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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
maturation stage
wound stabilized scar tissue structure
26
is secondary intention for clean or dirty wounds
dirty
27
scar tissue is never as strong as
original intact skin
28
serous
plasma clear/transparent yellow tinge
29
sanguineous
blood
30
serosanguineous
clear with blood pinkish tinge
31
purulent
pus green/yellow/brown infection and pathogens
32
biofilms
bacteria that grows in clumps of proteins and sugars that cover wound bed *inhibits healing
33
hemorrhage
wound bleeds
34
dehiscence
usually for abdominal wounds two edges have come apart *post abdominal surgery, coughing/vomiting puts pressure on suture line and it busts
35
evisceration
busts through muscles and skin down to organs
36
teaching to prevent dehiscence and evisceration
splinting hold pillow over stitches then cough
37
fistula
two things that should not be connected but are
38
actions for evisceration
cover with saline soaked sterile gauze and call physician
39
vitamins needed for wound healing
vitamin a vitamin c iron zinc copper
40
desication
dry skin
41
maceration
skin pruning
42
why do steroids affect wound healing
decrease immune response
43
why does aspirin affect wound healing
blood thinner affects hemostasis
44
why do antineoplastic (chemo) meds affect wound healing
kills all cells
45
RYB
red - protect yellow - clean black - debride
46
albumin measures
protein from 6 weeks prior
47
prealbumin measures
protein NOW
48
purpose of wound culture
identify organisms on surface *use Z method *clean first
49
healing wound bed
pink granulation tissue
50
penrose drain
empties into dressing *passive drain *not sutured
51
retention sutures are used for
large areas
52
Jackson Pratt (JP) drain
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
hemovac
active sutured used for bigger volumes
54
when to use heat therapy
few days after injury
55
when to use cold therapy
initially
56
what does heat therapy increase
blood flow (healing) O2 and nutrients leukocytes to area smooth muscle relaxation cellular metabolism
57
what does heat therapy decrease
pain
58
what does cold therapy decrease
edema and inflammation bleeding muscle spasms cellular metabolism (slows bacterial growth)
59
cold therapy causes ______ and ______
vasoconstriction (stops bleeding) local anesthetic effect
60
why use cold therapy initially
causes vasoconstriction = decreased blood flow = hemostasis decreases cellular metabolism = decreased pathogen amount
61
why use heat therapy after a couple days
increased blood flow = supplies O2, nutrients, and leukocytes to area = promotes inflammation and proliferation stage
62
normal saline
0.9 NS
63
surgical debridement
cut out in OR
64
chemical debridement
dakins bleach solution dressing
64
mechanical debridement
4x4 wet to dry and rip out tissue
65
maintain a moist wound environment
wet to moist dressing
66
if there is a wet to moist dressing and the dressing dries out, what do we do
rewet the dressing before removal
67
braden score less than ____ gets mepilex on the sacrum
18
68
tegaderm dressing
non-absorbent protective *clear sticker for IV sites and redness
69
mepilex uses
prevents pressure wounds waterproof worn up to 7 days absorbs drainage never used for infected protects wounds and surrounding skin
70
why don't you use mepilex for infected wounds
it seals in the infection and makes it worse
71
mepilex can prevent _____ and _____
friction and shear
72
negative pressure wound therapy
creates vacuum over the wound surface
73
what does NPWT do
draws out fluids decreases bacterial growth increases blood flow brings together wound edges
74
NPWT stimulates
epithelial growth tissue
75
silvadine cream for
burns *silver in silvadine is antibacterial properties
76
what is hydrogel
water goop *keeps moisture in *put on pink granulated tissue

Fundamentals NUR 220 (21 decks)

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