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Fundamentals (104) > Wound and Skin Care > Flashcards

Wound and Skin Care Flashcards

1
Q

What are the structures of the skin

A

Epidermis, dermis, subcutaneous

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2
Q

What are the functions of the skin?

A

Protection
Body temp regulation
Vitamin D prod
Sensation
Immunologic
Absorption
Elimination

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3
Q

T or F younger people have more resistance to skin injury

A

T

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4
Q

T or F does the skin need to be adequately nourished

A

T

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5
Q

T or F the skin does not need adequate circulation

A

F

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6
Q

T or F in children under 2 y/o the skin is thinner and weaker than adults?

A

T

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7
Q

T or F an infant’s skin and mucus membranes are injured and infected easily

A

T

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8
Q

In older adults what happens to their skin?

A

Epidermis gets thinner, collagen formation impaired, subcutaneous fat is decreased

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9
Q

Who is the most susceptible to skin injury in adults?

A

very thin or obese people

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10
Q

What does dehydration do to the skin?

A

Cause break down

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11
Q

T or F pt with jaundice are more likely to scratch and cause lesions?

A

T

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12
Q

T or F eczema and psoriasis do not cause lesions

A

F

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13
Q

What are the principles in wound healing?

A
  1. intact skin is the first line of defense against infection
  2. hand hygiene is required
  3. the body responds systematically to trauma of any of its parts
  4. an adequate blood supply is essentail for normal body response
  5. normal healing is promoted when the wound is not covered
  6. extent of damage and pt helath will effect healing
  7. proper nutrition
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14
Q

Phases of wound healing

A
  1. hemostasis
  2. inflammatory
  3. proliferation
  4. maturation
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15
Q

hemostasis

A

blood vessels constrict
blood clotting
exudate formed (pain and swelling)
increased perfusion
decreased platelets

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16
Q

inflammatory phase

A

after hemo
1-2 days
WBC move to wound (macrophages)
ingest debris
fibroblasts fill wound
exudate
generalized body response

17
Q

Proliferation

A

repair phase
many weeks
new tissue fills wound space
capillaries grow into wound
granulation and scar tissue

18
Q

Maturation

A

3 weeks after injury
collagen shows up and compresses blood vessels
new scar

19
Q

T or F children and healthy adults heal faster

A

t

20
Q

What drugs delays healing?

A

corticosteroid drugs and postoperative radiation therapy delay healing

21
Q

What are some wound complications

A

infection, hemmorrhage, dehiscence and evisceration, fistula formulation

22
Q

Where are the most common places for pressure ulcers

A

bony prominences

23
Q

What are the mechanisms in pressure injury development

A

external pressure
friction or shearing
microclimate

24
Q

what is external pressure

A

compression of blood vessels

25
Q

friction or shering is what

A

forces tering or injuring blood vessels

26
Q

microclimate is what

A

temperature and moisture of the skin

27
Q

Stage 1 pressure injuries

A

nonblanchable erythema of intact skin

28
Q

Stage 2 pressure ulcer

A

partial-thickness skin loss with exposed dermis

29
Q

Stage 3 pressrue ulcer

A

full thickness skin loss; not involving underlying fascia

30
Q

Stage 4

A

full-thickness skin and tissue loss

31
Q

Unstageable

A

obscured full-thickness skin and tissue loss

32
Q

Deep tissue pressure injury

A

persistent nonblacnchable deep red, marron, or purple discoloration

33
Q

Skin assessment

A

inspect and palpate
head to toe
bony prominences

34
Q

How often do you do a skin assesment

A

acute care: every shift
long-term settings: weekly for 4 weeks
home health: each visit

35
Q

Types of drainage

A

serous - clear normal
sanguineous - bloody (indicates site is bleeding)
serosanguineous - clear and bloody (normal)
purulent - thick yellow, green, brown (infection)

36
Q

Exudate is

A

pus

37
Q

How can the nurse prevent pressure injuries

A
  1. assess at risk pts daily
  2. cleanse the skin
  3. maintain higher humidity, use moisturizers
  4. protect skin from wetness (incontinence)
  5. proper positioning/turning
  6. appropriate support surface
  7. nutritional supplements
  8. improve mobility and activity
38
Q

When dressing a wound it is important to

A
  • know if you need to add moisture or remove moisture
  • protect surrounding skin from the wound
  • remove any damaged or necrotic tissue
39
Q

Types of drains

A

penrose (open hose)
jackson pratt and hemovac (closed system)

Fundamentals (104) (8 decks)

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