Skin & Wound Care - Unit 6 Flashcards
What are some skin functions?
Protection, thermoregulation, sensation, metabolism and communication.
What are some factors altering skin?
Age, sun, hydration, soaps, nutritions, medications, mechanical damage, chemical factors, infectious factors, allergic factors, misc factors.
What is induration?
Hardened tissue.
What are some parts of an infection?
Erythema, edema, induration, purulent drainage, crepitis, lack of healing.
What are some parts of inflammation?
Erythema, edema, pain, heat and clear drainage.
What is undermining?
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.
What is a partial thickness wound?
Shallow, painful epidermal loss and maybe has partial dermal loss.
Full-thickness wound - what is it?
Loss of epidermal and dermal layers, and may extend to subcutaneous or fascia, muscle, or bone.
What are some factors impacting wound healing?
Tissue perfusion, nutritional status, infection, immunosuppression, aging, etc.
What are some classifications of wounds?
Pressure ulcer, diabetic ulcer, arterial ulcer, venous status ulcer, surgical wound and traumatic wound.
What is a primary surgical wound?
Edges are very tight - minimum tissue loss.
What is a secondary surgical wound?
Edges not well approximated. Could be from trauma or a burn.
What is a tertiary (delayed secondary) wound?
Wound is left open until secondary can begin.
Scar Tissue - never more than __ percent the strength it was.
80%
Wounds are measured in __ x __ x ___.
LxWxD
What is wound tunnelling?
It’s when the wound goes down, but off to the side. So don’t just stick a swap straight down - feel around!
What are some foreign objects in a wound?
Sutures, staples, drains, mesh and packing.
What are some structures in a wound?
Bone, tendon, vein/artery, muscle, etc.
If a bone or tendon is exposed…..the wound can still heal on its own. T/F?
False - it will need other help!
What is slough/necrotic tissue?
Moist, yellowish, devitalized.
What is eschar tissue?
Dry, dead and thick.
What is granulation tissue?
Beefy red to pink.
Epithelialization - tissue type?
Regrowth of skin over wound.
What is serous fluid?
Clear/thin/watery.
Serosanguineous - what is it?
Clear with some blood.
What is sanguineous fluid?
Bloody!
What is purulent fluid?
Puss filled fluid.
Periwound - maceration?
Redness/shrinking.
Periwound - Callous?
Hardening/thickening of the outer layer.
Periwound - Erythema?
Redness.
Periwound - Yeast?
Fungus.
Periwound - Intact?
Skin is there.
Periwound - Crepitus?
Air/crackling around the wound.
Pressure ulcer - what is shear?
Caused by interplay of gravity and friction.
Pressure ulcer - what is friction?
Dermis and epidermis are abraided - like a sunburn!
What can cause a pressure ulcer?
Immobility, sensory deficits, nutrition, circulation/oxygenation, moisture, age, diseases, meds, friction, shear, surgery, etc.
Shear - skin sticks to a surface. T/F?
True!
Dry skin is 2.5x more likely to ulcerate than healthy skin. T/F?
True!
Skin with too much moisture is 5x more likely to ulcerate than dry skin. T/F?
True!
Pressure Ulcer - Stage 1- Info
An alteration in intact skin with a change in one of the following - skin temp, consistancy, sensation. redness appears.
Pressure ulcer - Stage 2 - Info?
Partial thickness skin loss involving epidermis and/or dermis. Superficial!
Stage 3 Pressure Ulcer - Info?
Full thickness loss involving change or necrosis of subcutaneous tissues! Extends to, but not through, the fascia.
Stage 4 Pressure Ulcer - info?
Full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone, or supporting structures.
Only pressure ulcers are staged. And never backstage! T/F?
True!
What are some goals of topical therapy?
Provide moist wound environment, either add/remove moisture and protect!
What is hydrocolloid?
Contains hydroactive absorbative particle - creates a gel! Impermeable to urine, stool and bacteria.
What are alginates?
Absorbative, gels in wound bed, biodegradable, but DO NOT USE on dry wounds.
Semipermiable polyurethane foam?
Can be adhesive or not, absorbs excessive exudate and is semipermeable.
Gel Dressings - ?
can me amorphus, sheet or impregnated gauze. These are soothing but can macerate wound edges if too wet.
Silver - ?
Comes in all modes, has a long wear time and is antimicrobial.
Wound Vac - what is it?
Provides suction! We change is every 48-72 hours - it sucks the shit out of the wound!
