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FUNDA > Skin Integrity > Flashcards

Skin Integrity Flashcards

1
Q

list some functions of the skin

A
  • Protects against disease causing organisms
  • Sensory organ for temperature, pain, and touch
  • Synthesizes Vitamin D
  • Injury to skin poses a risk to safety and triggers a complex healing process
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2
Q

factors affecting skin

A
  • Genetics and heredity
  • Age
  • Chronic illnesses and their treatments
  • Medications
  • Poor nutrition
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3
Q

outer and top layer of the skin that you can see and touch

A

epidermis

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4
Q

protein inside skin cell

A

keratin

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5
Q

inner layer of skin

A

dermis

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6
Q

what is the function of the epidermis

A

functions to resurface wounds & restore the barrier against bacteria

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7
Q

what is the function of the dermis

A

functions to restore structural integrity-collagen & physical properties of skin

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8
Q

list the types of wounds

A

open wounds
closed wounds
ulcers

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9
Q

list types of open wounds

A

abrasion
laceration
puncture
avulsion

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10
Q

This kind of wound is not deep, so there is little to no bleeding that occurs

A

abrasion

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11
Q

deep and jagged cut that results in skin tears and heavy bleeding

A

laceration

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12
Q

hole-shaped wounds caused by pointy objects such as needles and nails

A

puncture

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13
Q

severe wound that can result in the partial or complete tear of the skin and tissues

A

avulsion

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14
Q

list types of closed wounds

A

contusions
blisters
seroma
hematoma
crush injury

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15
Q

happens when small blood vessels get torn and leak blood under the skin

A

contusion

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16
Q

bubbles that pop up when fluid collects in pockets under the top laver of your skin

A

blisters

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17
Q

accumulation of clear fluid under the skin, typically near the site of a surgical incision

A

seroma

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18
Q

pool of mostly clotted blood that forms in an organ, tissue, or body space

A

hematoma

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19
Q

result of physical trauma from prolonged compression of the torso, limb(s), or other parts of the body

A

crush injury

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20
Q

list types of ulcers

A

pressure
venous
arterial
neuropathic

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21
Q

Injury to skin and/or underlying tissue usually over a bony prominence

A

pressure injuries

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22
Q

Deficiency in blood supply to tissue

A

ischemia

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23
Q

Bright red flush to skin when pressure is received

A

reactive hyperemia

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24
Q

Extra blood floods to compensate for preceding period of impeded blood flow

A

vasodilation

25
Q

trauma caused by tissue lavers sliding across each other, results in disruption or angulation of blood vessels

A

shear

26
Q

what are the common pressure sites within the supine position

A

heels
sacrum (tailbone)
scapulae (shoulder)
back of head

27
Q

what are the common pressure sites of the lateral position

A

malleolus (ankle)
knee
ilium (hips)
shoulder
ear
side of head

28
Q

what are the common pressure sites within the prone position

A

toas
knees
genitalia (men)
breasts (women)
shoulder (acromial process)
cheek and ear (zygomatic bone)

29
Q

what are the common pressure sites within the fowlers position

A

heels (calcaneus)
buttocks
sacrum
ball of foot
pelvis
vertebrae

30
Q

Intact skin with non-blanchable redness or erythema of a localized area usually over a bony prominence. Darkly pigmented skin may not have blanching: its color may differ from the surrounding area

What stage of pressure ulcer is this

A

stage 1

31
Q

list stage 1 pressure ulcer treatment

A
  • Off-load pressure
  • Transparent film dressing
  • Hydrocolloid dressing
  • Moisture barrier
32
Q

Partial thickness skin loss involving the epidermis and/or dermis. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow open ulcer. Presents as shiny or shallow ulcer red/ pink wound bed) without slough or bruising

what stage of pressure ulcer is this

A

stage 2

33
Q

list stage 2 pressure ulcer treatments

A

hydrocolloid dressing
absorptive dressing
hydrogel
off-load pressure

34
Q

Full thickness skin loss involving damage or necrosis to subcutaneous tissue that may extend down to, but not through underlying fascia. Ulcer presents as a deep crater with or without undermining or tunneling of adjacent tissue

what stage of pressure ulcer is this

A

stage 3

35
Q

list stage 3 pressure ulcer treatments

A
  • Requires physician order for Stage Ill or
  • Draining vs. Non-draining
  • Necrotic vs. Granulating
  • Draining wounds.-Absorptive dressings
  • Granulating wounds..*Hydrogel
  • Necrotic wounds-Require debridement (Chemical. Mechanical, Autolytic, Sharp
36
Q

Full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone, or supporting structures. Exposed bone or tendon is visible or directly palpable

what stage of pressure ulcer is this

A

stage 4

37
Q

Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown, black) in the wound bed. The true depth of the wound cannot be determined until slough or eschar is removed

what is this referred as

A

unstageable wound

38
Q

types of wound healing

A

primary intention
secondary intention
tertiary intention

39
Q
  • Tissue surfaces approximated (closed) with sutures
  • Minimal or no tissue loss
  • Formulation of minimal granulation tissue and scarring

healing by which intention

A

primary intention

40
Q
  • Extensive tissue loss
  • Edges cannot be approximated.
  • Repair time is longer.
  • Scarring is greater.
  • Susceptibility to infection is greater

healing by which intention

A

secondary intention

41
Q
  • Also known as delayed primary intention
  • Initially left open 3-5 days
  • Edema, infection to resolve, or exudate to drain
  • Closed with sutures, staples, or adhesive skin closures

healing by which intnetion

A

tertiary intention

42
Q

list phases of wound healing

A

inflammatory phase
proliferative phase
maturation phase

43
Q

list complications of wound healing

A

hemorrhage
infection
dehiscence with possible evisceration

44
Q

list factors affecting wound healing

A
  • Developmental considerations
  • Nutrition
  • Lifestyle
  • Medications
45
Q

types of exudates

A
  • Serous
  • Purulent
  • Sanguineous
  • Mixed Exudates
46
Q
  • Mostly serum
  • Derived from blood and serous membranes of the body
  • Looks watery, few cells
A

Serous Exudates

47
Q
  • Thicker
  • Presence of pus
  • Consists of leukocytes, liquified dead tissue debris, dead and living bacteria
  • Color varies with causative organism
A

Purulent exudate

48
Q
  • Large number of RBCs
  • Indicates severe damage to capillaries
  • Frequently seen in open wounds
A

Sanguineous exudate

49
Q

mixed exudate is composed of what

A

Serosanguineous
Purosanguineous

50
Q

Clear and blood-tinged drainage

A

Serosanguineous

51
Q

Pus and blood

A

Purosanguineous

52
Q

dry, leathery, black or brown

A

Eschar

53
Q

stringy, cheesy, loose, yellow, tart

A

Slough

54
Q

healthy, viable pink to beefy red

A

Granulation

55
Q

occurs along wound edges or as islands inside wound bed, pale pink resurfacing of wound

A

Epithelialization

56
Q

may mean infection

A

Erythema

57
Q

Whitish, wrinkled appearance

A

Maceration

58
Q

Macular or papular, may indicate fungal infection

A

Rash

FUNDA (6 decks)

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