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SKIN INTEGRITY Flashcards

1
Q

Many medications increase sensitivity to sunlight
and can predispose one to severe sunburns. Some of the most common medications that cause this damage are certain antibiotics

A

(e.g.,
tetracycline and doxycycline),

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2
Q

chemotherapy drugs for cancer

A

(e.g.,
methotrexate)

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3
Q

TYPES OF WOUNDS

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

A
  • Clean wound
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4
Q

TYPES OF WOUNDS

are surgical wounds in which the
respiratory, gastrointestinal, genital, or urinary tract has been entered. Such wounds show no evidence of infection.

A

Clean-contaminated wounds

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5
Q

TYPES OF WOUNDS

s 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. These wounds show evidence of inflammation

A

Contaminated wounds

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6
Q

TYPES OF WOUNDS

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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7
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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8
Q

Pressure ulcers were previously called

A

decubitus ulcers, pressure sores, or bedsores.

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9
Q

One of the
national patient safety goals for long-term care settings is prevention of
health care–associated pressure ulcers

A

(The Joint Commission, 2013).

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9
Q

they proposed objective is to reduce the
rate of pressure ulcer–related hospitalizations among older adults

A

. A Healthy People 2020

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10
Q

Types of Wounds

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, this becomes a closed wound.

A

Incision

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11
Q

Types of Wounds

Blow from a blunt instrument

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

A

Contusion

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12
Q

Types of Wounds

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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13
Q

Types of Wounds

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

Open wound

A

Puncture

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14
Q

Types of Wounds

Tissues torn apart, often from accidents (e.g., with machinery)

Open wound; edges are often jagged

A

Laceration

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15
Q

Types of Wounds

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

Open wound

A

Penetrating
wound

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16
Q

Classifying Wounds by Depth

confined to the skin, that is, the dermis and
epidermis; heal by regeneration

A
  • Partial thickness:
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17
Q

Classifying Wounds by Depth

involving the dermis, epidermis, subcutaneous
tissue, and possibly muscle and bone; require connective
tissue repair

A
  • Full thickness:
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18
Q

After the skin has been compressed, it appears pale, as if the
blood had been squeezed out of it. When pressure is relieved, the skin takes on a bright red flush, called

A

reactive hyperemia

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19
Q

Pressure ulcers are due to localized

A

ischemia

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20
Q

is a force acting parallel to the skin surface.

A

Friction

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21
Q

The flush
is due to ____, a process in which extra blood floods to the
area to compensate for the preceding period of impeded blood flow

A

vasodilation

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22
Q

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

A

Immobility

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22
Q

is a combination of friction and pressure

A

Shearing force

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23
Q

(abnormally low protein content in the
blood)

A

Hypoproteinemia

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24
Q

(the presence of excess interstitial fluid) makes skin more prone to injury by decreasing its elasticity, resilience, and vitality

A

Edema

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25
Q

(tissue
softened by prolonged wetting or soaking)

A

maceration

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26
Q

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

A

excoriation

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27
Q

what tool for Predicting Pressure Sore Risk consists of
six subscales: sensory perception, moisture, activity, mobility, nutrition, and friction and shear

A

The Braden Scale

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28
Q

braden scale
A total of___ points is
possible and an adult who scores below ___ points is considered at
risk

A

23, 18

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29
Q

what tools should be used when the client
first enters the health care agency and whenever the client’s condition
changes

A

The Braden and Norton tools

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30
Q

Healing is a quality of living tissue; it is also referred to as ___
(renewal) of tissues.

A

regeneration

31
Q

Norton’s Pressure Area
Risk Assessment Scoring System. It includes the categories of general physical condition, mental
state, activity, mobility, and incontinence. A category of medications
is added by some users, resulting in a possible score of ___ Scores of ____ should be viewed as indicators, not predictors, of risk.

A

24., 15 or 16

32
Q

Types of Wound Healing

occurs where the tissue surfaces
have been approximated (closed) and there is minimal or
no tissue loss; it is characterized by the formation of minimal
granulation tissue and scarring

A

Primary intention healing

33
Q

Types of Wound Healing

A wound that is extensive and involves considerable tissue loss,
and in which the edges cannot or should not be approximated, heals by

A

secondary intention healing

34
Q

Types of Wound Healing

Wounds that are left open for 3 to 5 days to allow edema or infection to resolve or exudate to drain and are then closed with sutures,
staples, or adhesive skin closures heal by

A

tertiary intention.

35
Q

tertiary intention. This is
also called

A

delayed primary intention.

36
Q

Phases of Wound Healing

begins immediately after injury and lasts 3
to 6 days

A

INFLAMMATORY PHASE

37
Q

Phases of Wound Healing

the second phase in healing, extends from day
3 or 4 to about day 21 postinjury. Fibroblasts (connective tissue cells),
which migrate into the wound starting about 24 hours after injury,
begin to synthesize collagen

A

PROLIFERATIVE PHAS

38
Q

Phases of Wound Healing

begins on about day 21 and can extend 1 or
2 years after the injury. Fibroblasts continue to synthesize collagen.
The collagen fibers themselves, which were initially laid in a haphazard fashion, reorganize into a more orderly structure. During
maturation, the wound is remodeled and contracted.

A

MATURATION PHASE

39
Q

INFLAMMATORY PHASE
Two major processes occur during this phase:

A

hemostasis
and phagocytosis

40
Q

(the cessation of bleeding) results from vasoconstriction of the larger blood vessels in the affected area, retraction
(drawing back) of injured blood vessels, the deposition of fibrin
(connective tissue), and the formation of blood clots in the area

A

Hemostasis

41
Q

. These macrophages engulf microorganisms and cellular debris by a process known as

A

phagocytosis.

42
Q

is a whitish protein substance
that adds tensile strength to the wound

A

Collagen

42
Q

Initially, wounds healing by secondary intention seep blood-tinged ____
drainage.

A

(serosanguineous)

43
Q

In some individuals, particularly dark-skinned individuals,
an abnormal amount of collagen is laid down. This can result in a

A

hypertrophic scar, or keloid

44
Q

One method of documenting the progress of healing in pressure ulcers is to use the

A

Pressure Ulcer Scale for Healing (PUSH) tool

45
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

46
Q

The three major types of exudate are

A

serous, purulent, and sanguineous.

47
Q

Types of Wound Exudate

consists chiefly of serum (the clear
portion of the blood) derived from blood and the serous membranes
of the body, such as the peritoneum. It looks watery and has few cells.
An example is the fluid in a blister from a burn.

A

serous exudate

48
Q

Types of Wound Exudate

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

49
Q

Types of Wound Exudate

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. This type of exudate
is frequently seen in open wounds

A

sanguineous exudate

50
Q

The process of pus formation
is referred to as

A

suppuration

51
Q

a localized collection of blood underneath the skin that may appear as a reddish blue swelling (bruise)

A

a hematoma,

52
Q

is the partial or total rupturing of a sutured wound. _____ usually involves an abdominal wound in which the layers
below the skin also separate

A

Dehiscence

53
Q

is the protrusion of the
internal viscera through an incision

A

Evisceration

54
Q

Diagnosing

: vulnerable to localized injury to the skin
and/or underlying tissue usually over a bony prominence as a result of pressure, or pressure in combination with shear

A
  • Risk for Pressure Ulcer
55
Q

Diagnosing

vulnerable to alteration in epidermis and/or dermis which may compromise health.

A
  • Risk for Impaired Skin Integrity
56
Q

Diagnosing

altered epidermis and/or dermis

A
  • Impaired Skin Integrity:
57
Q

Diagnosing

damage to mucous membrane, cornea,
integumentary system, muscular fascia, muscle, tendon, bone,
cartilage, joint capsule, and/or ligamen

A
  • Impaired Tissue Integrity
58
Q

Diagnosing

if the skin impairment is severe, the client is immunosuppressed, or the wound is caused by trauma

A

Risk for Infection

59
Q

Diagnosing

related to nerve involvement within the tissue impairment or as a consequence of procedures used to treat the
wound.

A

Acute Pain

60
Q

Mechanical Devices for Reducing Pressure on Body Parts

Polyvinyl, silicone, or Silastic pads filled with a
gelatinous substance similar to fat.

A

Gel flotation pads

61
Q

Mechanical Devices for Reducing Pressure on Body Parts

Supports positioning and offloads bone on bone
contact.

A

Pillows and wedges

62
Q

Mechanical Devices for Reducing Pressure on Body Parts

Can raise or “float” a body part (e.g., heels) off the
surface. Prevent shearing and limit pressure on heel
area

A

Heel protectors

63
Q

Mechanical Devices for Reducing Pressure on Body Parts

Polyurethane foam mattress distributes weight
over bony areas evenly. Foam molds to the body

A

Memory foam
mattress/chair pad

64
Q

Mechanical Devices for Reducing Pressure on Body Parts

Composed of a number of cells in which the
pressure alternately increases and decreases;
uses a pump.

A

Alternating pressure
mattress

65
Q

Mechanical Devices for Reducing Pressure on Body Parts

Support surface filled with water. Water temperature
can be controlled.

A

Water bed

66
Q

Mechanical Devices for Reducing Pressure on Body Parts

Consists of many air-filled cushions divided into
four or five sections. Separate controls permit each
section to be inflated to a different level of firmness;
thus pressure can be reduced on bony prominences
but increased under other body areas for support

A

Static low-air-loss (LAL) bed

67
Q

Mechanical Devices for Reducing Pressure on Body Parts

Like the static LAL, but in addition gently pulsates or
rotates from side to side, thus stimulating capillary
blood flow and facilitating movement of pulmonary
secretions.

A

Active or second-generation
LAL bed

68
Q

Mechanical Devices for Reducing Pressure on Body Parts

Forced temperature-controlled air is circulated
around millions of tiny silicone-coated beads,
producing a fluid-like movement. Provides uniform
support to body contours.

A

Air-fluidized (AF) bed (static
high-air-loss bed)

69
Q

Types of Dressings

are often applied to
wounds including ulcerated or burned skin areas.

A

Hydrocolloid Dressings

70
Q

Types of Dressings

are frequently used over pressure ulcers

A

Hydrocolloid Dressings

71
Q

Types of Dressings

The nurse tapes the dressing over the wound,
ensuring that the dressing covers the entire wound and does not become dislodged.

A

Securing Dressings

72
Q

has been a common source of dry heat used
in the home. It is convenient and relatively inexpensive. H

A

Hot Water Bag

73
Q

(also referred to as a K-pad) is constructed
with tubes containing water. The pad is attached by tubing to an
electrically powered control unit that has an opening for water and
a temperature gauge

A

Aquathermia Pad

74
Q

provide a constant, even heat, are lightweight, and can
be molded to a body part.

A

Electric Heating Pads

75
Q

is a moist
gauze dressing applied to a wound or injury

A

compress

76
Q

or hip bath, is used to soak a client’s perineal or rectal
area.

A

A sitz bath,

quizzes (11 decks)

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