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Nursing 1 > Skin Integrity > Flashcards

Skin Integrity Flashcards

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1
Q

layers of the skin

A

epidermis, dermis, subcutaneous tissue,

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2
Q

What layer of epidermis is the first line of defense?

A

Stratum corneum

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2
Q

what layer of the epidermis produces new cells

A

stratum germinativum

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2
Q

What layer houses sweat glands and hair follicles?

A

dermis

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3
Q

as we age what skin layer gets thinner and thinner?

A

subcutaneous

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4
Q

how do we classify wounds?

A

what layers it has entered

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5
Q

what factors affect skin integrity

A

surgery, injury, psoriasis, atopic dermatitis, meds, impaired circulation, slow healing

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6
Q

Of the following factors, which would put a client at greatest risk for impaired skin integrity:

Medication, digoxin
Moisture
Decreased sensation
Dehydration

A

decreased sensation

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7
Q

what is maceration

A

breakdown of skin from being wet

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8
Q

what are the stages of skin healing?

A

cleansing & granulation, epithelialization

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9
Q

how long does it take to form granulation tissue?

A

5-21 days

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10
Q

how long does it take to form scar tissue?

A

3-6 months

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11
Q

What is serous exudate?

A

clear, watery

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12
Q

what is sanguoneous drainage?

A

blood

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13
Q

what is serosanguinous drainage?

A

combination of blood and serous

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14
Q

what is purulent exudate

A

pus- thick, white/yellow

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15
Q

what is purosanguineous exudate?

A

red-tinged pus/purulent

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16
Q

what position do you place PT in for wound assessment?

A

neutral

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17
Q

what are some types of wounds

A

abrasions, abscess, contusion, crushing, excoriation (scratching), incision, laceration, penetrating wound, puncture wounds (mechanism goes in & out), tunnel wound

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18
Q

symptoms of internal hemorrhage

A

diaphoretic, anemic, tired

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19
Q

what is a dehiscence

A

separation of edges of a wound
EX; (sutures releasing and wound opening)

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20
Q

what are the signs to look for infection

A

Soft red hens produce furry fluffy chicks

swelling, redness, heat, pain, fever, foul smell, color change

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21
Q

What is an evisceration?

A

wound opens with internal tissue outside of the body

22
Q

what is a fistula?

A

unnatural opening between two body cavities

23
Q

what wounds would you culture?

A

any wound with a sign of infection or delayed healing of 2 weeks or <

24
Q

what is the biggest thing to remember about drains?

A

to document excrement’s

25
Q

what is a debridement?

A

cleaning out dead tissue/slough

26
Q

how do you take care of wounds at home?

A

Wet – dry it
Open – cover it
Unclean – clean it
Necrotic – Don’t scrub it
Dry – Moisten it

27
Q

what are pressure ulcers

A

Injury to the skin and underlying tissue over a bone

28
Q

How are ulcers staged?

A

by type of tissue involved

29
Q

can stages go back? can you go from a stage 4-stage 2?

A

No, they can only heal

30
Q

how can you prevent ulcers?

A

repositioning at least every 2 hours
inspect skin daily
assess the injury-Braden scale
manage moisture

31
Q

what is the Braden scale?

A

a scale used for predicting pressure ulcer risk

32
Q

what is a stage 1 pressure injury?

A

localized
non-blanchable redness
under a bony prominence
only epidermis is affected

33
Q

what is a stage 2 pressure injury?

A

partial thickness lost of dermis
open but shallow
red wound bed
can be blister or ulcer
no bruising/sloughing

34
Q

what is a stage 3 pressure injury?

A

crater with full thickness sin loss
damage or necrosis of SQ tissue
viable adipose tissue
no bone visible
may be very deep

35
Q

what is a stage 4 pressure injury?

A

full thickness skin loss
tissue necrosis
damage to muscle/bone
exposed bone/tendon/cartilage
slough or eschar may be present
minimum a year to heal

36
Q

what is a deep tissue injury?

A

skin is intact but discolored
purplish
boggy
blister

37
Q

what is an unstageable pressure injury?

A

full thickness skin loss
base of wound is not visible

38
Q

collagen

A

tough fibrous protein

39
Q

blanching

A

normal red tones of light skin are absent

40
Q

pressure factors that contribute to pressure ulcer development

A

pressure intensity
pressure duration
tissue tolerance

41
Q

risk factors that predispose a patient to pressure ulcer formation

A

impaired sensory perception
-impaired mobility
-alteration in LOC
-shear
-friction
-moisture

42
Q

granulation tissue

A

red, moist tissue composed of new blood vessels, which indicate wound healing

43
Q

slough

A

stringy substance attached to wound bed that is soft, yellow or white tissue

44
Q

eschar

A

black or brown necrotic tissue

45
Q

hemostasis

A

injured blood vessels constrict, and platelets gather to stop bleeding; clots form a fibrin matrix for cellular repair

46
Q

potential or actual nursing diagnoses related to impaired skin integrity

A

risk for infection
-imbalanced nutrition: less than body requirements
-acute or chronic pain
-impaired skin integrity
-impaired physical mobility
-risk for impaired skin integrity
-ineffective tissue perfusion
-impaired tissue integrity

47
Q

advantages of a transparent film dressing

A

-adheres to undamaged skin
-serves as barrier to external fluids and bacteria but allows wound surface to breathe
-promotes moist environment
-permits viewing
-does not require secondary dressing

48
Q

functions of hydrocolloid dressing

A

absorbs drainage through the use of exudate aborbers
-maintains wound moisture
-slowly liquefies necrotic debris
-impermeable to bacteria
-self-adhesive and molds well
-acts as a perventative dressing for high-risk friction areas
-may be left in place for 3-5 days, minimizing skin trauma and disruption of healing

49
Q

advantages of hydrogel dressing

A

soothing and reduces pain
-provides a moist environment
-debrides the wound
-does not adhere to the wound base and is easy to remove

50
Q

warm, moist compresses

A

improve circulation, relieve edema, and promote consolidation of pus and drainage

51
Q

warm, moist compresses

A

improve circulation, relieve edema, and promote consolidation of pus and drainage

52
Q

What can the nurse do for clients with a Braden score of no risk?

A

educate, evaluate on change of condition

53
Q

What can the nurse do for clients with a Braden score of mild/moderate risk?

A

reposition
promote activity
manage individual risk factors
educate
evaluate change of condition

54
Q

What can the nurse do for clients with a Braden score of high/severe risk?

A

supplement with small positional shifts
seating/posture assessment
nutrition assessment
educate
evaluate change of condition

55
Q

Fstage

A

Nursing 1 (14 decks)

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