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Nursing Fundamentals > Skin integrity and wound healing > Flashcards

Skin integrity and wound healing Flashcards

1
Q

The three layers of skin

A

Epidermis
Dermis
Subcutaneous fat

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2
Q

Skin protects against ….

A

pathogens

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3
Q

Dermis is relied on for

A

nutrition

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4
Q

Wound type:

epidermis and partial loss of dermis

A

partial thickness wound

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5
Q

Wound type:

All through dermis up to subcutaneous fat and possibly muscle and bone

A

Full thickness wound

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6
Q

another name for flesh eating disease

A

necrotizing fasciitis

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7
Q

Wound that heals in 6 months or less

A

acute

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8
Q

Wound that takes more than 6 months to heal

A

Chronic

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9
Q

Any break in skin is

A

an open wound

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10
Q

Open traumatic wound like a compound fracture is

A

Contaminated wound

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11
Q

wound caused by friction

A

abrasion

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12
Q

wound caused by penetrating trauma

A

Puncture

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13
Q

Deep, jagged cut in skin

A

laceration

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14
Q

laceration may be kept open for __ days to make sure no infection occurs

A

3 days

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15
Q

Another name for pressure ulcer

A

Decubitus

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16
Q

wound caused by skin trapped between a boney prominence and a hard surface

A

Pressure ulcer

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17
Q

Blood vessel collapse=

A

no blood flow

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18
Q

No blood flow =

A

necrosis

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19
Q

MDRPI

A

Medical device related pressure injury

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20
Q

Pressure ulcers are

A

not billable because they are preventable

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21
Q

Pressure Ulcer stage:

Blanchable, Redness fades in 1-2 hours

A

At risk

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22
Q

Pressure ulcer stage:

Non blanchable, stays red over compressed area, Skin intact

A

Stage 1

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23
Q

Pressure ulcer stage:

Skin break, superficial, like an abrasion, blister

A

Stage 2

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24
Q

treatment for stage 1 pressure ulcer

A

Relieve pressure, reposition, report

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25
Q

Treatment for stage 2 pressure ulcer

A

Saline dressing, moist environment

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26
Q

Esbar

A

Black slough dead tissue rubbed off

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27
Q

Pressure ulcer stage:

Full thickness with damage or loss of subcutaneous tissue

A

Stage 3

28
Q

Treatment for stage 3 ulcer

A

Usually requires debridement, wet to dry dressings, surgical intervention

29
Q

Debriding agent- chemical

A

santyl and collagenase combined with saline to activate

30
Q

If an ulcer is completely yellow, it is considered

A

unstageable

31
Q

An unstageable ulcer needs _____ to determine stage

A

debriding

32
Q

Pressure Ulcer stage:

Full thickness loss with destruction of muscle, bone or supporting structures (tendons, joint capsule)

A

Stage 4

33
Q

Treatment for Stage 4 Ulcer

A

Non adherent dressing. May need skin grafts, flaps

34
Q

Purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure &/or shear.

A

Deep tissue injury

35
Q

Deep tissue injury on an arm is considered

A

a bruise

36
Q

Base of wound builds from inside out, taking up to a year to heal

A

Epithelization

37
Q

A process by which fibrous tissue rich with blood capillaries replaces blood clots formed at the site of a healing wound.

A

Tissue granulation

38
Q

Stable eschar on heels should

A

not be removed

39
Q

Scale used to determine risk for ulcer

A

Braden scale

40
Q

Sometimes stage 3 and 4 are less ____ than stage 1 and 2

A

less painful

41
Q

Rash level with the skin surface

A

Macular rash

42
Q

rash involving elevated, raised area

A

papular rash

43
Q

rash covering most of body

A

generalized rash

44
Q

Itching and redness

A

pruritus

45
Q

increased pressure with one anatomical compartment characterized by pain, numbness, decreased mobility that is caused by edema

A

Compartment syndrome

46
Q

Bring back to normal

A

hemostasis

47
Q

Last 3 days with vasodilation, red, pain, warm swelling

A

inflammation

48
Q

hemostasis
Inflammation
Proliferation
maturation

A

partial thickness wound healing or full thickness healing

49
Q

Wounds with minimal tissue loss ex. clean surgical wounds
Edges of the primary wound can be approximated by sutures, staples, or tape
Healing by collagen synthesis occurs
Granulation tissue is not visible

A

Primary intention

50
Q

Tissue loss, edges that do not easily approximate ex. burns, pressure ulcers, deep lacerations
Healing involves inflammation, filling by granulation tissue & then epithelial cells
Scar is usually large & definite

A

Secondary Intention

51
Q

Occurs when there is a delay between injury and wound closure.
Usually due to wait for underlying infection or edema to resolve.
Some granulation tissue forms.

A

Tertiary intention

52
Q

An abnormal tube- like passageway that forms between two organs or from one organ to the outside of the body

A

Fistula

53
Q

A total or partial disruption of wound edged. The patient feels a “giving away” sensation

A

Dehiscence

54
Q

Is the protrusion of viscera through the abdominal opening

A

Evisceration

55
Q

Wound terms:

Watery, clear, light yellow

A

Serous

56
Q

Wound term:

Bloody

A

Sanguineous

57
Q

Wound term:

Pink, yellow drainage

A

Serosanguinous

58
Q

Wound term:

Yellow, green, tan and foul smelling (infection)

A

Purulent

59
Q

DSD

A

Dry sterile dressing

60
Q

Dressing types needed are determined by

A

Doc order

61
Q

MARSI

A

Medical adhesive related skin injury

62
Q

Using negative pressure to speed tissue healing

A

Vacuum assisted closure

63
Q

Vacuum uses continuous pressure at

A

125

64
Q

High Air Loss-air blows through “sand like” silicon beads making the surface less than capillary pressure in the skin.
Feels like a water bed when on & becomes a firm hard surface when off is capable of holding a patient in position
Causes a high fluid loss from the patient

A

Alternating Air-Pressure Mattress

65
Q

Heating unit consistent of waterproof pad thru which water circulates-for inflammation muscle spasms etc.

A

Aquathermia Pads

Nursing Fundamentals (19 decks)

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