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NU 307 - Nursing Fundamentals > T3 - Chapter 36 Skin Integrity & Wound Healing > Flashcards

T3 - Chapter 36 Skin Integrity & Wound Healing Flashcards

1
Q

epidermis

A

outer portion of the skin and is made up of 4 or 5 layers

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2
Q

stratum germinativum

A

innermost layer of epidermis and continually produces new cells

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3
Q

infants and children

A
  • skin is thinner and more permeable

- more prone to skin breakdown

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4
Q

adolescents and adults

A

-sex hormones release during puberty and increase sweat gland activity

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5
Q

older adults

A
  • drier skin
  • xerosis
  • wound healing takes longer
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6
Q

why is protein essential?

A

helps maintain healthy skin

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7
Q

why is cholesterol essential?

A
  • helps prevent skin breakdown

- low cholesterol makes skin prone to breakdown

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8
Q

what happens if caloric intake is inadequate?

A
  • body uses protein for energy and then its unavailable for building and maintenance
  • weight loss, loss of subcutaneous tissue, and muscle atrophy
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9
Q

what vitamins and minerals are involved in formation of collagen?

A
  • ascorbic acid
  • zinc
  • copper
  • vitamin C
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10
Q

macetration

A

excessive exposure to moisture that leads to skin breakdown

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11
Q

excoriation

A

when superficial skin layers get scrapped off often through digestive enzymes

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12
Q

contamination of wound

A

there are microorganisms in the wound

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13
Q

colonization of wound

A

bacteria increase in number but dont cause harm

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14
Q

critical colonization

A

bacteria begin to overwhelm the bodies defenses

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15
Q

infection

A

bacteria are causing harm by releasing toxins or invading body tissues

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16
Q

closed wound

A

no breaks in the skin

ex: bruises or tissue swelling

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17
Q

open wound

A

when there is a break in the skin or mucous membranes

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18
Q

actue wound

A

heal spontaneous without complications through the 3 phases of wound healing

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19
Q

chronic wound

A

exceed expected recovery time because the natural healing process has been interrupted

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20
Q

clean wound

A

uninfected with minimal inflammation

limited risk for infection

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21
Q

clean-contaminated wound

A

surgical incisions that enter GI, respiratory, or genitourinary tracts
increased risk of infection

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22
Q

contaminated wounds

A

open/traumatic/surgical with a break in asepsis

high risk of infection

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23
Q

infected wounds

A

bacteria is above 100,000 organisms per gram of tissue

s/s: swelling, fever, foul oder, drainage, warmth to surrounding tissue

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24
Q

abrasion

A

scrape in superficial layers of skin

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25
abscess
- localized collection of pus resulting from invasion of pathogen - must be opened and drained in order to heal
26
contusion
closed wound caused by blunt trauma
27
crushing
- caused by force leading to compression or disruption of tissue - usually no break in the skin
28
incision
open, intentional wound caused by a sharp instrument
29
laceration
- skin or mucous membrane are torn open | - wound often has jagged margins
30
penetrating
open wound with an object lodged in it
31
puncture
wound caused by sharp object
32
tunnel
wound with an entrance and exit site
33
pressure injury
- caused by prolonged pressure or shear | - located over boney prominences
34
arterial ulcers
- blockage of arterial blood to an area, causes tissue necrosis - s/s: commonly found in lower leg, loss of hair in surrounding area, delayed capillary refill, very painful at night and with increased activity
35
venous stasis ulcers
- due to incompetent venous valves or inadequate calf muscle function - results in venous pooling, edema, impaired circulation of skin - s/s: surrounding skin is reddened or brown - pain occurs with leg dependence or dressing changes
36
diabetic foot ulcer
- narrowing of arteries, reduced O2 to feet result in delayed wound healing - s/s: often painless, mainly on planter surfaces and toes
37
superficial wounds
- only the epidermal layer | - injury usually result of friction, shearing, or burning
38
partial-thickness
extend through the epidermis but not through the dermis
39
full-thickness
extend into subcutaneous tissue and beyond
40
regenerative/epithelial healing
- when wound only effects epidermis | - no scar
41
primary intention healing
- minimal or no tissue loss - little scaring is expected - surgical wounds heal this way
42
secondary intention healing
- extensive tissue loss - wound is left open and heals from inner layer to surface by filling with granulated tissue - heal slowly and more prone to infection
43
tertiary intention healing
- when two surfaces of granulated tissue are brought together - require strict aseptic technique - less scaring than secondary
44
what are the phases of healing?
- inflammatory - proliferative - maturation
45
inflammatory
- cleansing | - lasts 1-5 days
46
proliferative
- granulation - lasts 5-21 days - collagen is formed here
47
maturation
- epithelialization - remodling - 3-6 months
48
approximated
closed, with the wounds edges touching each other
49
bulla
blister greater than 1 cm in diameter that is filled with clear fluid commonly seen in burns
50
cyst
abnormal, closed epithelium sac that contains a liquid
51
dehiscence
opening of edges of a surgical wound with partial or total separation of wound layers
52
ecchymosis
hemorrhagic spot caused by bleeding under the skin and irregularly formed in blue, purple, or yellow patches
53
erythema
reddening of skin caused by congestion of capillaries
54
eschar
slough produced by thermal burn, corrosive application, or gangrene
55
granulation
development of red, moist tissue made up of new blood vessels indicates progress of wound healing
56
hematoma
localized collection of blood underneath tissues, appearing as swelling or mass with bluish discoloration
57
keloid
enlarged, elevated scar due to excess collagen
58
petechiae
minute reddish or purplish spots containing blood that appear in skin or mucous membrane as a result of hemorrhage in dermal layers
59
pruritus
itching
60
purulent
- wound drainage that is yellow, green or brown | - sign that infection is present
61
dry dressings
- simple | - can be used in sterile and clean environments
62
wet to dry dressings
- used for wounds requiring debridement - as dressing drys it pulls exudate from wound - can become macerated
63
foam dressing
-can be beneficial over boney prominences
64
transparent film dressing
-allow for more oxygen exchange
65
antiseptic agents
-inhibits or kills microorganisms
66
antibacterial agents
- destroy bacteria and inhibit growth | ex: neomycin or bacitracin
67
anti-fungal agents
ex: nystatin, ketoconazole, and miconazole
68
serous drainage
portion of blood that is water and clear or slightly yellow in appearance
69
sanguineous draingage
contains serum and red blood cells, its thick and reddish
70
serosanguineous drainage
- contains both serum and blood | - appears watery and pink
71
hydrocolloid dressing
- swells in the presence of exudate - forms seal on skins surface to prevent evaporation of moisture - maintains a granulating wound bed - can stay in place for 3-5 days
72
hydrogel dressing
- promotes cooling - rehydrates and fills dead space - good for infected, deep wounds or necrotic tissue - prevents skin breakdown
73
alginates
-non adherent dressing that conforms to wounds shape and absorbs drainage
74
evisceration
a dehiscence that involves the protrusion of visceral organs through a wound opening

NU 307 - Nursing Fundamentals (16 decks)

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