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NUR 101- Unit 4 Content > Skin Integrity & Wound Types > Flashcards

Skin Integrity & Wound Types Flashcards

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1
Q

Layers of skin

A

Epidermis- avascular
Dermis
SubQ tissue

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2
Q

1st line of defense, largest organ in body

A

Skin

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3
Q

Factors affecting normal fx of skin

A

Circulation
Nutrition
Epidermis condition
Abnormal growth
Allergy/infection/ Systemic Diseases
Substance Abuse

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4
Q

Adequate skin perfusion requires four factors

A

-Heart must pump adequately.
-Volume of circulating blood must be sufficient
-Arteries * veins must be apparent and fx well
-Capillary pressure must be higher than external pressure

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5
Q

break in skin integrity that can be acute, chronic, open, closed

A

wound

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6
Q

Injury, such as knife, gunshot, burn, or surgical incision; heals within 6 mo

A

acute wound

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7
Q

Wound that persists beyond usual healing time (>6 mo) or recurs without new injury to the area

A

chronic wound

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8
Q

Break present in the skin; tissue damage present

A

open wound

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9
Q

No break seen in the skin, but soft tissue damage evident

A

closed wound

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10
Q

Closed surgical wound that did not enter gastrointestinal, respiratory, or genitourinary systems; low infection risk

A

clean wound

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11
Q

Wound entering gastrointestinal, respiratory, or genitourinary systems; increased infection risk

A

clean contaminated

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12
Q

Open, traumatic wound; surgical wound with break in asepsis; high infection risk

A

contaminated

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13
Q

Wound site with pathogens present; signs of infection

A

infected

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14
Q

when tissue layers move on each other, causing blood vessels to stretch as they pass through the subcutaneous tissue

A

shear force

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15
Q

localized damage to the skin or tissueover a bony prominence, as a result of pressure or pressure. This pressure decreases the blood flow, impairing the supply of nutrients & oxygen to the skin and underlying tissues that form an ulcer as cells die

A

pressure ulcer

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16
Q

Sitting in urine and stool breaks down skin easier and faster. T or F

A

True

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17
Q

Wound w/ ragged edges with torn tissue

A

laceration

18
Q

a wound caused by shear, friction, or blunt force, resulting in separation of skin layers

A

skin tear

19
Q

COntributing factors to pressure injuries

A

Friction
Shear Force
Moisture
Age/ Declined Mental status
Immobility
Poor Nutrition

20
Q

over bony prominence, Blanchable skin that is a warning sign for potential breakdown and can be reversed

A

“At risk” area for pressure ulcer

21
Q

over bony prominence; non blanchable erythema of intact skin; reportable; measure and document

A

Stage 1 Pressure Ulcer

22
Q

Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, can be opened or closedwithout slough or bruising

A

Stage 2 pressure ulcer

23
Q

dead/nercrotic tissue that can be various colors

A

sloth/eschar

24
Q

deep, crater appearing, full thickness tissue loss where fat is visible, but doesn’t expose bone, tendon, or muscle

A

Stage 3 pressure ulcer

25
Q

Wound edges not attached to wound bed

A

undermining

26
Q

A narrow channel or pathway that extends from a wound

A

tunneling

27
Q

What makes a wound unstageable?

A

Slough or eschar covering the majroity of the ulcer

28
Q

rolled, curled under wound edges/ callus

A

epibole

29
Q

abnormal hardening of tissue around wound

A

induration

30
Q

How to debride wound

A

Wet-dry dressings
Surgical intervention
Proteolytic enzymes

31
Q

a medical procedure that removes dead, damaged, or infected tissue from a wound to help the healthy tissue heal

A

debridement

32
Q

full-thickness tissue loss with exposed bone, tendon, or muscle

A

Stage 4 pressure ulcer

33
Q

a serious bone infection that occurs when bacteria or fungi spread to the bone

A

osteomyelitis

34
Q

purple maroon/localized area if discolored intact skin where the soft tissue beneath the skin is damaged by pressure or shear forces

A

DTI- deep tissue injury

35
Q

full-thickness skin and tissue loss where the base of the wound is covered by a layer of dead tissue, or eschar,

A

unstageable pressure ulcer

36
Q

Stable eschar on heels can be removed. T or F

A

FALSE- shout NOT be removed from heels

37
Q

predictor scale for skin breakdown

A

Braden Scale

38
Q

wound involving friction of skin

A

Abrasion

39
Q

a close wound w/ bleeding in underlying tissues

A

contusion

40
Q

a wound involving penetration of skin & underlying tissue

A

puncture

NUR 101- Unit 4 Content (19 decks)

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