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NUCM 103 Fundamentals in Nursing > Skin Integrity > Flashcards

Skin Integrity Flashcards

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1
Q

refers to the presence of normal skin and skin layers uninterrupted by wounds.

A

intact skin

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2
Q

Factors affecting skin integrity

A

genetics
age
illnesses
medications
nutrition

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3
Q

Types of wounds

A

cut
stab
stab and cut
torn
bitten
chopped
crush
hurt
firearms
scalped
surgery
poisoned

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4
Q

are uninfected wounds in which there is minimal inflammation and the respiratory, gastrointestinal, genital, and urinary tracts are not entered

A

clean wounds

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5
Q

are surgical wounds in which the respiratory, gastrointestinal, genital, or urinary tract has been entered.

A

clean contaminated wounds

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6
Q

include open, fresh, accidental wounds and surgical wounds involving a major break in sterile technique or a large amount of spillage from the gastrointestinal tract.

A

contaminated wounds

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7
Q

include wounds containing dead tissue and wounds with evidence of a clinical infection, such as purulent drainage.

A

dirty or infected wounds

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8
Q

Types of Wounds

A

incision
contusion
abrasion
puncture
laceration
penetrating wound

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9
Q

Sharp instrument (e.g., knife or scalpel)

Open wound; deep or shallow; once the edges have been sealed together as a part of treatment or healing, the incision becomes a closed wound

A

incision wound

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10
Q

Blow from a blunt instrument

Closed wound, skin appears ecchymotic (bruised) because of damaged blood vessels.

A

contusion

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11
Q

Surface scrape, either unintentional (e.g., scraped knee from a fall) or intentional (e.g., dermal abrasion to remove pockmarks)

Open wound involving the skin

A

abrasion

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12
Q

Penetration of the skin and often the underlying tissues by a sharp instrument, either intentional or unintentional

A

puncture

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13
Q

Tissues torn apart, often from accidents

A

lacerations

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14
Q

Penetration of the skin and the underlying tissues, usually unintentional (e.g., from a bullet or metal fragments)

A

penetrating wound

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15
Q

are one of the many signs of nursing home abuse, nursing home neglect, or medical malpractice in a hospital.

A

bedsores

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16
Q

consist of injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of force alone or in combination with movement.

A

pressure ulcers

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17
Q

What are the risk factors of pressure ulcers?

A

friction and shearing
immobility
inadequate nutrition
fecal and urinary incontinence
decreased mental status
diminished sensation
excessive body heat
advance age
presence of certain chronic condition

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18
Q

is a force acting parallel to the skin surface.

A

friction

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19
Q

is a combination of friction and pressure. It occurs commonly when a client assumes a sitting position in bed.

A

shearing force

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20
Q

refers to a reduction in the amount and control of movement a person has.

A

immobility

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21
Q

causes weight loss, muscle atrophy, and the loss of subcutaneous tissue.

A

inadequate nutrition

22
Q

More specifically, inadequate intake of
1.
2.
3.
4.
5.
contributes to pressure ulcer formation

A

protein
carbohydrates
fluids
zinc
vitamin c

23
Q

Moisture from incontinence promotes skin maceration (tissue softened by prolonged wetting or soaking) and makes the epidermis more easily eroded and susceptible to injury.

A

fecal and urinary incontinence

24
Q

tissue softened by prolonged wetting or soaking

A

maceration

25
Q

area of loss of the superficial layers of the skin; also known as denuded area

A

excoriation

26
Q

Individuals with a reduced level of awareness, for example, those who are unconscious, heavily sedated, or have dementia, are at risk for pressure ulcers because they are less able to recognize and respond to pain associated with prolonged pressure

A

decreased mental status

27
Q

Paralysis, stroke, or other neurologic disease may cause loss of sensation in a body area.

A

diminished sensation

28
Q

is another factor in the development of pressure ulcers. An elevated body temperature increases the metabolic rate, thus increasing the cells’ need for oxygen

A

excessive body heat

29
Q

The aging process brings about several changes in the skin and its supporting structures, making the older person more prone to impaired skin integrity. These changes include the following:

A

loss of lean body mass
Generalized thinning of the epidermis
• Decreased strength and elasticity of the skin due to changes in the collagen fibers of the dermis
• Increased dryness due to a decrease in the amount of oil produced by the sebaceous glands
• Diminished pain perception due to a reduction in the number of cutaneous end organs responsible for the sensation of pressure and light touch
• Diminished venous and arterial flow due to aging vascular walls.

30
Q

These conditions compromise oxygen delivery to tissues by poor perfusion and thus cause poor and delayed healing and increase risk of pressure sores.

A

chronic medical conditions

31
Q

Other factors contributing to the formation of pressure ulcers are
1.
2.
3.
4.

A

poor lifting and transferring technique
incorrect positioning
hard support surfaces
incorrect application of pressure-relieving devices

32
Q

nonblanchable erythema signaling potential ulceration

what stage

A

stage 1

33
Q

partial-thickness skin loss (abrasion, blister, or shallow crater) involving the epidermis and possibly the dermis

what stage

A

stage 2

34
Q

full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia

A

stage 3

35
Q

full-thickness skin loss with tissue necrosis or damage to muscle, bone, or supporting structures

what stage

A

stage 4

36
Q

is material, such as fluid and cells, that has escaped from blood vessels during the inflammatory process and is deposited in tissue or on tissue surfaces.

A

exudate

37
Q

consists chiefly of serum (the clear portion of the blood) derived from blood and the serous membranes of the body, such as the peritoneum.

A

serous exudate

38
Q

is thicker than serous exudate because of the presence of pus, which consists of leukocytes, liquefied dead tissue debris, and dead and living bacteria.

A

purulent exudate

39
Q

The process of pus formation is referred to as

A

suppuration

40
Q

consists of large amounts of red blood cells, indicating damage to capillaries that is severe enough to allow the escape of red blood cells from plasma.

A

sanguineous exudate

41
Q

consisting of both clear and blood-tinged drainage, is commonly seen in surgical incisions.

A

serosangioneous exudate

42
Q

discharge, consisting of pus and blood, is often seen in a new wound that is infected.

A

purosanguineous

43
Q

complications of wound healing

A

hemorrhage
infection
dehiscence with possible evisceration

44
Q

is the partial or total rupturing of a sutured wound

A

dehiscence

45
Q

usually involves an abdominal wound in which the layers below the skin also separate

A

dehiscence

46
Q

is the protrusion of the internal viscera through an incision.

A

evisceration

47
Q

a scalpel or scissors is u s e d to separate and remove dead tissue.

A

sharp debridement

48
Q

removal of the necrotic material

A

debridement

49
Q

is accomplished through scrubbing force or damp-todamp dressings.

A

mechanical debridement

50
Q

is more selective than sharp or mechanical techniques. Collagenase enzyme agents such as papainurea are currently most recommended for this use.

A

chemical debridement

51
Q

dressings such as hydrocolloid and clear absorbent acrylic dressings trap the wound drainage against the eschar

A

autolytic debridement

NUCM 103 Fundamentals in Nursing (20 decks)

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