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Nursing - 115 > Skin & Wound Care - Unit 6 > Flashcards

Skin & Wound Care - Unit 6 Flashcards

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1
Q

What are some skin functions?

A

Protection, thermoregulation, sensation, metabolism and communication.

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2
Q

What are some factors altering skin?

A

Age, sun, hydration, soaps, nutritions, medications, mechanical damage, chemical factors, infectious factors, allergic factors, misc factors.

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3
Q

What is induration?

A

Hardened tissue.

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4
Q

What are some parts of an infection?

A

Erythema, edema, induration, purulent drainage, crepitis, lack of healing.

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5
Q

What are some parts of inflammation?

A

Erythema, edema, pain, heat and clear drainage.

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6
Q

What is undermining?

A

Fibrous tissue is cut - decreases tensions in the wound, frees up edges, but might cause a problem if a nerve of blood vessel is cut.

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7
Q

What is a partial thickness wound?

A

Shallow, painful epidermal loss and maybe has partial dermal loss.

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8
Q

Full-thickness wound - what is it?

A

Loss of epidermal and dermal layers, and may extend to subcutaneous or fascia, muscle, or bone.

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9
Q

What are some factors impacting wound healing?

A

Tissue perfusion, nutritional status, infection, immunosuppression, aging, etc.

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10
Q

What are some classifications of wounds?

A

Pressure ulcer, diabetic ulcer, arterial ulcer, venous status ulcer, surgical wound and traumatic wound.

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11
Q

What is a primary surgical wound?

A

Edges are very tight - minimum tissue loss.

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12
Q

What is a secondary surgical wound?

A

Edges not well approximated. Could be from trauma or a burn.

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13
Q

What is a tertiary (delayed secondary) wound?

A

Wound is left open until secondary can begin.

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14
Q

Scar Tissue - never more than __ percent the strength it was.

A

80%

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15
Q

Wounds are measured in __ x __ x ___.

A

LxWxD

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16
Q

What is wound tunnelling?

A

It’s when the wound goes down, but off to the side. So don’t just stick a swap straight down - feel around!

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17
Q

What are some foreign objects in a wound?

A

Sutures, staples, drains, mesh and packing.

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18
Q

What are some structures in a wound?

A

Bone, tendon, vein/artery, muscle, etc.

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19
Q

If a bone or tendon is exposed…..the wound can still heal on its own. T/F?

A

False - it will need other help!

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20
Q

What is slough/necrotic tissue?

A

Moist, yellowish, devitalized.

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21
Q

What is eschar tissue?

A

Dry, dead and thick.

22
Q

What is granulation tissue?

A

Beefy red to pink.

23
Q

Epithelialization - tissue type?

A

Regrowth of skin over wound.

24
Q

What is serous fluid?

A

Clear/thin/watery.

25
Q

Serosanguineous - what is it?

A

Clear with some blood.

26
Q

What is sanguineous fluid?

A

Bloody!

27
Q

What is purulent fluid?

A

Puss filled fluid.

28
Q

Periwound - maceration?

A

Redness/shrinking.

29
Q

Periwound - Callous?

A

Hardening/thickening of the outer layer.

30
Q

Periwound - Erythema?

A

Redness.

31
Q

Periwound - Yeast?

A

Fungus.

32
Q

Periwound - Intact?

A

Skin is there.

33
Q

Periwound - Crepitus?

A

Air/crackling around the wound.

34
Q

Pressure ulcer - what is shear?

A

Caused by interplay of gravity and friction.

35
Q

Pressure ulcer - what is friction?

A

Dermis and epidermis are abraided - like a sunburn!

36
Q

What can cause a pressure ulcer?

A

Immobility, sensory deficits, nutrition, circulation/oxygenation, moisture, age, diseases, meds, friction, shear, surgery, etc.

37
Q

Shear - skin sticks to a surface. T/F?

A

True!

38
Q

Dry skin is 2.5x more likely to ulcerate than healthy skin. T/F?

A

True!

39
Q

Skin with too much moisture is 5x more likely to ulcerate than dry skin. T/F?

A

True!

40
Q

Pressure Ulcer - Stage 1- Info

A

An alteration in intact skin with a change in one of the following - skin temp, consistancy, sensation. redness appears.

41
Q

Pressure ulcer - Stage 2 - Info?

A

Partial thickness skin loss involving epidermis and/or dermis. Superficial!

42
Q

Stage 3 Pressure Ulcer - Info?

A

Full thickness loss involving change or necrosis of subcutaneous tissues! Extends to, but not through, the fascia.

43
Q

Stage 4 Pressure Ulcer - info?

A

Full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone, or supporting structures.

44
Q

Only pressure ulcers are staged. And never backstage! T/F?

A

True!

45
Q

What are some goals of topical therapy?

A

Provide moist wound environment, either add/remove moisture and protect!

46
Q

What is hydrocolloid?

A

Contains hydroactive absorbative particle - creates a gel! Impermeable to urine, stool and bacteria.

47
Q

What are alginates?

A

Absorbative, gels in wound bed, biodegradable, but DO NOT USE on dry wounds.

48
Q

Semipermiable polyurethane foam?

A

Can be adhesive or not, absorbs excessive exudate and is semipermeable.

49
Q

Gel Dressings - ?

A

can me amorphus, sheet or impregnated gauze. These are soothing but can macerate wound edges if too wet.

50
Q

Silver - ?

A

Comes in all modes, has a long wear time and is antimicrobial.

51
Q

Wound Vac - what is it?

A

Provides suction! We change is every 48-72 hours - it sucks the shit out of the wound!

Nursing - 115 (35 decks)

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