Skin Intergrity/Wounds Flashcards
Closed wound
when there are no breaks in the skin. contusions (bruises) or tissue swelling from fractures are common closed wounds
Open wound
occurs when there is a break in the skin or mucous membranes. open wounds include abrasions, lacerations, puncture wounds, and surgical incisions
Partial thickness wounds
extend through the epidermis but not through the dermis
Full thickness wounds
extend into the subcutaneous tissue and beyond
Impaired skin intergrity
altered epidermis and/or dermis
impaired tissue integrity
Damage to mucous membrane, cornea, integumentary, muscular fascia, muscle, tendon, bone, cartilage, joint capsule, and/or ligament
arterial ulcers
blockage of arterial blood to an area (clot or stenosis of the arterioles) causes tissue necrosis. Will be cooler when touch. Patient will have lose of hair.
CM numbness, weakness, generalized skin discoloration, changes in growth of hair and nails.
Ulcer appears punched out, small and round with borders. Surrounding skin is shiny, thin, and dry, cool to touch.
venous ulcer
caused by incompetent venous valves, deep vein obstruction, or inadequate calf muscle function.
Usually located in the inner ankle or lower calf. wound bed is “beefy”. Surrounding skin is reddended or brown and edematous
pressure injury
caused by intense or prolonged pressure in combination with shear, resulting in tissue ischemia and injury
- turn and reposition at least every 2 hours, teach patient to shift weight every 15 minutes
stage 1 pressure injury
intact skin with localized area of nonblanchable erythema
stage 2 pressure injury
partial thickness skin loss with exposed dermis; serum filled or ruptured blister
stage 3 pressure injury
full thickness loss of skin, no bone or muscle is visible
stage 4 pressure injury
full thickness skin and tissure loss with exposed bone, muscle, tendon, ligament, or cartilage
Slough
soft, moist, devitalized (necrotic) tissue; may seem white, yellow, tan: may be stringy, loose, or adherent to bed.
-Debride the wound
eschar
necrotic tissue; dry, thick, leathery; may be black, brown, or gray depending on moisture level
-debride the wound
tunneling
a channel where tissue has been lost and can extend through any direction, and extend to soft tissue to any muscle. Measure dept by using a gloved finger.
undermining
its not a channel, simply an overhang. Tissue has been destroyed underneath.
Unstageable pressure injury
full thickness wound covered by slough or eschar. Will be stage 3 or 4
Deep tissure injury (DTI)
- localized area of persistent non-blanchable deep red, maroon, purple discoloration blood filled blister.
- skin may be in tact or nonintact
Medical device related pressure injury
- states the etiology of injury
- staged using the system
Mucosal membrane pressure injury
- pressure injury found on mucous membranes with history of a medical device in use at the location of the injury.
- can not be staged.
When is clients skin assessed?
- on admission
- daily
- as needed based on assessment findings.
what are the two common tools used in a skin assessment?
they are also called _______ _______ tools.
- Braden and Norton scales
Do we delegate skin assessment?
NO!
Where are you most likely to find pressure injuries?
- bony prominences
- areas under weight
- medical appliances
- damp skin
- intertriginous
Assessing dressing/wound you assess the..
amount
odor
consistency
-color
Penrose
a plastic tube that allows drainage from the opening.
-placed into patient body in a seperate opening other than the incision
Jackson pratt
looks like a little hand grenade, placed into patietns skin by very small puncture wound. Used by suction
Hemovac
looks like a stack of pancakes, used by suction
do not use ….. to irrigate wounds
alcohol or hydrogen peroxide unless instructed to
use …. to irrigate wounds
water, saline, or sterile saline
Autolytic debridement
auto- body ltyic- breaking down.
Surgical incision
an open, intentional wound caused by a sharp instrument
Laceration
skin or mucous membranes are torn open , resulting in a wound with jagged margins
Abrasion
scrape of the superficial layers of skin.
Puncture wound
an open wound caused by a sharp object . Often there is a collapse of tissue around entry point making prone to infection
Dehiscence
Separation of one or more layers of a wound approximately 3-11 days after injury of surgery. Often occurs with activity and is seen in obese individuals due to the increased pressure.
Cover it up with a sterile dressing, and notify the surgeon
Debridement
the removal of a foreign matter or dead tissue from a wound
