilation & vasoconstriction with cold <60º

50
Q

cold slows _______

mild _______ effect

A

bacterial growth

anesthetic

51
Q

cold indications

A

muscle spasm
inflammation
pain
traumatic injury

52
Q

cold has no effect on

A

contracture

joint stiffness

53
Q

do not use cold….

A

Open wounds
Impaired circulation
Allergy or hypersensitivity to cold

54
Q

rebound phenomenon

A

occurs at maximum therapeutic effect of hot or cold applications is achieved and the opposite effect begins - Lewis Hunting

55
Q

to know about heat/cold devices

A

cover them

do not use heat beneath pt

NS371—Fundamentals of Nursing (12 decks)

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