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NURS 200 > Skin Integrity & Wound Care > Flashcards

Skin Integrity & Wound Care Flashcards

1
Q

describe the SKIN ANATOMY

A

EPIDERMIS;
- the TOP LAYER OF THE SKIN
*come lets get sun burnt

DERMIS;
- the INNER LAYER OF THE SKIN
- COLLAGEN

DERMAL-EPIDERMAL JUNCTION;
- separates the dermis & epidermis

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2
Q

how do pressure injuries occur?

A
  • due to UNRELIEVED PROLONGED PRESSURE
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3
Q

what are other names for PRESSURE INJURIES?

A
  • pressure ulcer
  • decubitus ulcer
  • bedsore
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4
Q

describe the PATHOGENESIS of PRESSURE INJURIES

A
  • PRESSURE INTENSITY
  • PRESSURE DURATION
  • TISSUE TOLERANCE
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5
Q

functions of skin

A
  • the LARGEST ORGAN of the body
  • serves as a protective barrier
  • sensory organ
  • synthesizes vitamin D
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6
Q

important focus on older adults

A
  • have an easier breakdown and risk for injury in the skin;
    • decreased collagen formation
    • thinning muscle and tissue
    • decreased skin elasticity
    • slower wound healing
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7
Q

who is AT RISK for pressure injuries?

A
  • impaired sensory perception
  • impaired mobility
  • changes in LOC (dementia patients)
  • diabetic/stroke/SCI/hip fracture patients
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8
Q

definition of SHEAR

A
  • the SLIDING MOVEMENT of SKIN and SUBQ. tissue while underlying muscle and bone are STATIONARY
  • SKIN + SUBQ. adhere to surface, while bones/muscle slide in direction of body movement
  • causes DEEPER FASCIAL LEVEL DAMAGE
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9
Q

definition of FRICTION

A
  • the force of TWO SURFACES moving across from one another
  • affects the EPIDERMIS
    • painful and red; sheet burn
    • often seen in restless patients
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10
Q

definition of MOISTURE:

A
  • allows for more SOFTENED SKIN and creates more SUSCEPTIBILITY
  • can cause MOISTURE-ASSOCIATED SKIN DAMAGE (MASD
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11
Q

describe the stages of CLASSIFICATION OF PRESSURE ULCERS

A

Stage 1: Non-blanchable erythema of intact skin
 Stage 2: Partial-thickness skin loss with exposed dermis
 Stage 3: Full-thickness skin loss
 Stage 4: Pressure Injury: Full-thickness skin and tissue loss

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12
Q

deep tissue pressure injury (DTPI)

A
  • show case of dark marron discoloration
  • probable injury to tissue underneath
  • can have nonintact/intact skin
  • from intense/prolonged pressure
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13
Q

granulation tissue

A

new healing tissue; pink or red

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14
Q

slough

A

dead tissue; cream/yellow color

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15
Q

eschar

A

dead tissue; dry, black and hard

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16
Q

exudate

A

drainage

17
Q

what are our WOUND CLASSIFICATIONS

A
  • PARTIAL THICKNESS WOUNDS
  • FULL THICKNESS WOUNDS
  • PRIMARY INTENTION
  • SECONDARY INTENTION
18
Q

unstageable wound injury

A
  • OBSURED FULL-THICKNESS SKIN and tissue loss
  • has tissue damage due to OBSCURED SLOUGH or ESCHAR
    • once removed can possibly be classified as either stage 3 or 4
19
Q

what are some COMPLICATIONS when it comes to wound healing?

A
  • HEMORRHAGE
  • INFECTION
  • DEHISCENCE
  • EVISCERATION
20
Q

HEMORRHAGE

A

bleeding out

21
Q

infection

A

showcase of fever, odor, purulent drainage, erythema, increased WBC, pain

22
Q

dehiscence

A

the opening of the wound

23
Q

evisceration

A

the opening of a wound and anatomical structures come out

**MEDICAL EMERGENCY; need covering of saline & surgery

24
Q

MEDICAL DEVICE-RELATED PRESSURE INJURY (MDRPI):

A
  • where skin or underlying tissues are subjected to SUSTAINED PRESSURE or SHEAR from medical devices or equipment
  • injury begins to CONFORM to pattern or shape of the device
    mainly seen in face, head, or ear region
25
Q

what are the TWO MAJOR TYPES OF WOUNDS?

A

CLOSED;
- surface of skin is INTACT—damage of UNDERLYING TISSUES
- ex. hematomas, stage 1 pressure injuries, contusions

OPEN;
- surface of skin is SPLIT, INCISED, or CRACKED
- exposed underlying tissues
- very high chance of INFECTION DEVELOPMENT

26
Q

primary intention

A
  • closed wound
  • healing undergoes epithelialization - quick, minimal scaring
  • seen in hematomas, surgical incisions
27
Q

secondary intention

A
  • open wound edges
  • healing undergoes granulation, tissue formation, wound contraction, & epithelialization
  • wounds with tissue loss/contamination
28
Q

tertiary intention

A
  • open wound (for several days)
  • delayed healing process and closing
  • contaminated wounds and signs of inflammation
29
Q

what are factors that influence pressure injury formation & wound healing?

A
  • NUTRITION (vitamins A & C - reduces steroid effects of healing/collagen synthesis
  • TISSUE PERFUSION
  • INFECTION
  • AGE
  • PSYCHOSOCIAL IMPACT OF WOUNDS
30
Q

heat therapy

A
  • allows for VASODILATION
  • allows for flexibility
  • relaxation of muscles
31
Q

cold therapy

A
  • use of vasoconstriction
  • for inflammation, wound sprains/strains
  • often for SOFT TISSUE INJURIES
32
Q

what types of heat and cold therapies can be applied?

A
  • moist or dry compresses
  • warm soaks/cold soaks
  • hot and cold packs
    **NEVER APPLY DIRECT COLD OR HEAT TO SURGICAL WOUND
    **Always start at the LOWEST SETTING
33
Q

what are the types of EXUDATE?

A
  • SEROUS
  • PURULENT
  • SEROSANGUINEOUS
  • SANGUINEOUS
34
Q

serous exudate

A
  • clear, watery plasma
35
Q

purulent exudate

A

thick, yellow or brown, tan

36
Q

serosanguineous exudate

A

pale, pink, watery; mix of clear & red

37
Q

sanguineous exudate

A

bright red; sign of active bleeding

38
Q

tissue perfusion

A
  • perfusion ability of oxygenated blood
  • RISK;
    • diabetic patients
    • peripheral vascular disease patients

NURS 200 (24 decks)

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