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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
Q

How long does the proliferation phase last?

A

Several weeks

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26
Q

What happens during the proliferation phase?

A

Fibroblasts secrete collagen and growth factors for blood vessels and endothelial regeneration

Granulation tissue forms

Collagen deposit continues for weeks to years

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27
Q

When does the maturation or remodeling phase occur?

A

Begins around three weeks and can last years

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28
Q

What happens during the maturation phase?

A

Collagen remodeling and additional collagen deposits

Scar finalizes

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29
Q

What are acute wounds?

A

Heal within days to weeks

Edges approximated

Risk of infection lessened

First or second intention

30
Q

What are chronic wounds?

A

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
Q

What are some complications of wound healing?

A

Infection

Hemorrhage

Dehiscence and evisceration

Fistula formation

32
Q

What is dehiscence?

A

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
Q

What is evisceration

A

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
Q

What do you do if evisceration happens?

A

Immediately cover with saline dampened sterile towels, and call MD

Keep patient in low Fowlers position

35
Q

What type of patients are at high risk for evisceration?

A

Obese

Malnourished

Infected wound

Smoker

Excessive coughing, vomiting, straining

“Something popped”

36
Q

How can you tell if there is an infection in a wound?

A

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
Q

What is an abscess?

A

A collection of infective fluid that has not been drained

38
Q

What is a fistula?

A

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
Q

How are wounds healed by primary intention?

A

They are well approximated (skin edges tightly together).

40
Q

What are examples of wound repair by primary intention?

A

Intentional wounds with minimal tissue loss, such as those made by a surgical incision with sutured approximated edges

41
Q

What are examples of secondary intention?

A

Large open wounds, such as from burns, or major trauma, which require more tissue replacement and are often contaminated

42
Q

What are wounds healed by tertiary intention?

A

Wounds left open for several days to allow edema or infection to resolve or fluid to drain, and then are closed

43
Q

What causes arterial wounds?

A

Insufficient blood supply to area, causing ischemia (tissue death)

44
Q

What causes venous wounds?

A

Pooling of blood causing increased pressure in veins

45
Q

Risk factors for arterial wounds?

A

Vascular insufficiency

Uncontrolled blood sugars in people with diabetes

Limited joint mobility

Improper footwear

46
Q

Risk factors in venous wounds?

A

Varicose veins

Deep vein thrombosis

Muscle weakness in legs

Pregnancy

47
Q

Characteristics of arterial wounds?

A

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
Q

Characteristics of venous wounds

A

Shallow and superficial

Irregular shape

Painful from edema

49
Q

Who are at risk population for pressure ulcers?

A

Aging skin, chronic illness, malnutrition

Fecal and urinary incontinence

Altered level of consciousness

Spinal cord injuries

Neuromuscular diseases

50
Q

How would you assess a pressure ulcer?

A

Wound assessment
Blanching
Staging

51
Q

What would a wound assessment for a pressure ulcer consist of?

A

Size of wound

Depth of wound

General appearance - location, drainage (colour, amount, odor, consistency)

Presence of undermining, tunneling, or sinus tract

Surrounding skin

52
Q

What are three mechanisms that contribute to pressure injury development

A

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
Q

Why do pressure injuries usually occur over bony prominences?

A

Body weight is distributed over small area without much subcutaneous tissue to cushion damage to the skin

54
Q

How can friction cause pressure ulcers?

A

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
Q

How does shear cause pressure ulcers

A

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
Q

What is microclimate?

A

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
Q

What is stage 1 pressure ulcer?

A

Intact skin

Non blanchable erythema

58
Q

What is stage 2 pressure ulcer?

A

Partial thickness skin loss involving epidermis and/or dermis. The ulcer is superficial and presents as an abrasion or blister

59
Q

What is stage 3 pressure ulcer?

A

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
Q

What is stage 4 pressure ulcers?

A

Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures

61
Q

What is an unstageable pressure ulcer?

A

Covered with eschar or slough, requires debridement

62
Q

What is the goal of wound care?

A

Promote tissue repair and regeneration to restore skin integrity

63
Q

When you see red in a wound, how do you care for it?

A

Protect

Wound bed should be beefy red- granulation tissue= protect with dressing, moisture, keep clean with prescribed dressing changes

64
Q

When you see yellow in a wound how do you care for it?

A

Cleanse

Yellow exudate. Dead cells, could be infection

65
Q

When you see black in a wound, how do you care for it?

A

Debride

Necrotic eschar (could be grey or tan but primarily black and dry)

66
Q

How do you cleanse a wound?

A

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
Q

The phase of wound healing were exudate is typically formed is called

A

Inflammatory phase

68
Q

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

A

Shearing

69
Q

A wound where the entire dermis, sweat, glands, and hair follicles are severed, is classified as a what?

A

Full thickness wound

70
Q

True or false
Penrose and Jackson Pratt drains are examples of closed drainage systems used to drain blood and fluid from wounds

A

False

71
Q

True or false
Granulation tissue forms the foundation for scar tissue development during the proliferation phase of wound healing

A

True

Concepts Exam 2 (8 decks)

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