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307 skin/wound > Skin/wound > Flashcards

Skin/wound Flashcards

1
Q

Functions of the skin:

A 
protection
temperature regulation
psychosocial (self esteem)
sensation
vitamin D production
immunologic
absorption (topical medications)
elimination (sweat)

p. 958

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2
Q

Factors affecting skin integrity:

A

resistance to injury varies (age, amount underlying tissue, illness conditions)
nourished/hydrated body cells resist injury
adequate circulation necessary to cell life

p.958

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3
Q

Developmental considerations in infant/child:

A

Less than 2y.o. skin is thinner and weaker than adult
easily injured
subject to infection

p.958

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4
Q

Developmental considerations in aging adult:

A 
epidermal cell maturation is prolonged
thin skin
easily damaged
circulation/collagen/elasticity is impaired
^ risk tissue damage from pressure

p.958

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5
Q

dehydration can occur from these situations:

A

fluid loss from fever, vomiting, diarrhea
skin appears loose/flabby

p958

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6
Q

Jaundice is characterized by:

A

excessive bile pigments in the skin
resulting in yellowish skin color
skin is often itchy/dry
^ risk for scratching/open lesion

p958

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7
Q

wound definition:

A

break or disruption in the normal integrity of the skin and tissues

p958

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8
Q

Factors placing an individual at risk for skin alterations:

A

lifestyle variables (sexual practices/occupation/body piercing)
Age
changes in health state (dehydration/malnutrition)
illness (DM)
diagnostic measures (GI cleansing)
therapeutic measures (bed rest/cast/medications/therapy)

p959

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9
Q

Wound classifications: intentional/unintentional:

A 
Intentional: 
planned invasive therapy or treatment (surgery/IV therapy/lumbar puncture)
edges are clean
bleeding controlled
decreased risk of infection
^ for healing
Unintentional: 
accidental (unexpected trauma/injury/burns)
Edges jagged
uncontrolled bleeding
^ risk of infection
longer healing time

p960

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10
Q

Wound classifications: open/closed:

A 
Open:
intentional/unintentional (incisions/abrasions)
surface is broken/bleeding/tissue damage
^ risk for infection
delayed healing

Closed:
result from blow/force/strain (ecchymosis/hematoma)
soft tissue damage/ internal injury/hemorrhage
surface not broken

p960

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11
Q

Wound classifications: Acute/Chronic:

A

Acute:
heal within days to weeks
edges well approximated
risk infection lessened

Chronic:
healing process impeded
edges not approximated
^ risk infection
healing time delayed
remain in inflammatory phase of healing

p961

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12
Q

Wound repair classifications:

A

primary intention
secondary intention
tertiary intention

p961

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13
Q

primary intention is:

A

well approximated edges
wounds with minimal tissue damage

p961

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14
Q

secondary intention is:

A 
edges not well approximated
large open wounds (burns)
sometimes contaminated 
take longer to heal
form more scar tissue

p961

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15
Q

tertiary intention is:

A

wounds left open for several days
allow edema or infection to resolve
fluid to drain
and then are closed

p961

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16
Q

Types of wounds:

A 
incision
contusion
abrasion
laceration
puncture
penetrating
avulsion
chemical
thermal
irradiation
pressure ulcers
venous ulcers
arterial ulcers
diabetic ulcers

p961

17
Q

phases of wound healing:

A

hemostasis
inflammatory
proliferation
maturation

pp 962-963

18
Q

factors affecting wound healing:

A 
LOCAL FACTORS
pressure
desiccation
maceration
trauma
edema
infection
excessive bleeding
necrosis
biofilm
SYSTEMIC FACTORS
age
circulation
oxygenation
nutritional status
medications
health status
immunosuppression

pp 963-965

19
Q

wound complications:

A 
infection
hemorrhage
dehiscence
evisceration
fistula formation

pp 965-966

20
Q

Dehiscence is:

A

the partial or total separation of wound layers was a result of excessive stress on wounds that are not healed.

p.965

21
Q

Evisceration is:

A

is the most serious complication of dehiscence– complete separation with protrusion of viscera through incisional area

p965

22
Q

increase in the flow of fluid from wound between postoperative day 4/5 may be a sign of what?

A

impending dehiscence

p966

23
Q

What would you do if your patient is experiencing dehiscence?

A

cover the wound area with sterile towels moistened with sterile 0.9% sodium chloride solution and notify provider

p.966

24
Q

Is dehiscence or evisceration of an abdominal incision an emergency?

A

YES!
Place the pt in low fowlers position and cover the exposed abdominal contents (with sterile towels moistened with sterile 0.9% sodium chloride solution)
DO NOT leave the pt alone
notify PCP immediately

p966

25
Q

Pressure ulcer development/factors:

A
  1. external pressure that compresses blood vessels
  2. friction and shearing forces that tear and injure blood vessels and abrade the top layer of skin

pp 966-967

26
Q

Risks for pressure ulcer development:

A 
immobility
nutrition and hydration
moisture
mental status
age

p 967-968

27
Q

Eschar is:

A

a thick, leathery, scab or dry crust that is necrotic and must be removed before the stage can be determined

except for stable eschar on the heels

28
Q

Suspected deep tissue injury:

A

underlying soft tissue damage from pressure/shear
purple or maroon
intact skin
painful/firm/boggy/warm/cool than adjacent skin

29
Q

Stage I:

A

Intact skin
non-blanchable redness
painful/firm/soft/warmer/cooler than adjacent skin
may indicate “at risk”

30
Q

Stage II:

A 
partial thickness loss of dermis
shallow/open ulcer
red/pink wound bed
without slough or bruising
May be: intact/open/rupture serum-filled blister
31
Q

Stage III:

A

full thickness tissue loss
subcut fat may be visible
NO bone/tendon/muscle
may include undermining/tunneling

32
Q

Stage IV:

A

Full thickness loss
palpable/visible bone/tendon/muscle/surrounding structures
slough/eschar present
includes undermining/tunneling

33
Q

Unstageable:

A

full thickness tissue loss
base of ulcer covered by slough/eschar
cannot be determined until cleaned up

34
Q

How long after surgery should wound have “closer to normal appearance?”

A

1 week– with edges healing together.

p 974

35
Q

Venus pressure ulcers:

A

lower leg- shin/ankle, pooling of blood, moist/exudate/slough, irregular border, surrounding brown skin (brawny)

36
Q

Arterial pressure ulcers:

A

lower leg- toes/feet, injury-lack of blood, dry, “punched out” round, neurotic, surrounding pale skin

37
Q

Appearance of infected wound:

A

wound is swollen, deep red, hot on palpation, drainage is increased and purulent, sometimes edges dehiscence,

307 skin/wound (3 decks)

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