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Fundamentals NUR 220 > Skin Integrity > Flashcards

Skin Integrity Flashcards

1
Q

wound

A

break or disruption in normal skin and tissue integrity

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2
Q

wound types

A

closed/open
clean/dirty

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3
Q

closed

A

deep but skin is closed on top

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4
Q

incision

A

clean cut
sterile
edges well approximated

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5
Q

clean wound example

A

surgical

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6
Q

dirty wound example

A

PI

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7
Q

contusion

A

bruise

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8
Q

abrasion

A

like rug burn
scrape atop skin

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9
Q

puncture

A

anything going into skin
*bullet, IV

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10
Q

laceration

A

cut not clean
jagged
traumatic

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11
Q

partial thickness

A

epidermis
dermis

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12
Q

full thickness

A

down to SUBQ and muscle

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13
Q

acute wound

A

wound that heals in normal expected time

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14
Q

chronic wound

A

wound that takes extended time to heal

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15
Q

intentional wound

A

surgery

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16
Q

unintentional wound

A

trauma/accidents

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17
Q

what is the first line of defense

A

INTACT skin

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18
Q

what does normal healing require

A

circulation
clean environment
nutrition/hydration

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19
Q

primary healing

A

wound edges well approximated and closed

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20
Q

secondary healing

A

edges not approximated
extensive tissue loss
repair time longer
scarring greater
susceptibility to infection increased
*takes a long time bc cell regeneration

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21
Q

tertiary healing

A

wounds left open for 3-5 days then closed with sutures

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22
Q

hemostasis

A

clotting
*happens right away

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23
Q

inflammatory phase

A

white cells (macrophages) come in to clean wound, presents with redness and swelling

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24
Q

proliferation stage

A

cells are growing and renewing
epithelial cells and new tissue

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25
Q

maturation stage

A

wound stabilized
scar tissue
structure

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26
Q

is secondary intention for clean or dirty wounds

A

dirty

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27
Q

scar tissue is never as strong as

A

original intact skin

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28
Q

serous

A

plasma
clear/transparent
yellow tinge

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29
Q

sanguineous

A

blood

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30
Q

serosanguineous

A

clear with blood
pinkish tinge

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31
Q

purulent

A

pus
green/yellow/brown
infection and pathogens

32
Q

biofilms

A

bacteria that grows in clumps of proteins and sugars that cover wound bed
*inhibits healing

33
Q

hemorrhage

A

wound bleeds

34
Q

dehiscence

A

usually for abdominal wounds
two edges have come apart
*post abdominal surgery, coughing/vomiting puts pressure on suture line and it busts

35
Q

evisceration

A

busts through muscles and skin down to organs

36
Q

teaching to prevent dehiscence and evisceration

A

splinting
hold pillow over stitches then cough

37
Q

fistula

A

two things that should not be connected but are

38
Q

actions for evisceration

A

cover with saline soaked sterile gauze and call physician

39
Q

vitamins needed for wound healing

A

vitamin a
vitamin c
iron
zinc
copper

40
Q

desication

A

dry skin

41
Q

maceration

A

skin pruning

42
Q

why do steroids affect wound healing

A

decrease immune response

43
Q

why does aspirin affect wound healing

A

blood thinner
affects hemostasis

44
Q

why do antineoplastic (chemo) meds affect wound healing

A

kills all cells

45
Q

RYB

A

red - protect
yellow - clean
black - debride

46
Q

albumin measures

A

protein from 6 weeks prior

47
Q

prealbumin measures

A

protein NOW

48
Q

purpose of wound culture

A

identify organisms on surface
*use Z method
*clean first

49
Q

healing wound bed

A

pink granulation tissue

50
Q

penrose drain

A

empties into dressing
*passive drain
*not sutured

51
Q

retention sutures are used for

A

large areas

52
Q

Jackson Pratt (JP) drain

A

bulb like drains adjacent to surgical area
*during inflammatory phase fluid is not drained, could cause abscess
*drains fluids or exudates
*we measure how much and what its draining
*take out if nothing after 8is hours
*active drain
*sutured in

53
Q

hemovac

A

active
sutured
used for bigger volumes

54
Q

when to use heat therapy

A

few days after injury

55
Q

when to use cold therapy

A

initially

56
Q

what does heat therapy increase

A

blood flow (healing)
O2 and nutrients
leukocytes to area
smooth muscle relaxation
cellular metabolism

57
Q

what does heat therapy decrease

A

pain

58
Q

what does cold therapy decrease

A

edema and inflammation
bleeding
muscle spasms
cellular metabolism (slows bacterial growth)

59
Q

cold therapy causes ______ and ______

A

vasoconstriction (stops bleeding)
local anesthetic effect

60
Q

why use cold therapy initially

A

causes vasoconstriction = decreased blood flow = hemostasis
decreases cellular metabolism = decreased pathogen amount

61
Q

why use heat therapy after a couple days

A

increased blood flow = supplies O2, nutrients, and leukocytes to area = promotes inflammation and proliferation stage

62
Q

normal saline

A

0.9 NS

63
Q

surgical debridement

A

cut out in OR

64
Q

chemical debridement

A

dakins bleach solution dressing

64
Q

mechanical debridement

A

4x4 wet to dry and rip out tissue

65
Q

maintain a moist wound environment

A

wet to moist dressing

66
Q

if there is a wet to moist dressing and the dressing dries out, what do we do

A

rewet the dressing before removal

67
Q

braden score less than ____ gets mepilex on the sacrum

A

18

68
Q

tegaderm dressing

A

non-absorbent
protective
*clear sticker
for IV sites and redness

69
Q

mepilex uses

A

prevents pressure wounds
waterproof
worn up to 7 days
absorbs drainage
never used for infected
protects wounds and surrounding skin

70
Q

why don’t you use mepilex for infected wounds

A

it seals in the infection and makes it worse

71
Q

mepilex can prevent _____ and _____

A

friction and shear

72
Q

negative pressure wound therapy

A

creates vacuum over the wound surface

73
Q

what does NPWT do

A

draws out fluids
decreases bacterial growth
increases blood flow
brings together wound edges

74
Q

NPWT stimulates

A

epithelial growth tissue

75
Q

silvadine cream for

A

burns
*silver in silvadine is antibacterial properties

76
Q

what is hydrogel

A

water goop
*keeps moisture in
*put on pink granulated tissue

Fundamentals NUR 220 (21 decks)

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