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Nuts 213 > Skin integrity and wound care > Flashcards

Skin integrity and wound care Flashcards

1
Q

Functions of the skin

A 
Temp regulation
protection
Vitamin d production
psychosocial
sensation
immune
absorb
eliminate
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2
Q

Intentional

A

planned invasive therapy or treatment

surgery, iv, clean cuts with controlled bleeding

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3
Q

Unintentional

A

accidental cuts

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4
Q

Open

A

Trauma that breaks the skin’s surface

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5
Q

Closed

A

Trauma that may cause bleeding but skin is not broken

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6
Q

Acute

A

Surgical incisions usually heal in days to weeks
Edges meet to close skin
Infection risk lessened

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7
Q

Chronic

A

Doesn’t progress through normal sequence of repair
risk of infection increased
Healing time delayed
EX: pressure ulcer

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8
Q

Partial thickness

A

Portion of dermis is intact

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9
Q

Full-thickness

A

Entere dermis, swear glands, and hair follicles are severed

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10
Q

Complex

A

Dermis and underlying subcutaneous fat tissue are damaged

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11
Q

Incision

A

Cutting or sharp instrument, wound edges in close approximation and aligned

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12
Q

Contusion

A

Blunt instrument, overlying skin remains intact with injury to underlying soft tissue possible resultant bruising and/or hematoma

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13
Q

Abrasion

A

Friction, rubbing, or scraping epidermal layers of skin. Top layer abraded

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14
Q

Laceration

A

Tearing of skin and tissue with blunt or irregular instrument, tissue not aligned, often with loose flaps of skin and tissue

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15
Q

Puncture

A

Blunt or sharp instrument puncturing the skin; intentional or accidental

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16
Q

Penetrating

A

Foreign object entering the skin, fragments possible scattered throughout tissue

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17
Q

Avulsion

A

Tearing a structure from normal anatomic position, possible damage to blood vessels, nerves and other structures

18
Q

Chemical

A

Toxic agents such as drugs, acids, alcohols, metals

19
Q

Thermal

A

high/low temperatures

20
Q

Irridation

A

UV light or radiation

21
Q

Pressure ulcers

A

Compromised circulation due to pressure or pressure combined with friction

22
Q

Venous ulcers

A

Injury and poor venous return

23
Q

Diabetic ulcers

A

Injury and diabetic neuropathy

24
Q

Hemostasis

A

Immediately after injury. Involved blood vessels constrict and blood clotting begins

25
Q

Inflammatory phase

A

4-6 days. White blood cells more in. Leukocytes drive to ingest bacteria and cellular debris. (increase temp, malaise, leukocytes)

26
Q

Proliferation phase

A

Several weeks - new tissue is build to fill wound space

Fibroblasts

27
Q

Maturation phase

A

Scarring - approx 3 weeks after injury can continue months to years. Formation of scar tissue

28
Q

Stage 1 ulcer

A

Intact redness of localized area
Non blanch able
May be painful, firm, soft, warm/cool
May be difficult to detect with dark skin tone

29
Q

Stage 2 ulcer

A

Partial thickness loss.
Red/pink without slough
Shinny or dry shallow ulcer

30
Q

Stage 3 ulcer

A

Full thickness loss, fat visible. Slough present and may tunnel

31
Q

Stage 4 ulcer

A

Full thickness loss with bone and muscle exposed. Slough or eschar present. Undermining and tunneling

32
Q

Unstageable

A

full thickness, slough and/or eschar until eschar are removed it is unstageable

33
Q

Infection

A

when a patients immune system fail to control the growth of microorganisms

34
Q

Hemorrhage

A

Slipped suture, dislodged clot, infection, or erosion of a blood vessel from a foreign body

35
Q

Dehisence

A

Partial or total separation of wound layers as a result of excessive stress on wounds that are not healed

36
Q

Evisceration

A

Wound completely separates with protrusion of visceral throughout incisional area

37
Q

Fistula formation

A

Abnormal passage from internal organ or vessel to outside the body or from one internal organ to another

38
Q

Serous drainage

A

Clear and watery

39
Q

Sanguineous drainage

A

blood

40
Q

Serosanguineous

A

mixture of clear and watery with blood to become pink

41
Q

Purulent

A

Thick and pussy

Nuts 213 (3 decks)

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