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Concepts Exam 2 > Wounds and Skin Integrity > Flashcards

Wounds and Skin Integrity Flashcards

1
Q

What is the name of the top layer of skin?

A

The epidermis

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2
Q

What is the second layer of skin?

A

Dermis

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3
Q

What is the 3rd layer of skin

A

Subcutaneous

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4
Q

Key points about the epidermis?

A

No blood vessels

Regenerates easy

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5
Q

Key points about the dermis?

A

Consists of a framework of elastic connective tissue comprised primarily of collagen

Also has nerves, blood vessels, hair follicles

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6
Q

Key points of the subcutaneous layer

A

Anchors skin to underlying tissue

Stores fat for energy

Heat insulator

Cushioning for protection

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7
Q

Factors affecting the skin

A

1) unbroken and healthy skin and mucus membranes defend against harmful agents

2) resistance to injury is affected by age, amount of underlying tissue, and illness

3) adequately nourished and hydrated body cells are resistant to injury.

4) adequate circulation is necessary to maintain cell life

5) very thin and very obese people are more susceptible to skin injury

6) fluid loss during illness cause dehydration

7) excessive perspiration during illness predisposes skin to breakdown

8) jaundice causes yellowish, itchy skin

9) diseases of the skin, such as eczema or psoriasis, may cause lesions that require special care

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8
Q

What is an incision?

A

Cutting or sharp instrument; wound edges well approximated and aligned; surrounding tissue undamaged; bleeds freely and leased likely to become infected

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9
Q

What is a laceration?

A

Tearing of skin and tissue with blunt or irregular instrument; tissue not aligned, often with loose flaps of skip and tissue; frequently contaminated and likely to become infected

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10
Q

What is an abrasion?

A

Friction; rubbing or scraping epidermal layers of skin; top layer of skin scraped away

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11
Q

What is a puncture?

A

Blunt or sharp instrument puncturing the skin

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12
Q

What is penetrating?

A

Foreign object entering the skin or mucous membranes and lodging in underlying tissue

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13
Q

What is avulsion?

A

Tearing a structure from normal anatomic position

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14
Q

What is a chemical wound?

A

Toxic agents, such as drugs, acids, alcohols, metals, and substances released from cellular necrosis

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15
Q

What is a thermal wound?

A

High or low temperatures; cellular necrosis as a possible result

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16
Q

What are pressure ulcers?

A

Compromised circulation secondary to pressure or pressure combined with friction

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17
Q

What are the wounds that are closed?

A

Contusion

Irradiation

Pressure ulcers (stage 1)

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18
Q

What is a contusion?

A

Blunt instrument, overlying skin remains intact, with injury to underlying soft tissue

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19
Q

What is irradiation?

A

Ultraviolet light or radiation exposure

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20
Q

What are the phases of wound healing?

A

Hemostasis

Inflammatory

Proliferation

Maturation/remodeling

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21
Q

When does hemostasis occur

A

Occurs immediately after injury primarily to stop the bleeding

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22
Q

What happens during the hemostasis phase?

A

Blood vessels constrict to stop blood loss

Clotting begins because of platelet aggregation

Blood vessels dilate, which increases blood flow with plasma components

Exudate forms- made up of plasma and blood

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23
Q

When does the inflammatory phase happen?

A

Follows hemostasis and last about 2 to 3 days

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24
Q

What happens during the inflammatory phase?

A

Leukocytes come in to clean wound

Macrophages come to clean and also promote growth of new epithelial cells

Fibroblast move to help fill in the wound

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25
How long does the proliferation phase last?
Several weeks
26
What happens during the proliferation phase?
Fibroblasts secrete collagen and growth factors for blood vessels and endothelial regeneration Granulation tissue forms Collagen deposit continues for weeks to years
27
When does the maturation or remodeling phase occur?
Begins around three weeks and can last years
28
What happens during the maturation phase?
Collagen remodeling and additional collagen deposits Scar finalizes
29
What are acute wounds?
Heal within days to weeks Edges approximated Risk of infection lessened First or second intention
30
What are chronic wounds?
Often remain in the inflammatory phase generally more than three months Wound edges not approximated Risk of infection is high Healing delayed Examples are: venous insufficiency, arterial, pressure ulcers
31
What are some complications of wound healing?
Infection Hemorrhage Dehiscence and evisceration Fistula formation
32
What is dehiscence?
A partial or total separation of previously approximated wound edges, due to a failure of proper wound healing. From book: partial or total separation of wound layers as a result of excessive stress on wounds that are not healed
33
What is evisceration
Most serious complications of dehiscence Protrusion of viscera through the incision Google: Evisceration is a rare but severe surgical complication where the surgical incision opens (dehiscence) and the abdominal organs then protrude or come out of the incision (evisceration).
34
What do you do if evisceration happens?
Immediately cover with saline dampened sterile towels, and call MD Keep patient in low Fowlers position
35
What type of patients are at high risk for evisceration?
Obese Malnourished Infected wound Smoker Excessive coughing, vomiting, straining “Something popped”
36
How can you tell if there is an infection in a wound?
Assessment of 3 or more signs/symptoms from the following lists STONEES Size is bigger Temperature increased O- exposed bone New areas of breakdown Exudate Erythema, edema Smell
37
What is an abscess?
A collection of infective fluid that has not been drained
38
What is a fistula?
A fistula formation is often the result of infection that has developed into an abscess. Accumulated fluid applies pressure to surrounding tissues, leading to the formation of the unnatural passage between two visceral organs, or an organ and the skin.
39
How are wounds healed by primary intention?
They are well approximated (skin edges tightly together).
40
What are examples of wound repair by primary intention?
Intentional wounds with minimal tissue loss, such as those made by a surgical incision with sutured approximated edges
41
What are examples of secondary intention?
Large open wounds, such as from burns, or major trauma, which require more tissue replacement and are often contaminated
42
What are wounds healed by tertiary intention?
Wounds left open for several days to allow edema or infection to resolve or fluid to drain, and then are closed
43
What causes arterial wounds?
Insufficient blood supply to area, causing ischemia (tissue death)
44
What causes venous wounds?
Pooling of blood causing increased pressure in veins
45
Risk factors for arterial wounds?
Vascular insufficiency Uncontrolled blood sugars in people with diabetes Limited joint mobility Improper footwear
46
Risk factors in venous wounds?
Varicose veins Deep vein thrombosis Muscle weakness in legs Pregnancy
47
Characteristics of arterial wounds?
Punched out appearance Pain at night and relived by elevating leg Usually occurs on the lateral foot, but can occur anywhere on the lower legs Lower extremities are cool to touch, pale, shiny, thin skin and minimal to no hair growth
48
Characteristics of venous wounds
Shallow and superficial Irregular shape Painful from edema
49
Who are at risk population for pressure ulcers?
Aging skin, chronic illness, malnutrition Fecal and urinary incontinence Altered level of consciousness Spinal cord injuries Neuromuscular diseases
50
How would you assess a pressure ulcer?
Wound assessment Blanching Staging
51
What would a wound assessment for a pressure ulcer consist of?
Size of wound Depth of wound General appearance - location, drainage (colour, amount, odor, consistency) Presence of undermining, tunneling, or sinus tract Surrounding skin
52
What are three mechanisms that contribute to pressure injury development
1) external pressure that compresses blood vessels 2) friction and shearing forces that tear and injure blood vessels, and abrade the top layer of skin 3) micro climate of the skin related to temperature and moisture on the skin
53
Why do pressure injuries usually occur over bony prominences?
Body weight is distributed over small area without much subcutaneous tissue to cushion damage to the skin
54
How can friction cause pressure ulcers?
Friction occurs when two surfaces rub against each other. The injury, which resembles an abrasion, can also damage superficial blood vessels directly under the skin. A patient who lies on wrinkled sheets, is likely to sustain tissue damage as a result of friction. The skin over the elbows and heels often is injured due to friction when patients lift and help move themselves up in bed with the use of their arms and feet.
55
How does shear cause pressure ulcers
Shear results when one layer of tissue slides over another layer. Shear separates the skin from underlying tissues. The small blood vessels and capillaries in the area are stretched, and possibly tear resulting in decreased circulation to the tissue cells under the skin. Patients who are pulled, rather than lifted are at risk for injury from shearing forced
56
What is microclimate?
Microclimate refers to the temperature and moisture (humidity) of the skin that comes into contact with the support surface, like a bed. Skin that is moist does not have the same tolerance for pressure and shearing forces as skin that is dry When skin is damp, it requires less friction to blister and abrade which can lead to pressure injury
57
What is stage 1 pressure ulcer?
Intact skin Non blanchable erythema
58
What is stage 2 pressure ulcer?
Partial thickness skin loss involving epidermis and/or dermis. The ulcer is superficial and presents as an abrasion or blister
59
What is stage 3 pressure ulcer?
Full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. Adipose tissue is visible.
60
What is stage 4 pressure ulcers?
Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures
61
What is an unstageable pressure ulcer?
Covered with eschar or slough, requires debridement
62
What is the goal of wound care?
Promote tissue repair and regeneration to restore skin integrity
63
When you see red in a wound, how do you care for it?
Protect Wound bed should be beefy red- granulation tissue= protect with dressing, moisture, keep clean with prescribed dressing changes
64
When you see yellow in a wound how do you care for it?
Cleanse Yellow exudate. Dead cells, could be infection
65
When you see black in a wound, how do you care for it?
Debride Necrotic eschar (could be grey or tan but primarily black and dry)
66
How do you cleanse a wound?
Clean with each dressing change. Use careful, gentle motions to minimize trauma Pre medicate for pain management Use 0.9% normal saline solution or wound cleanser spray to irrigate and clean the ulcer Report any drainage or necrotic tissue
67
The phase of wound healing were exudate is typically formed is called
Inflammatory phase
68
Patients who are pulled, rather than lifted, when being moved up in bed, or from the bed to the chair are at risk for a which types of injury
Shearing
69
A wound where the entire dermis, sweat, glands, and hair follicles are severed, is classified as a what?
Full thickness wound
70
True or false Penrose and Jackson Pratt drains are examples of closed drainage systems used to drain blood and fluid from wounds
False
71
True or false Granulation tissue forms the foundation for scar tissue development during the proliferation phase of wound healing
True

Concepts Exam 2 (8 decks)

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