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Fundamentals of Nursing > Skin, Wound, & PICC > Flashcards

Skin, Wound, & PICC Flashcards

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1
Q

What is tissue integrity ?

A

state of structurally intact and physiolocially functioning epithelial tissues such as integument and mucous membranes

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2
Q

What is the ideal way we describe tissue integrity ?

A

pink, warm, dry, and intact

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3
Q

What are some characteristics of the epidermis ?

A
  • outermost layer
  • cells are flattened and dead
  • protects underlying cells and tissues from dehydration
  • prevents entrance of certain chemical agents
  • allows evaporation of water from the skin
  • permits absorption of certain topical medications
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4
Q

What are some characteristics of the dermis ?

A
  • inner, middle layer
  • provides tensile strength
  • mechanical support
  • protection to the underlying muscles, bones and organs
  • contains mostly connective tissue and few skin cells
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5
Q

What are pressure injuries ?

A

localized injury to the skin and other underlying tissue as a result of pressure or pressure + shear and/or friction

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6
Q

What is tissue ischemia ?

A

longer you lay on a part of body and the capillaries/vessels are being compressed which reduces blood flow
- start of pressure injury
- blanching

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7
Q

What is shear ?

A

sliding movement of skin and subcutaneous tissue while the underlying muscle and bone are stationary
- vessels gets stretched

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8
Q

What is friction ?

A

force of 2 surfaces moving across one another such as the mechanical force exerted when skin is dragged across a coarse surface such as bed linens

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9
Q

How do we prevent friction ?

A

use draw sheet
- when pulling pt ensure you have someone to assist

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10
Q

How does moisture affect the skin ?

A

it softens the skin makes it easier to damage

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11
Q

What does HAPIS stand for ?

A

hospital acquired pressure injuries
- as RN’s we don’t diagnose these PI’s (pressure injuries)

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12
Q

What are some characteristics of a stage 1 pressure injury ?

A

nonblanchable redness of intact skin
- discoloration of skin, warmth, edema, hardness or pain may also be present

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13
Q

What are some characteristics of stage 2 pressure injuries ?

A

partial-thickness skin loss or blister
- shallow open ulcer with red-pink wound bed without slough
- blister may be serum/fluid filled (don’t burst)
- involves epidermis, dermis or both

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14
Q

What are some characteristics of stage 3 pressure injuries ?

A

full thickness skin loss (fat visible)
- subcutaneous fat may be visible: but bone, tendon, or muscle is not exposed
- slough may be present
- may include undermining and tunneling

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15
Q

What is undermining ?

A

an area of tissue injury beneath intact skin around the margins of a wound

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16
Q

What is tunnelling ?

A

tract of injury occurring in any direction from surface or edge of wound
- starts to migrate and branch out that forms “tunnels”

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17
Q

What are some characteristics of stage IV (4) pressure injuries ?

A

full-thickness tissue loss with muscle/bone visible
- slough or eschar may be present
- often includes undermining and tunneling

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18
Q

What are some characteristics of a unstageable pressure injury ?

A

full-thickness tissue loss in which the depth of the ulcer is completely obscured by slough/eschar
- base of wound can’t be visualized
- is either stage 3 or 4

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19
Q

What is special about any eschar on the heel ?

A

it serves as a “natural (biological) cover of the body” and SHOULD NOT be removed

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20
Q

What are some characteristics of deep tissue injuries ?

A

full-thickness skin or tissue loss with depth unknown
- purple or maroon localized area of discolored intact skin
- stable (dry, adherent, intact without erythema)
- may also present as a blood filled blister
- caused by pressure or shear

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21
Q

What is granulation tissue ?

A

soft, pink, fleshy HEALTHY tissue

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22
Q

What is slough ?

A

stringy substance attached to wound bed

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23
Q

What is eschar ?

A

thick layer of dead, dry tissue that covers a wound bed

24
Q

What is exudate ?

A

fluid, cells, or other substances that have been discharged from cells or blood vessels (think drainage from wound)

25
Q

What is a primary intention in wound healing ?

A

no loss of tissue (clean cut/ surgical incision)
- sutures
- glue
- steri strips

26
Q

What is a secondary intention ?

A

loss of tissue (pressure ulcers)
- infection
- foreign material
- dead tissue

27
Q

What is a laceration ?

A

deep skin cut

28
Q

What is a abrasion ?

A

scrapping injury
- like a scrapped knee

29
Q

What is a puncture wound ?

A

like being poked or “stabbed”

30
Q

What do you assess in a wound assessment ?

A
  • bleeding/drainage
  • foreign bodies/contamination
  • size depth (L/W/D, units of measure, describing location like face of clock)
  • odor
  • characteristics of tissues (wound bed and surrounding)
31
Q

What are some causes of a hemorrhage ?

A
  • slipped suture
  • dislodged clot
  • infection
  • erosion of blood vessel
32
Q

What are some signs/symptoms of a hemorrhage ?

A
  • internal: swelling, distension, hematoma, hypovolemic shock
  • external: obvious ! (risk is higher in first 24-48 hrs)
33
Q

What are some interventions of a hemorrhage ?

A
  • apply pressure/dressing
  • if internal, notify MD for possible OR
34
Q

What do you do if you have wrapped a hemorrhage in a dressing ?

A
  • don’t want to remove this because you could remove any clotting that is starting to happen
  • apply more dressing and mark it so you can notice any further change
35
Q

What are some causes of infection ?

A
  • contaminated wounds
  • SSI
  • foreign body in wound
36
Q

What are some signs/symptoms of infection ?

A
  • purulent drainage
  • fever
  • increased WBC
  • erythema
  • pain/tenderness
37
Q

What are some interventions of infections ?

A
  • topical and IV antibiotics
  • wound irrigation/cleaning solutions
38
Q

What are some characteristics of serous drainage ?

A

clear/watery plasma

39
Q

What are some characteristics of serosanguineous drainage ?

A

pale, pink, watery

40
Q

What are some characteristics of sanguineous drainage ?

A

bright red/active bleed

41
Q

What are some characteristics of purulent drainage ?

A

thick, yellow, green, tan, brown

42
Q

What does dehiscence mean ?

A

partial or total separation of wound layers

43
Q

What does evisceration mean ?

A

with total separation of wound the visceral organ protrudes through the wound opening (when the organs start to come out)
- surgical emergency
- cover with damp/sterile gauze, NPO, contact surgery

44
Q

What does dead space mean ?

A

open space that needs dressing and attention to

45
Q

What does moist dressing mean ?

A

put just enough onto the hurt skin that needs it and now on the skin that doesn’t need it cause then that healthy skin can start to breakdown

46
Q

What is debridement ?

A

removal of nonviable, necrotic tissue
- wet to moist dressings1

47
Q

What is hydrocolloid ?

A

protects the wound from surface contamination

48
Q

What is hydrogel ?

A

maintains a moist surface to support healing
- for necrotic and infection
- swells on contact with exudate

49
Q

What is a wound vacuum assisted closure (VAC) ?

A

uses negative pressure to support healing

50
Q

What do you asess when packing a wound ?

A
  • assess size, depth, and shape
  • do not pack too tightly
  • do not let packing contact intact skin
51
Q

How do you clean skin/incisions/drains ?

A
  • least contaminated to most contaminated
  • gentle friction
  • when irrigating, allow the solution to flow from the least to the most contaminated area
  • never use the same piece of gauze to cleanse across a wound twice
52
Q

What is skin glue ?

A

clear gel or paste applied to the edges of small wounds to hold approximated edges together
- comes off in 7-14 days
- educate pts to keep site dry at least 5 days and avoid soaking
- avoid using over joints, on hands, and in groin area

53
Q

What are some characteristics of a PICC line ?

A
  • goes straight to the heart
  • peripherally inserted catheter
  • don’t want dressing at the sire because you won’t be able to see any redness, bleeding, drainage
  • can do any IV
  • TPN
54
Q

In what types of wounds do you not use cytotoxic wound cleaners ?

A

clean/granulating wounds

55
Q

Which scale is used to measure pressure injuries ?

A

braden scale

Fundamentals of Nursing (14 decks)

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