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skin & wounds Flashcards

1
Q

skin functions

A

protection
thermoregulation
metabolism
sensation

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2
Q

friction wound

A

very superficial

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3
Q

shearing wound

A

layers of the skin has separated

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4
Q

diminished sensation

A

decreases patient’s response to pain

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5
Q

examples of diseases that diminish sensation

A

diabetic neuropathy
stroke
alzheimer’s

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6
Q

intrinsic injury examples

A

decreased motility
poor nutrition
aging

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7
Q

extrinsic injury examples

A

shearing & friction injuries
hygiene
moisture
positioning

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8
Q

extrinsic injury examples

A

shearing & friction injuries
hygiene
moisture
positioning

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9
Q

for a patient in the hospital, what braden score indicates risk for a pressure injury?

A

18 or less

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10
Q

acute wound

A

surgical incision that goes through all 3 phases of healing in a short duration without complication

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11
Q

chronic wound

A

natural healing process is much slower because it is occurring from inside out

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12
Q

clean wound

A

uninfected, minimal inflammation, may be open or closed

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13
Q

clean-contaminated wound

A

incision with a high risk of infection requiring antibiotics, breached barrier

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14
Q

contaminated wound

A

traumatic or surgical wound where there was a break in sterile procedure

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15
Q

infected wound

A

overgrowth of microorganisms, bacteria has overwhelmed immune defense

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16
Q

what do you NOT give to a patient with a colonization of proliferating bacteria?

A

antibiotics

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17
Q

superficial wound

A

only epidermis

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18
Q

partial-thickness wound

A

through epidermis, but not fully dermis

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19
Q

full-thickness wound

A

through dermis and maybe sub q tissue

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20
Q

penetrating wound

A

foreign body pierced through all layers of skin

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21
Q

contusion

A

localized, bruising

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22
Q

stage 1 pressure ulcer

A

area of redness does not blanch

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23
Q

stage 2 pressure ulcer

A

small break in skin= partial thickness into epidermis or dermis, but relatively shallow

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24
Q

stage 3 pressure ulcer

A

down to sub q tissue. can go down to muscle, but not through it

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25
Q

stage 4 pressure ulcer

A

full thickness into muscle, may be able to see tendons and bone

26
Q

maceration

A

moisture causes skin to be pale and wrinkled, not healthy tissue

27
Q

undermining

A

erosion underneath the wound margins resulting in tissue damage beneath the skin

28
Q

blistering

A

small bubble on skin filled with serum common in burn vitims

29
Q

crepitus

A

crackling sensation under the skin

30
Q

erythema

A

redness

31
Q

epiboly

A

wound with rolled or curled under edges that may be dry or calloused

32
Q

used for low tension, small wounds and fall off on their own

A

steri strips

33
Q

why do you remove every other one when removing sutures?

A

make sure skin edges stay closed when supports are removed

34
Q

purulent

A

thick yellow, white, or green pus

35
Q

sanguineous

A

blood drainage

36
Q

serous

A

straw-colored, serum portion of blood

37
Q

primary intention

A

closed, surgical incision and well approximated

38
Q

secondary intention

A

cannot be closed, needs to heal from inside out

39
Q

tertiary intention

A

close wound at a later date

40
Q

phases of healing

A

1 inflammation 1-5
2 proliferation 5-21
3 maturation up to 6 months

41
Q

fistula

A

passage between two body cavities

42
Q

common fistula area

A

between vagina and rectum

43
Q

internal bleeding

A

cannot see; lowered BP, raised pulse, increases tenderness and pain

44
Q

what do you assess for internal bleeding?

A

vital signs, hemoglobin/hematocrit

45
Q

negative pressure wound therapy

A

woundvac stimulates granulation tissue and decreases edema to promote healing

46
Q

hyperbaric oxygen therapy

A

stimulates new blood vessels and white cells to promote healing in serious wounds

47
Q

debridement surgical option

A

removal of dead tissue

48
Q

hydrotherapy

A

like a powerwasher to removed dead tissue

49
Q

enzymatic

A

gel helps to dissolve dead tissue

50
Q

autolysis

A

body naturally dissolves dead tissue

51
Q

biotherapy

A

sterile maggots or leeches

52
Q

primary dressing

A

covering the wound

53
Q

secondary dressing

A

placed over the primary

54
Q

what are hydrocolloids helpful for?

A

stage 2 pressure wounds

55
Q

hydrogels

A

add moisture to wound

56
Q

transparent films

A

used over IV site

57
Q

what does low protein, albumin, & prealbumin indicate?

A

poor wound healing

58
Q

normal WBC count range

A

4-11

59
Q

what does elevated ESR indicate?

A

inflammatory reaction

60
Q

localized wound dehydration

A

desiccation

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