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Foundations of Nursing > Skin Integrity and Wound Healing > Flashcards

Skin Integrity and Wound Healing Flashcards

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1
Q

** The nurse is caring for a client in the hospital. Which type of skin-related issue is most prevalent in healthcare?

A

pressure ulcer formation

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2
Q

Function of melanin and sebum

A

protection

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3
Q

Ways skin promotes thermoregulation

A

sweating

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4
Q

lifespan changes for skin: babies

A

reduced ability to thermoregulate

more susceptible to rashes, blistering, chafing

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5
Q

lifespan changes for skin: toddler/preschool

A

sunscreen

injuries from playing

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6
Q

lifespan changes for skin: school/ adolescent

A
  • lice, scabies, impetigo
  • acne
  • sunscreen
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7
Q

lifespan changes for skin: adult/older adult

A
  • dry skin more common
  • wrinkling and poor skin turgor
  • slower healing
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8
Q

health related factors that can damage skin

A
  • nutrition
  • circulation
  • allergy or infection
  • abnormal growth rate
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9
Q

mechanical forces that can damage skin

A
  • pressure
  • friction
  • shear
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10
Q

injury, such as knife, gunshot, burn, or surgical incision; heals within 6 weeks

A

acute wound

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11
Q

wound that persists beyond usual healing time (>6 mo) or recurs without new injury to the area

A

chronic

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12
Q

break present in the skin; tissue damage present

A

open

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13
Q

no break seen in the skin, but soft tissue damage evident

A

closed

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14
Q

closed surgical wound that did not enter GI, respiratory, or genitourinary tract

A

clean

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15
Q

wound entering GI, respiratory, or genitourinary systems; infection risk

A

clean/contaminated

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16
Q

Open, traumatic wound; surgical wound with break in sepsis; high infection risk

A

contaminated

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17
Q

Wound site with pathogens present; signs of infection

A

infected

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18
Q

pressure ulcer with sloughing, eschar, potential tunneling. bone/tendon/muscle NOT exposed

A

stage III

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19
Q

pressure ulcer that’s blanchable

A

stage I

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20
Q

pressure ulcer that exposes bone/tendon/muscle

A

stage IV

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21
Q

pressure ulcer that’s partial-thickness loss of dermis

A

stage II

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22
Q

stage of a full-thickness wound that doesn’t extend to the bone, tendon, or muscle. The wound tunnels and has some sloughing. What stage?

A

stage III

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23
Q

Measures to prevent pressure ulcers

A
  • repositioning and turning
  • lift rather than drag patients when pulling up in bed
  • specialty mattress/bed
  • protective creams or lotions
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24
Q

immediate phase of wound healing

A

hemostasis: vasoconstriction, platelet aggregation, clot formation

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25
Q

up to day three of wound healing

A

inflammatory phase: vasodilation, phagocytosis

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26
Q

day 4-21 of wound healing

A

proliferative phase:

  • partial thickness - epithelialization
  • full thickness - granulation/contracture
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27
Q

21 days to 2 years of wound healing

A

maturation (full thickness only)

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28
Q

small spot, like freckle or peticheae

A

macule

29
Q

larger than macule, like vitiligo

A

patch

30
Q

clean incision, early suture, hairline scar

A

primary intention

31
Q

gaping irregular wound, granulation, epithelium grows over

A

secondary intention (contraction and epithelialization)

32
Q

wound, granulation, closure with wide scar

A

tertiary intension (delayed closure)

33
Q

measures to keep wound edges close together

A
  • binder
  • steri-strips
  • sutures, staples, clips
  • cyanoacrylate glue
  • elastic wraps, bandages, stretch netting
34
Q

purulent drainage, inflamed incisional area, fever, elevated leukocyte count

A

infection

35
Q

partial or total disruption in wound edges, the wound opens up

A

dehiscence

36
Q

protrusion of viscera through wound opening (inside goes outside)

A

evisceration

37
Q

passage between two areas that don’t normally connect

A

fistula

38
Q

elements to assess with wound

A
  • type/location/size/ classification/base
  • drainage
  • undermining or tunneling
  • infection or pain
  • if connect to a drain, measure output and confirm it’s working
39
Q

bloody drainage

A

sanguinous

40
Q

pale pink-yellow drainage

A

serosanguinous

41
Q

pale yellow, watery (like fluid from a blister) drainage

A

serous

42
Q

tube placed in wound, no suction

A

penrose

43
Q

drain with suction present and bloody cavity

A

hemovac

44
Q

drain with bulb – gentle suction when bulb is compressed and released

A

Jackson Pratt (JP)

45
Q

Who should remove a surgical dressing

A

surgeon first! they’ll write orders

46
Q

dressing designed to be placed inside wound

A

alginate

47
Q

dressing made of woven cotton material. Nonocclusive

A

gauze

48
Q

dressing contains ionic silver – either immediate or controlled release of silver into the wound bed

A

silver

49
Q

pad of compressed foam with moderate absorptive capacity

A

polyurethane foam

50
Q

type of dressing over IV site

A

transparent

51
Q

dressing with sodium carboxymethylcellulose fibers

A

hydrofiber dressing

52
Q

water-resistant gel-like dressing

A

hydrocolloid wafer

53
Q

which type of wound product requires a doctor’s order

A

silver

All of them except transparent when you’re in a hospital, but silver is never available OTC

54
Q

When would a wound involve packing or filling?

A

If tunneling or undermining are present

55
Q

wound therapy with hydrophobic sponge, negative pressure machine, transparent dressing

A

negative pressure wound therapy (wound vac)

56
Q

type of debridement not done by nurses

A

surgical

57
Q

debridement using a chemical product to break down debris

A

enzymatic

58
Q

debridement that’s occlusive or hydrogel, debris gets eroded then irrigated with saline

A

autolytic

59
Q

debridement with wet-to-dry dressing

A

mechanical

60
Q

heat or cold: promotes healing and suppuration

A

heat

61
Q

heat or cold: controls bleeding

A

cold

62
Q

diet to promote wound healing

A

high in protein, vitamin A, C, E, zinc, water, arginine, carbs, fats

63
Q

problematic meds for wound healing

A

blood thinners (anticoagulants), chemo, corticosteroids and other immunosuppressants

64
Q

lifestyle choice that impairs wound healing

A

smoking

65
Q

stage this wound

A

2

66
Q

stage this wound

A

3

67
Q

stage this wound

A

1

68
Q

stage this wound

A

4

Foundations of Nursing (22 decks)

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