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PCC > Skin Integrity (Final) > Flashcards

Skin Integrity (Final) Flashcards

1
Q

Epidermis

A

stratum corneum

stratum germinativum

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2
Q

Age affecting skin integrity

A

older adult skin is less elastic, drier, reduced collagen, areas of hyperpigmentation, more prone to injury

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3
Q

Mobility status affecting skin integrity

A

SKIN BREAKDOWN

increased pressure
shearing and friction (moving patients)

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4
Q

Nutrition/hydration affecting skin integrity

A

PROTEIN: maintains the skin, repair minor defects, preserves intravascular volume

vitamin C, zinc and copper for formation of collagen

more fluids, calories, cholesterol

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5
Q

Sensation level affecting skin integrity

A

diminished sensation leads to increased risk for pressure and breakdown

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6
Q

Impaired circulation affecting skin integrity

A

negatively affects tissue metabolism

less oxygenation to tissues, ischemia, increased risk of pressure ulcers!

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7
Q

Meds affecting skin integrity

A

side effects like itching or severe rashes

blood thinners, inhibits wound healing!

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8
Q

Moisture affecting skin integrity

A

leads to maceration

incontinence, sweating (fever)-depletes moisture, increases metabolic rate

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9
Q

Infection affecting skin integrity

A

impedes healing

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10
Q

Lifestyle affecting skin integrity

A

tanning
bathing
piercings and tats

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11
Q

Cognition affecting skin integrity

A

may not resposition and may not recognize any dangers

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12
Q

Classification of wounds

A

• open/closed
• acute/chronic
• clean/contaminated/infected
• superficial/partial or full thickness
• penetrating

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13
Q

Regeneration

A

in epidermal (or dermis) wounds, no scar

epithelial healing!

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14
Q

Primary (First intention)

A

clean surgical incision/edges approximated, minimal scarring

mininal/no tissue loss, easily closed

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15
Q

Secondary

A

wound edges not approximated, tissue loss (prevents wound edges from approximating), heals from inner layer to surface

wouldn’t shouldn’t be closed in cases of infection or animal bites

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16
Q

Tertiary

A

granulating tissue brought together, delayed primary closure of wound edges

when a wound is allowed to heal by secondary intention and suture the surface only when no signs of infection are seen

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17
Q

Phases of wound healing

A

hemostasis
inflammation
proliferation
maturation (tissue remodeling)

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18
Q

Wound closures

A

adhesive strips
sutures
surgical staples
surgical glue

19
Q

Serous exudate

A

straw colored, watery

20
Q

Sanguineous exudate

A

bloody drainage

21
Q

Serosanguineous exudate

A

mix of bloody and straw colored fluid

red, watery, clear

22
Q

Purulent exudate

A

yellow, contains pus, thick odor

23
Q

Purosanguineous exudate

A

contains blood and pus, red-tinged

24
Q

Complications: Hemorrhage

A

internal/external; profuse or rapid loss of blood and bruising

25
Q

Complications: Infections

A

red, swelling, warmth, odor, purulent discharge, fever, tenderness or pain

26
Q

Complications: Dehiscence

A

MEDICAL EMERGENCY!!!

rupture/separation of 1+ layers of wound

27
Q

Complications: Evisceration

A

MEDICAL EMERGENCY!!!

total separation of all layers of a wound with internal viscera protruding through incision

28
Q

Complications: Fistula formation

A

abnormal passive connecting 2 body cavities/cavities in the skin

29
Q

Braden scale

A

sensory perception, moisture, activity, mobility, nutrition, and friction/shear

total score less than 18=risk

30
Q

Wound assessment (Nursing Interventions)

A

• location
• size
• undermining/tunneling
• appearance (color)
• odor
• drainage
• redness
• swelling
• pain
• nutritional status
• output

31
Q

Lab Data

A

blood studies
wound cultures (swabbing, needle aspiration, tissue biopsy)

32
Q

Nursing Interventions: Drains

A

Jackson-Pratt, Hemo-vac

33
Q

Nursing Interventions: Debriding a wound

A

wet/dry mechanical hypotherapy (removes tissue and can reopen wound)

enzymatic, autolysis (moisture-retentive dressings aid), biotherapy (applying maggots), sharp

34
Q

Leech therapy

A

BIOLOGICAL WOUND DEBRIDEMENT

can be used to “detox” wound

predominantly used to increase blood flow

35
Q

Other nursing interventions

A

• cleansing/irrigating
• applying negative pressure wound therapy
• dressing a wound (gauze/transparent film, hydrocolloids/hydrogels)
• supporting/immobilizing a wound (binders/bandages)
• applying heat and cold
• monitor wound, nutrition, hydration and weight

36
Q

Pressure injuries

A

15% OF HOSPITALIZED CLIENTS!

caused by unrelieved pressure to an area, resulting in ischemia

USE PUSH TOOL

37
Q

Preventing pressure ulcers

A

reposition every 2 hours
barrier cream
nutrition
elevate heels off the bed
Braden scale
prevention
skin care and moisture control
therapeutic mattresses (sand/air filled)
client and family teaching

38
Q

Risk factors of pressure injuries

A

• mobility, activity and sensation (time and pressure)
• intrinsic factors like nutrition, age, circulation, underlying health status (tissue tolerance)
• extrinsic factors like friction, shearing, and moisture (tissue tolerance)

39
Q

Stage 1 pressure ulcer

A

red, non-blanchable, INTACT!, no open areas

40
Q

Stage 2 pressure ulcer

A

OPEN, blistered, partial thickness loss of epidermis and dermis, superficial

41
Q

Stage 3 pressure ulcer

A

full thickness loss, ADIPOSE visual, damage/necrosis, may extend into fascia, may see granulation tissue

42
Q

Stage 4 pressure ulcer

A

full thickness loss, extensive destruction, tissue necrosis/damage to bone, muscle/support structures like tendons and ligaments

43
Q

Unstageable pressure ulcer

A

presence of eschar (black/necrotic) or if deep tissue like a bruise

PCC (11 decks)

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