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Nursing 202 > Skin Integrity and Wound Care > Flashcards

Skin Integrity and Wound Care Flashcards

1
Q

Dermal-epidermal junction

A

Separates dermis and epidermis

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2
Q

Epidermis

A

Top layer of skin

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3
Q

Dermis

A

Inner layer of skin

Collagen

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4
Q

Common Skin Problems

A

Xerosis (abnormal drying)
Pruritus (itching)
Sunburn
Urticaria (hives)

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5
Q

A Pressure ulcer classifies as

A

Pressure sore, decubitus ulcer, or bed sore

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6
Q

Pathogenesis: 3 Pressure Related Factors contribute to pressure ulcer development

A
  1. Pressure intensity: Tissue ischemia, Blanching
  2. Pressure duration
  3. Tissue tolerance
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7
Q

Tissue ischemia:

A

the pressure applied over a capillary exceeds the normal capillary pressure range (15-32 mmHg)

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8
Q

Blanching:

A

occurs when the normal red tones of the light skinned patient are absent

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9
Q

Pressure ulcer definition:

A

Compression of skin and underlying soft tissue between bony prominence and external surface for extended period

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10
Q

What Mechanical forces create ulcers? (3)

A

Pressure
Friction
Shear

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11
Q

Risk factors for pressure ulcer development?

A 
Impaired sensory perception
Alterations in level of consciousness
Impaired mobility
Shear
Friction
Moisture
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12
Q

Shear:

A

sliding movement of skin and subcutaneous tissue while the underlying muscle and bone are stationary

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13
Q

Stages of Pressure Ulcers:

A
  1. Nonblancable Redness of intact skin
  2. Partial thickness Skin Loss or Blister
  3. Full-thickness skin loss (Fat Visible)
  4. Full thickness tissue loss (Muscle/Bone Visible)
    Unstageable: Full thickness skin or tissue loss-depth unknown (either 3 or 4)
    Suspected deep-tissue injury - depth unknown: boggy, mushy, warmer, or cooler adjacent tissue
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14
Q

Stage 1 description:

A

shiny or dry shallow ulcer without slough or bruising

-Difficult to detect with persons with dark skin = risk

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15
Q

Stage 2 description:

A

Skin not intact, shiny or dry shallow ulcer without slough or bruising. May appear as abrasion, blister, or shallow crater. Should not be used to describe skin tears, tape burns, incontinence-associated dermatitis, maceration, or excoriation

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16
Q

Stage 3 description:

A

Varies by anatomical location - Can be shallow, subcutaneous tissue may be damaged or necrotic
Bone, tendon, muscle not exposed
May have tunneling and undermining

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17
Q

Stage 4 description:

A

Varies by anatomical location - some areas can be shallow, exposed bone/muscle is visible or directly palpable - risks include getting osteomyelitis or osteitis

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18
Q

Ways of Pressure Ulcer Prevention:

A
  • Identify high-risk patients early!: Risk scale, Nutrition assessment
  • Implement aggressive intervention of prevention with pressure relief devices
  • Pressure mapping
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19
Q

Pressure-Relieving Techniques:

A

Capillary closing pressure
Pressure-relief products/devices: support therapeutic beds
Positioning: reduce shearing force to skin

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20
Q

Avoid pressure points by positioning the patient at a ….

A

30 degree angle

Turn every 1-2 hours

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21
Q

Top 3 interventions for pressure ulcers:

A
  1. skin care and management of incontinence
  2. Supporting devices and positioning
  3. Education
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22
Q

Need to perform skin assessment how many times?

A

once a day basis

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23
Q

Wounds consists of ..

A

Classification
Wound healing
Repair

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24
Q

Repairing of wounds has 2 categories:

A

-Partial-thickness wound repair
-Full-thickness wound repair:
Hemostasis (fibrin)
Inflammatory phase
Proliferative phase (epithelialization)
Remodeling

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25
Q

Partial-Thickness Wounds:

A
  • Damage to epidermis, upper layers of dermis
  • Heal by re-epithelialization within 5 to 7 days
  • Skin injury immediately followed by local inflammation
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26
Q

Full-Thickness Wounds:

A
  • Damage extends into lower layers of dermis, underlying subcutaneous tissue
  • Must be filled with granulation tissue to heal
  • Contraction develops in healing process
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27
Q

Phases of wound healing:

A
  1. Inflammatory (lag)
  2. Proliferative (connective tissue repair)
  3. Maturation (remodeling)
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28
Q

Process of Wound Healing (3):

A
  1. First intention – Edges brought together with skin lined up in approximated position
  2. Second intention –Granulation and contraction; deeper tissue injury or wound
  3. Third intention –Delayed closure; high risk for infection with resulting scar
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29
Q
  1. Hemostasis:
A

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

30
Q
  1. Inflammatory Phase:
A

damaged tissue and mast cells secrete histamine, resulting in vasodilation of surrounding capillaries and exudation of serum and white blood cells into damaged tissues

31
Q
  1. Proliferative Phase:
A

begins and lasts from 3-24 days

filling the wound with granulation tissue, contraction of the wound, and resurfacing by epithelialization

32
Q
  1. Remodeling:
A

Takes sometimes more than a year

The collagen scar continues to reorganize and gain strength over several months

33
Q

Wound Assessment:

A 
Location
Size
Color
Extent of tissue involvement
Cell types in wound base and margins
Exudate
Condition of surrounding tissue
Presence of foreign bodies
34
Q

Wound Management: Nonsurgical:

A 
Dressings
Physical/drug/nutrition therapies
Electrical stimulation
VAC
HBOT
Topical growth factors
Skin substitutes
35
Q

Types of Wound drainage:

A

Serous
Purulent
Serosanguineous
Sanguineous

36
Q

Serous:

A

clear, watery plasma

37
Q

Purulent:

A

thick, yellow, green, tan, or brown

38
Q

Serosanguineous:

A

pale, pink, watery mixture of clear and red fluid

39
Q

Sanguineous:

A

bright red, indicates active bleeding

40
Q

Complications of Wound Healing:

A 
Hemorrhage
Hematoma
Infection
Dehiscence
Evisceration
41
Q

An exposed wound is always

A

contaminated but not always infected!

42
Q

Contamination –

A

Presence of organisms without infection

43
Q

Infection –

A

Pathogenic organisms grow and spread, cannot be controlled by body’s immune defenses

44
Q

Acute care includes:

A

Management of pressure ulcers

Wound management

45
Q

Wound management includes:

A

-Debridement (removal of nonviable, necrotic tissue)
Mechanical, autolytic, chemical, or sharp/surgical
-Education
-Nutritional status
-Protein status
-Hemoglobin

46
Q

First Aid for Wounds:

A
  1. Hemostasis: controls bleeding
  2. Cleaning: gentle, normal saline
  3. Protection
47
Q

Hemostasis allows what?

A

Allows puncture wounds to bleed

-Do not remove a penetrating object

48
Q

Assessment of Pressure ulcers:

A 
Predictive measures
Mobility
Nutritional status
Body fluids
Pain
49
Q

Risk assessment scale =

A

Braden scale

50
Q

Braden scale includes assessment of:

A 
Sensory perception
Moisture
Activity
Mobility
Nutrition
Friction and Shear
51
Q

Changes in skin condition can be a

A

manifestation of a systemic medical conditions

52
Q

Purposes of Dressings:

A

Protect a wound from microorganism contamination
Aid in hemostasis
Promote healing by absorbing drainage and debriding a wound
Support or splint the wound site
Protect patients from seeing the wound (if perceived as unpleasant)
Promote thermal insulation of the wound surface

53
Q

Dressing Types:

A 
Dry or moist
Film dressing
Hydrocolloid
Hydrogel
Wound vacuum assisted closure (V.A.C.)
54
Q

Dry or moist dressings:

55
Q

Hydrocolloid—

A

protects the wound from surface contamination

56
Q

Hydrogel—

A

maintains a moist surface to support healing

57
Q

Wound vacuum assisted closure (V.A.C.)—

A

uses negative pressure to support healing

58
Q

Prepare the patient for a dressing change by

A 
Evaluate pain.
Describe procedure steps.
Gather supplies.
Recognize normal signs of healing.
Answer questions about the procedure or wound.
59
Q

Before directly touching an open or fresh wound, what should you do?

A

Wear sterile gloves

60
Q

When Packing a wound what should you assess?

A

Assess size, depth, and shape

61
Q

Comfort measures include:

A

Carefully remove tape.
Gently clean the wound.
Administer analgesics before dressing change.

62
Q

Bandages and Binders Functions:

A

create pressure, immobilize and/or support a wound, reduce or prevent edema, secure a splint, secure dressings

63
Q

When Cleaning a drain site, you should apply what?

A

noncytotoxic solution

64
Q

When applying suture care you should firstly do what?

A

Consult health care facility policy.

65
Q

When irrigating a drain site, to remove exudates, what should you do?

A

use sterile technique with 35-mL syringe and 19-gauge needle.

66
Q

What do drainage evacuators do?

A

Portable units exert a safe, constant, low-pressure vacuum to remove and collect drainage

67
Q

The GNASC tool is used to assess

A

stage I pressure ulcers in clients with dark skin tone.

68
Q

The Bates-Jensen tool is used to assess

A

the wound status

69
Q

Calcium alginate along with secondary dressing is used to

A

dress stage III pressure ulcers

70
Q

Adherent film is used to cover

A

unstageable pressure ulcers

71
Q

Composite film dressing is used for

A

stage II pressure ulcers.

72
Q

A transparent dressing is used to

A

dress stage I pressure ulcers.

Nursing 202 (20 decks)

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