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Foundations of Nursing > Week 3 Skin Integrity > Flashcards

Week 3 Skin Integrity Flashcards

1
Q

What are some of the factors that affect skin integrity, specifically diminished sensation?

Why is it so important to pay attention to

A
  • peripheral vascular disease
  • spinal cord injury
  • diabetes, stroke
  • trauma or fractures

These make them vulnerable

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2
Q

What are some of the factors that can impair cognition and ultimately affect skin integrity

A
  • Alzheimer’s disease
  • dementia
  • altered level of consciousness
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3
Q

What is maceration

A

wrinkly toes and fingers after being in water too long

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4
Q

What does denuded mean

A

skin breakdown (diaper rash on babies)

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5
Q

What are some lifestyle habits that can affect skin integrity

A
  • cigarette smoking
  • tanning salons
  • piercings and tattoos
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6
Q

What are the two types of wounds?

Give examples of each

A

Open wound: lacerations, abrasions (breakdown in tissues)

Closed wounds; contusions, bruises (no breakdown in tissues)

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7
Q

What is an example of excoriation

A

scratching at chicken pox which pops the vesicle

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8
Q

What are the characteristics of an arterial ulcer

A
  • appears punched out
  • pale wound base
  • shiny, thin, and dry surrounding tissue
  • very painful
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9
Q

Is an arterial ulcer considered acute or chronic

A

chronic

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10
Q

Where are arterial ulcers commonly found

A

ankles, toes, side of foot

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11
Q

Where are venous stasis ulcers commonly found

A

inner ankle, lower part of calf

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12
Q

What are the characteristics of a venous stasis ulcer

A
  • shallow with irregular wound margins
  • ruddy or beefy red wound base
  • red/brown and edematous surrounding tissue
  • moderate to heavy drainage
  • painful when dependent or with dressing change
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13
Q

Where do diabetic foot ulcers typically occur

A

plantar surfaces (ball of foot, heel, toes)

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14
Q

What are the characteristics of a diabetic foot ulcer

A
  • drainage, swelling, redness
  • painless
  • highly susceptible to infection
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15
Q

What are the 4 wound tissue types

Explain the characteristics of each

A
  1. epithelization - pink and dry
  2. granulation - red and moist (good thing)
  3. slough - yellow
  4. eschar - black
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16
Q

What are some of the characteristics of slough

A
  • yellow
  • liquefying and separating necrotic tissue
  • rough and stringy texture
  • must be debrided
17
Q

What is necrotic tissue

A

dead or avascular or devitalized tissue

18
Q

What are the characteristics of eschar

A
  • black or brown
  • soft or hard
  • wet or dry
  • full thickness tissue destruction
  • black sheets, not just small patches
  • need to be surgically removed
  • whatever is underneath is likely full thickness
19
Q

What are the 4 wound healing processes. Explain each

A
  • regeneration: very superficial; heals on its own
  • primary intention: typically seen with surgery
  • secondary intention: wound w/ more width and depth
  • tertiary intention: combination of primary and secondary
20
Q

Which type of healing will include granulation

A

secondary and tertiary intention

21
Q

What are the 3 phases of wound healing found in the book. what happens during each

A
  1. inflammatory phase - cleansing
  2. proliferative phase - granulation
  3. maturation phase: epithelialization
22
Q

State and explain the 5 types of wound drainage

A
  • serous: clear
  • sanguineous: bloody
  • serosanguinous: mix of bloody and clear
  • purulent: yellow, contains pus
  • purosanguineous: contains blood and pus
23
Q

What are some of the complications of wounds

explain each

A
  • hemorrhage
  • infection
  • dehiscence: sutures have burst
  • evisceration: protruding organs, particularly with abdominal surgery
  • fistula: can be anywhere in the body; a pathway that has occurred between tissues and creates opening to skin
24
Q

Which 2 complications of wounds are likely to occur with any surgical wound

A

hemorrhage and infection

25
Q

What are some of the nursing diagnoses that we can use for skin integrity

A
  1. risk for surgical site infection
  2. risk for infection
  3. impaired skin integrity
  4. risk for impaired skin integrity
  5. impaired tissue integrity
  6. risk for pressure injury
26
Q

What are some of the nursing interventions related to wound care

A
  • cleansing or irrigating

- caring for drainage devices (JP drain, hemovac, penrose)

27
Q

List and explain the different methods of wound debridement

A
  1. sharp - surgical (should be under anesthesia)
  2. mechanical - wet to dry
  3. enzymatic - medicines with enzymes that you put on dressings
  4. autolysis - let the body do its own thing
  5. Biotherapy - using insects to clean wound
28
Q

What would a negative pressure dressing be used for

A

a wound that needs constant debridement

29
Q

What are the characteristics of a stage one pressure ulcer

A
  • skin intact
  • non blanchable
  • possibly painful
  • different from adjacent skin
30
Q

What are the characteristics of a stage 2 pressure ulcer

A
  • partial thickness loss of dermis
  • skin not intact
  • open/ruptured serum filled blister (blister does not have to be popped)
31
Q

What are the characteristics of a stage 3 pressure ulcer

A
  • full thickness tissue loss
  • subcutaneous fat may be visible
  • bone, tendon or muscle not exposed
  • slough present but does not obscure the depth
  • may include undermining and tunneling
  • you can see wound base
32
Q

What are the characteristics of a stage 4 pressure ulcer

A
  • full thickness tissue loss
  • exposed bone, tendon or muscle
  • undermining and tunneling
  • slough or eschar
  • able to see underlying structures
33
Q

What are the characteristics of an unstageable pressure ulcer

A
  • base of ulcer covered with either slough or eschar
  • full thickness tissue loss
  • cannot see the wound base
34
Q

What are the characteristics of a suspect deep tissue injury pressure ulcer

A
  • purple or marron
  • intact skin
  • blood filled blister
  • preceded by tissue (painful, firm, mushy and firm)
35
Q

What are the categories of the braden scale?

A score below what is concerning

A
  • sensory perception
  • moisture
  • activity
  • mobility
  • nutrition
  • friction and shear

Lower score means higher risk: below 18 or less is worrisome

36
Q

How often should you shift a client’s weight when sitting in a chair to prevent pressure injury

A

every 15 minutes

37
Q

When speaking of duration, what does intractable mean

A

used for patients with cancer

38
Q

What are some of the factors shaping pain experience

A
  • emotions
  • previous pain experiences
  • developmental stage
  • sociocultural factors
  • communication skills
  • cognitive impairments

Foundations of Nursing (12 decks)

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