Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Fundamentals Exam 3 > Skin Integrity and Wounds > Flashcards

Skin Integrity and Wounds Flashcards

1
Q

Epidermis

A
  • protective waterproof layer of keratin
  • cells have no blood vessels of their own
  • regenerates easily and quickly
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Dermis

A
  • elastic tissue made mainly of collagen
  • nerves, hair follicles, glands, immune cells, blood vessels
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Subcutaneous

A
  • anchors skin layers to underlying tissue
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

functions of skin

A
  • protection
  • body temp regulation
  • psychosocial
  • sensation
  • immunologic
  • vitamin d prodution
  • absorption
  • elimination
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

factors affecting skin integrity

A
  • unbroken, healthy skin and mucous membranes defend against harmful agents
  • resistance to injury affected by age, amount of tissue, illness
  • adequately nourished/hydrated cells resistant to injury
  • adequate circulation
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

developmental considerations

skin

A
  • maturation of epidermal cells is prolonged, leading to thin, easily damaged skin
  • circulation and collagen formation are impaired, leading to ⬇️ elasticity and increased risk for tissue damage from pressure
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

causes of skin alterations

A
  • very thin and very obese people more susceptible to skin injury especially in skin folds
  • fluid loss during illness causes dehydration
  • jaundice causes yellow, itchy skin
  • diseases of skin (eczema/psoriasis) cause lesions requiring special care
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

types of wounds

A
  • intentional (surgical) or unintentional (traumatic)
  • neuropathic or vascular
  • pressure related
  • open or closed
  • acute or chronic
  • partial thickness, full thickness, complex
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

phases of wound healing

A
  1. hemostasis
  2. inflammatory
  3. proliferation
  4. maturation
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

hemostasis

A
  • immediately after injury
  • vasoconstriction, clotting begins
  • exudate is formed, causing swelling and pain
  • ⬆️ perfusion leads to heat and redness
  • platelets stimulate other cells to migrate to site of injury
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

inflammatory phase

A
  • after hemostasis, lasts 2-3 days
  • WBCs move to wound (leukocytes and macrophages)
  • macrophages injest debris and release growth factors that attract fibroblasts to fill the wound
  • exudate accumulates, pain, swelling, redness
  • generalized body response
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

proliferation phase

A
  • several weeks
  • new tissue is built by fibroblasts
  • capillaries grow across the wound
  • thin layer of epithelial cells forms across wound
  • granulation tissue forms foundation for scar tissue
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

maturation phase

A
  • begins approx 3 weeks after injury, leasts months to years
  • collagen is remodeled
  • new collagen tissue depositied, compressing the blood vessels which causes a scar
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

what is a scar?

A
  • flat, thin, white line
  • avascular collagen tissue that does not sweat, grow hair, or tan in the sunlight
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

local factors affecting wound healing

A
  • pressure
  • desiccation (dehydration)
  • maceration (overhydration)
  • trauma
  • edema
  • infection
  • excessive bleeding
  • necrosis
  • presence of biofilm
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

systemic factors affecting wound healing

A
  • age: older adults take longest
  • circulation/oxygenation
  • nutritional status
  • wound etiology
  • health status: steriods/postop radiation delay healing
  • medication use
  • adherence to treatment plan
17
Q

wound complications

A
  • infection
  • hemorrhage
  • dehiscence and evisceration
  • fistula formation
18
Q

factors involved in pressure injury formation

A
  • urinary/bowel incontinence
  • aging skin
  • chronic illness
  • immobility
  • malnutrition
  • altered level of consciousness
  • neuromuscular disorder/ cns injury
19
Q

stage 1

stages of pressure ulcers

A

nonblanchable erythema of intact skin

20
Q

stage 2

stages of pressure ulcers

A

partial-thickness skin loss with exposed dermis

21
Q

stage 3

stages of pressure ulcers

A

full-thickness skin loss, not involving underlying fascia

22
Q

stage 4

stages of pressure ulcers

A

full thickness skin and tissue loss
muscle and bone exposed

23
Q

unstageable

stages of pressure ulcers

A

obscured full-thickness skin and tissue loss

24
Q

deep tissue pressure injury

stages of pressure ulcers

A

persistent nonblanchable deep red, purple or maroon discoloration

25
Q

wound assessment

A
  • appearance (size, depth, undermining, tunneling)
  • drainage (serous, sanguineous, serosanguineous, purulent)
26
Q

serous drainage

A
  • comprised of mostly the clear, serous portion of blood and from serous membranes
  • clear and watery
  • normal sign of healing
27
Q

sanguineous drainage

A
  • large number of RBC and looks like blood
  • bright red or dark red
  • normal sign of healing in the beginning, abnormal if prolonged
28
Q

serosanguineous drainage

A
  • mixture of serum and RBCs
  • light pink to blood tinged
  • normal, most common type of wound drainage
29
Q

purulent drainage

A
  • made up of WBCs, dead tissue debris, dead and live bacteria
  • thick, foul odor, varies in color (yellow or green)
  • not normal, sign of infection
30
Q

open drains

A
  • gauze: allow healing from base of wound, infected wound
  • penrose: soft rubber tube to drain blood and fluid, abd surgery
31
Q

closed drains

A
  • blake: silicone tube with 4 chambers to drain blood and fluid. cardiac surgery in place of chest tube or JP
  • chest tube: mediastinal placement to drain blood after cardiac surgery
  • hemovac: portable negative pressure suction device to drain blood and fluid, after abd or orthopedic surgery
  • JP: bulb suction device to drain blood and fluid, after breast surgery/masectomy/abd surgery
  • T tube: tube placed in common bile duct to collect bile after gallbladder surgery
32
Q

types of wound dressings

A
  • maintain moisture
  • add moisture
  • absorb moisture
33
Q

maintaining moisture wound dressing

A
  • hydrogels, foams, alginate, hydrocolloid, film
  • used for ulcers, pressure injuries
34
Q

adding moisture wound dressing

A
  • hydrogels
  • for ulcers, surgical wounds, sensitive skin
35
Q

absorbing moisture wound dressing

A
  • gauze, absorbent cotton, antimicrobials, negative pressure wound healing
  • for burns, skin grafts, diabetic injury
36
Q

changing wound dressing

A
  • maintain aseptic technique
  • remove old dressing
  • cleanse wound
  • apply new dressing
  • secure dressing
37
Q

types of bandages

A
  • roller bandage
  • circular turn
  • spiral turn
  • figure of eight turn

Fundamentals Exam 3 (7 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2025 Bold Learning Solutions. Terms and Conditions