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Nursing > Skin Integrity and Wound Healing > Flashcards

Skin Integrity and Wound Healing Flashcards

1
Q

Wound Healing

A

process the body takes anything there is a break in skin integrity

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2
Q

Epidermis

A

Outermost layer of skin. It is avascular and made of stratified epithelial squamous cells. Relies on the dermis for nutrition

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3
Q

Dermis

A

Second layer of skin. Thick. Vascular. Made of tough skin tissue

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4
Q

Subcutaneous Layer

A

Fatty tissue that provides insulation.

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5
Q

Sweat

A

Water and salt. Keeps body cool and helps get rid of fluids

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6
Q

Sebaceous Glands

A

Secrete waxy substance that regulates pH of skin and keeps it lubricated

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7
Q

Functions of Integument

A

Protection, Absorption, Metabolism, Thermoregulation, Elimination, Sensation, Psychosocial

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8
Q

Insensible Water Loss

A

unmeasurable but occurs

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9
Q

Factors affecting Skin Function

A

Circulation, Nutrition, Allergies, Abnormal Growth Rate, Infection, Conditions of Epidermis

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10
Q

Neuropathy

A

Affects the skin’s ability to feel

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11
Q

Diabetes

A

Affects the skin’s healing process

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12
Q

Psoriasis

A

Increased skin production resulting in red skin. Chronic issue that is most present on the joints

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13
Q

Intentional Alteration to Skin Integrity

A

Surgury

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14
Q

Unintentional Alteration to Skin Integrity

A

Accidental and more prone to infection

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15
Q

Abrasions

A

Rubbing or scraping of epidermis

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16
Q

Lacerations

A

Tearing of skin and tissue with blunt or irregular objects. Tissue is not aligned

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17
Q

Puncture

A

pointed object penetrates the skin

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18
Q

Exposure Wound

A

Thermal wound leading to cellular death

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19
Q

Causes of Exposure wound

A

Radiation, electricity, caustic chemicals

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20
Q

Closed wound

A

Soft tissue damage under in-tact skin

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21
Q

Open wound

A

Break in the Skin

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22
Q

Chronic

A

Remains in inflammatory stage and remains susceptible to infection

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23
Q

Acute

A

heals quickly and easily

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24
Q

Primary Intervention for a Pressure Injury

A

Prevention

25
Q

Pressure Injury

A

Pressure over a boney surface that reduces the oxygen/bloodflow/nutrients to skin and underlying tissue

26
Q

At Risk Patients for Pressure Injury

A

excess moisture, age, low nutrition, more friction, comorbid condition

27
Q

Shearing Forces

A

Any force that breaks the skin from the tissue underneath. For this reason, we do not raise HOB more than 40 degrees

28
Q

Identification of Pressure injury

A

Name the pressure injury based on the boney location that it is from (Ex. Coccyx pressure injury 2)

29
Q

Stage 1 Pressure Injury

A

Non-blanchable erythema. For this, reduce pressure

30
Q

Stage 2 Pressure Injury

A

Partial thickness skin loss. Looks like an abrasion or blister. For these, we relieve pressure

31
Q

Stage 3 Pressure Injury

A

Full-Thickness skin loss to subcutaneous tissue with damage or necrosis. presents as a deep crater. Frequent dressing changes

32
Q

Stage 4 Pressure injury

A

Full thickness skin loss with extreme destruction, necrosis, or damage to the muscle, bone, or tendon. Months to Years to fully heal

33
Q

Slough

A

Yellow, pale, green, tan, grey tissue within a wound bed. Non-Viable and must be removed

34
Q

Eschar

A

Dark brown or black crust-like non-viable tissue that must be removed

35
Q

Suspected Deep Tissue Injury

A

Skin is closed but there is something underneath

36
Q

Debridement

A

Cleaning a wound

37
Q

autolytic

A

allowing the body’s enzymes to clean its self by changing wound with special dressings. Good for small and shallow wounds. Takes 3-7 days

38
Q

Enzymatic

A

Use of prescribed/commercially prepared enzymes in bandages by a physician.

39
Q

Sharp/Surgical

A

Use of a scalpel to cut away dead tissue. Needs a physician or a trained nurse

40
Q

Bio-Surgical:

A

Use of grade/science large from flies to eat the enzymes in the wound

41
Q

Mechanical

A

Rare and painful. Use of wet-dry towel method, irrigation, or H2O2 for removal.

42
Q

4 Phases of Wound Healing

A
  1. Hemostasis
  2. Inflammatory
  3. Proliferative
  4. Maturation
43
Q

Homostasis

A

Vasoconstriction occurs to stop the bleeding and platelets begin clustering
Voasodhilation occurs to increase the volume of the wound and allows the plasma to seep into the wound
Exudate Production: Plasma seeps into the wound
Clot Forms
48 Hours

44
Q

Inflammatory

A

White Blood Cells arrive to injury
Phagocytosis takes place
Localized inflammatory response is good and normal
4-6 Days

45
Q

Proliferation

A

New tissue is built to fill the space
Fibroblasts produce collagen and growth facto for blood vessel formation
Granulation tissue forms

46
Q

Granulation Tissue

A

Thin layer of epithelia cells that are beefy red and very vascular

47
Q

Maturation

A

Collagen matures and continues to be prepared
Avascular scar remains

48
Q

primary intention

A

clean incision that will heal quickly with no granulation and well approximated edges

49
Q

Secondary Intention

A

Wound without approximated edges. Granulation will occur. More tissue damage occurs. Scar occurs

50
Q

Tertiary Intention

A

Delayed closure of a wound

51
Q

Desiccation

A

Dryness of a wound

52
Q

Maceration

A

Moistness of a wound

53
Q

Biofilm

A

Thick slimy self-made film that has bacteria that are resistant to the body’s natural defense mechanisms

54
Q

hematoma

A

Popped blood vessel leaking into the body. Localized collection of blood

55
Q

Dehiscence

A

Wound edges separate due to excessive stress (edema, infection, weight, vomiting)

56
Q

Evisceration

A

Emergency. Organs seeping from a wound/wound opening

57
Q

Infection

A

Invasion of wound by microorganisms

58
Q

Fistula

A

Abnormal connection between two passageways or organs that do not typically connect

Nursing (17 decks)

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