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Foundations exam 2 > SKIN Wound > Flashcards

SKIN Wound Flashcards

1
Q

Function of skin

A
  • Protection (melanin and sebum)
  • Thermoregulation (sweating, vasodilation, vasoconstriction)
  • Sensation (touch)
  • Metabolism (synthesis of vit D)
  • Communication (nonverbal language)
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2
Q

Skin Changes Newborn/ Infant

A
  • Reduced ability to thermoreg

- more susceptible to rashes, chafing, blistering

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3
Q

Skin changes toddler/ preschool

A
  • sunscreen

- playing causes injuries

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4
Q

School age/ adolescent skin changes

A
  • lice, scabies, impetigo
  • acne
  • sunscreen
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5
Q

Adult and older adult skin changes

A
  • dry skin more common
  • wrinkling and poor skin turgor
  • slower healing
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6
Q

What can damage skin?

A

Surgery, burns, mechanical force, cancer causes abnormal growth, health-related (nutrition, circulation, allergy or infection, abnormal growth rate), pressure ulcers (mech friction and shear)

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7
Q

Acute wound

A

injury such as knife, gunshot, burn or incision heals within 6 mos

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8
Q

Chronic wound

A

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

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9
Q

Open wound

A

Break present in the skin; tissue damage present

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10
Q

Closed wound

A

No break in skin is seen but soft tissue damage is evident

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11
Q

Clean surgical wound

A

closed surgical wound that did not enter Gi, resp, genitourinary systems; low infection risk

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12
Q

Clean/ contaminated

A

wound entering gi, resp, or genitourinary systems; infection risk

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13
Q

Contaminated

A

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

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14
Q

Infected

A

Wound site with pathogen present; signs of infection

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15
Q

What is pressure?

A

Localized damage to the skin or underlying tissue, usually over a bony prominence as a result of pressure, or pressure in combination with shear
-heels, sacrum, elbows

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16
Q

Stage 1 pressure ulcer

A
  • skin is intact
  • nonblanchable redness
  • May be painful or have diff feel to the rest of the skin
  • temp sensation
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17
Q

Stage 2 pressure ulcer

A
  • Shallow open ulcer with a pink wound bed
  • partial- thickness loss of dermis
  • skin tears, tape burns, maceration, excoriation with no sloughing
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18
Q

Stage 3 pressure ulcer

A

Full thickness tissue loss

  • May have slough
  • bone,tendon, and muscle not exposed
  • undermining and tunneling may be present
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19
Q

Stage 4 pressure ulcer

A
  • exposed bone, tendon, or muscle
  • slough and eschar may be present
  • tunneling and undermining
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20
Q

tunneling/ undermining

A

tunneling: narrow passageway in soft tissue of an open wound
undermining: area of tissue destruction under the edge of wound opening

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21
Q

Unstageable pressure ulcer

A
  • Unstageable means that the wound cannot be visualized

- the base is covered with slough or eschar

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22
Q

Pressure ulcer screening

A
  • Braden scale

- numerical tool that calculates a patient’s risk for developing pressure ulcers

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23
Q

Measures to prevent pressure ulcers

A
  • turn every 2 hours
  • lift rather than drag patients when pulling up in the bed
  • specialty mattresses: air in mattress circulates to keep in flat to distribute pressure evenly
  • Specialty beds: combine bed with specialty mattress. Can feel almost like a waterbed to prevent pressure
  • Nursing: Protective creams or lotions, zinc, petroleum
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24
Q

Primary lesions

A

May arise from previously normal skin

-Macule, papule, patch, plaque, nodule, wheal, vesicle, bulla, pustule

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25
Q

Secondary lesions

A

Result form changes in primary lesions

-Erosion, crust, ulcer, scale, fissure

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26
Q

Hemostasis (immediate) phase

A
  • Vasoconstriction, platelet aggregation, clot formation
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27
Q

Inflammatory phase

A
  • Up to day 3
  • vasodilation
  • phagocytosis
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28
Q

Proliferative phase

A 
Partial thickness (day 4-day 21) 
-epithelialization

Full thickness ( day 4- day 21)

  • Granulation tissue
  • Contracture
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29
Q

Maturation phase

A

(21 days - 2 years)

-Full-thickness only (brownish- yellowish)

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30
Q

Primary intention

A
  • clear incision
  • early suture
  • Hairline scar
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31
Q

Secondary intention

A
  • gaping irregular wound
  • granulation
  • epithelium grows over scar
32
Q

Tertiary intention

A
  • wound
  • granulation
  • closure with wide scar
33
Q

Measures to keep wound edges close together

A
  • Binder
  • Steri-strips: adhesive strip to hold edges together
  • Sutures, staples, and clips: thread or metal that holds edges together
  • Cyanoacrylate Glue: parts of the body that do not experience tension or stretching
  • Elastic wraps, bandages, and stretch netting: apply distal to proximal, ensure it is not too tight, check distal circulation
34
Q

Complications that can occur

A
  • hemorrhage or hematoma
  • infection: purulent drainage, inflamed incisional area, fever, elevated leukocyte count
  • Dehiscence: partial or total disruption, wound opens up
    evisceration: protrusion of viscera through wound opening
  • Inside body stuff goes outside

Fistula: passage btwn 2 areas that do not normally connect. name= location

35
Q

Wound assessment?

A
  • Type, size, location, classification, and base
  • Drainage
  • Undermining and tunneling
  • infection or pain
  • if connected to a drain, measure output and ensure it works
36
Q

Sanguineous

A

bloody

37
Q

Serosanguineous

A

pale- pink yellow

38
Q

Serous

A

clear yellow watery

39
Q

Drain types

A

Penrose: tube placed in wound no suction
Hemovac: suction present, bloody cavity
Jackson-Pratt: gentle suction when bulb compressed

40
Q

A wound is present who should assess it?

A
  • Wound ostomy continence nurse (WOCN)
  • Specialist in wound care who will assess the wound and come up with a specific dressing change for it
  • If it is a surgical wound : only surgeon removes the dressing, the surgeon will write orders on how to do the dressing change, follow that order
41
Q

Alginate Dressing

A
  • Absorption for draining wounds
42
Q

Collagens

A
  • Partial and full-thickness
43
Q

Composites

A

-Use multiple products

44
Q

Foams

A
  • Hydrophillic polyurethane

- Partial and full-thickness with small to moderate drainage

45
Q

Hydrocolloids

A

Water-resistant gel-like wafer dressing

46
Q

Hydrofiber

A

Sodium carboxymethylcellulose

-very absorptive

47
Q

Hydrogels

A

Assist in autolytic debridement of necrotic tissue in full-thickness wound

48
Q

Nonadherent dressings

A

Minimize disruption of new cells

49
Q

Silver dressings

A

Antimicrobial for infected wounds

-bacteria

50
Q

Transparent films

A

Cover the wound but see it

51
Q

What dressings need an order?

A

All but transparent dressings

52
Q

How often is a dressing changed?

A

Determined by wound status, type of dressing, amt of drainage, freq of wound assessment.

53
Q

What supplies are needed?

A

clean and sterile gloves, tape, syringe with saline flush

54
Q

Does it involve cleaning or irrigation

A

mainly saline irrigation

55
Q

When do you pack and fill a wound?

A

when tunneling or undermining is present

56
Q

Neg-pressure wound therapy

A

Hydrophobic sponge dressing fills a wound cavity

  • Cover with transparent dressing
  • Connect to a machine that provides negative pressure
57
Q

Surgical Debridement

A
  • Not done by nurses

- Use of sharp tools to remove debris

58
Q

Enzymatic Debridement

A

-Place chemical product on wound to break down debris

59
Q

Autolytic

A

Occlusive or hydrogel

  • debris gets eroded then irrigated out with saline
  • eschar will be affected by hydrogel
60
Q

Mechanical

A

Wet-dry dressing

  • saline sock gauze pulls exudate
  • exudate comes out
61
Q

Heat: Promote healing and suppuration (consolidation of pus)

A

Results in vasodilation leading to increased blood flow, thus increasing oxygen and nutrients to the area and promoting removal of waste products.

62
Q

Heat: Decrease inflammation by accelerating inflammatory process

A

Increases capillary wall permeability, increases leukocyte and antibody flow to area, and promotes action of phagocytes

63
Q

Heat: Decrease musculoskeletal discomfort

A

increases sensory nerve conduction, promotes muscle relaxation, and decreases viscosity of synovial fluid

64
Q

Cold: controls bleeding

A

Results in vasoconstriction, decreases blood flow, decreases metabolic tissue demands and the supply of oxygen and nutrients

65
Q

Cold: Decreases edema

A

Decreases capillary permeability; cause vasoconstriction

66
Q

Cold: Relieves Pain

A

Decreases nerve conduction velocity; induces numbness or paresthesia

67
Q

Acute sudden pain that may indicate abscessed tooth or appendicitis

A
  • Application of heat may cause rupture and spread a systemic infection
68
Q

Broken skin or deep open wounds

A

subq and visceral tissues are more sensitive to extreme temps

69
Q

Circualtory impairment

A

cold application constricts, thus decreasing circulation. heat does not disspate well from comprimse areas increasing tissue damage .

70
Q

Sensory deficits

A

alterations in nerve conduction limit the sensation of temp or pain incresing the likehood of tissue damage

71
Q

Mental status impairment

A

decreased reliability of reporting pain and altered sensation

72
Q

Age extreme

A

Young children can not properly thermoregulate and cannot communicate pain or discomfort or alter their enviornment. Elderly may have reduced sensation to pain and often have other impairment that compounds risk. Heat should not be applied to abdomen of a pregnant woman because of fetal growth.

73
Q

Metallic implants

A

Metal is a good conductor of heat thus increasing the potential for burns since implants cannot be readily removed

74
Q

What diet promotes optimal wound healing

A

Protien, vit A,C,E, zinc, water, arginine, carbs, fats

75
Q

Meds that are problematic with wound healing

A

Anticoagulants- increase potential for bleeding

Corticosteroids- reduced body’s ability to fight infection

76
Q

What lifestyle choice decreases fxn hemoglobin, causes vasoconstriction, and impairs tissue oxygenation

A

smoking

Foundations exam 2 (7 decks)

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