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NURS 402: Lecture > Skin Integrity and Wound Care > Flashcards

Skin Integrity and Wound Care Flashcards

Exam 3

1
Q

What are the three main structures of the skin?

A
  1. Epidermis
  2. Dermis
  3. Subcutaneous
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2
Q

Epidermis

A

Protective waterproof layer of keratin

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3
Q

How are the cells of the Epidermis?

A

Cells have no blood vessels of their own

Regenerates easily and quickly

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4
Q

Dermis

A

Elastic tissue made primarily of collagen

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5
Q

What is the Dermis made up of?

A

Nerves, hair follicles, glands, immune cells, and blood vessels

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6
Q

Subcutaneous

A

Anchors the skin layers to underlying tissues

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7
Q

Functions of the Skin:

A
  1. Protection
  2. Body temp regulation
  3. Psychosocial
  4. Sensation
  5. Vitamin D production
  6. Immunologic
  7. Absorption
  8. Elimination
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8
Q

Cross section of Normal Skin

A

Slide 4

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9
Q

What are factors affecting the skin

A
  1. Unbroken and healthy skin and mucous membranes
  2. Resistance to injury is affected by age
  3. Adequately nourished and hydrated body cells
  4. Adequate circulation
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10
Q

What does unbroken and health skin and mucous membranes do?

A

Unbroken and healthy skin and mucous membranes defend against harmful agents

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11
Q

Resistance to injury of skin is affected by?

A

Resistance to injury is affected by age, amount of underlying tissues, and illness

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12
Q

What does adequately nourished and hydrated body cells do?

A

Adequately nourished and hydrated body cells are resistant to injury

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13
Q

What is adequate circulation of skin necessary for?

A

Adequate circulation is necessary to maintain cell life

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14
Q

In children 2 years and younger, how does the skin compare to adults?

A

In children younger than 2 years, the skin is thinner and weaker than it is in adults

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15
Q

How is an infant’s skin? How is a child’s skin?

A

An infant’s skin and mucous membranes are easily injured and subject to infection;

a child’s skin becomes increasingly resistant to injury and infection

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16
Q

When does the structure of skin change?

A

The structure of the skin changes as a person ages; the maturation of epidermal cells is prolonged, leading to thin, easily damaged skin

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17
Q

How is the skin of older adults?

A

Older adults: circulation and collagen formation are impaired, leading to decreased elasticity and increased risk for tissue damage from pressure

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18
Q

Causes of skin alterations

A
  1. Very thin and very obese people are more susceptible to skin injury
  2. Fluid loss during illness causes dehydration and predisposes skin to breakdown
  3. Jaundice
  4. Diseases of the skin, such as eczema and psoriasis, may cause lesions that require special care
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19
Q

What does Jaundice do to the skin?

A

Jaundice causes yellowish, itchy skin

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20
Q

Types of wounds?

A
  1. Intentional (surgical) or unintentional (traumatic)
  2. Neuropathic or vascular
  3. Pressure related
  4. Open or closed
  5. Acute or chronic
  6. Partial thickness, full thickness, complex
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21
Q

Wound terminology

A

Incision

Contusion

Abrasion

Laceration

Puncture

Penetrating

Avulsion

Chemical

Thermal

Irradiation

Pressure ulcers

Venous ulcers

Arterial ulcers

Diabetic ulcers

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22
Q

What is the first line of defense against microorganisms?

A

Intact skin is the first line of defense against microorganisms

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23
Q

What is used in caring for a wound?

A

Careful hand hygiene is used in caring for a wound

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24
Q

How does the body respond to trauma?

A

The body responds systematically to trauma of any of its parts

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25
Q

What is essential for normal body response to injury?

A

An adequate blood supply is essential for normal body response to injury

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26
Q

How is normal healing promoted?

A

Normal healing is promoted when the wound is free of foreign material

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27
Q

What affects wound healing?

A

The extent of damage and the person’s state of health affect wound healing

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28
Q

How can response to wound be more effective?

A

Response to wound is more effective if proper nutrition is maintained

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29
Q

What are the phases of wound healing?

A
  1. Hemostasis
  2. Inflammatory
  3. Proliferation
  4. Maturation
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30
Q

Hemostasis- when does it occur?

A

Occurs immediately after initial injury

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31
Q

What occurs during hemostasis?

A

Involved blood vessels constrict and blood clotting begins

Exudate is formed, causing swelling and pain

Increased perfusion results in heat and redness

Platelets stimulate other cells to migrate to the
injury to participate in other phases of healing

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32
Q

Inflammatory Phase- when does it occur?

A

Follows hemostasis and lasts about 2 to 3 days

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33
Q

Inflammatory Phase- what occurs?

A

White blood cells, predominantly leukocytes and macrophages, move to the wound

Macrophages enter the wound area and remain for an extended period. They ingest debris and release growth factors that attract fibroblasts to fill in the wound

Exudate is formed and accumulates, causing pain, redness, and swelling at the site of injury
The patient has a generalized body response

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34
Q

Proliferation Phase- how long does it occur?

A

Lasts for several weeks

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35
Q

Proliferation Phase- what occurs?

A

New tissue is built to fill the wound space through the action of fibroblasts

Capillaries grow across the wound

A thin layer of epithelial cells forms across the wound

Granulation tissue forms a foundation for scar tissue development

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36
Q

Maturation Phase- when does it occur?

A

begins about 3 weeks after the injury, possibly continuing for months or years

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37
Q

Maturation Phase- what occurs?

A

Collagen is remodeled

New collagen tissue is deposited, which compresses the blood vessels in the wound, causing a scar

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38
Q

Scar

A

Scar: flat, thin, white line; avascular collagen tissue that does not sweat, grow hair, or tan in sunlight

39
Q

Local Factors Affecting Wound Healing

A

Pressure

Desiccation (dehydration)

Maceration (overhydration)

Trauma

Edema

Infection

Excessive bleeding

Necrosis (death of tissue)

Presence of biofilm (thick grouping of microorganisms)

40
Q

Biofilm

A

(thick grouping of microorganisms)

41
Q

Necrosis

A

Death of tissue

42
Q

Maceration

A

overhydration

43
Q

Desiccation

A

dehydration

44
Q

Systemic Factors Affecting Wound Healing

A
  1. Age
  2. Circulation and oxygenation
  3. Nutritional status
  4. Wound etiology
  5. Health status
  6. Immunosuppression
  7. Medication use
  8. Adherence to treatment plan
45
Q

Systemic Factors Affecting Wound Healing: Age

A

children and healthy adults heal more rapidly

46
Q

Systemic Factors Affecting Wound Healing: Circulation and oxygenation:

A

adequate blood flow is essential

47
Q

Systemic Factors Affecting Wound Healing: Nutritional status

A

healing requires adequate nutrition

48
Q

Systemic Factors Affecting Wound Healing: Wound etiology

A

specific condition of the wound affects healing

49
Q

Systemic Factors Affecting Wound Healing: Health status

A

corticosteroid drugs and postoperative radiation therapy delay healing

50
Q

Wound complications

A
  1. Infection
  2. Hemorrhage
  3. Dehiscence and evisceration
  4. Fistula formation
51
Q
  1. Dehiscence and evisceration
A

Slide 20?

52
Q

Factors Affecting Pressure Injury Development

A

Aging skin
Chronic illnesses
Immobility
Malnutrition
Fecal and urinary incontinence
Altered level of consciousness
Spinal cord and brain injuries
Neuromuscular disorders

53
Q

Microclimate

A

temperature and moisture of the skin

54
Q

Mechanisms in Pressure Injury Development

A

External pressure compressing blood vessels

Friction or shearing forces tearing or injuring blood vessels

Microclimate

55
Q

Risks for Pressure Injury Development

A

Nutrition and hydration

Immobility

Mental status

Age

56
Q

Stages of Pressure injuries: How many actual stages are there?

A

4

(not including unstageable and deep tissue pressure injury)

57
Q

Stages of Pressure injuries: Stage 1

A

Stage 1: nonblanchable erythema of intact skin

58
Q

Stages of Pressure injuries: Stage 2

A

Stage 2: partial-thickness skin loss with exposed dermis

59
Q

Stages of Pressure injuries: Stage 3

A

Stage 3: full-thickness skin loss; not involving underlying fascia

60
Q

Stages of Pressure injuries: Stage 4

A

Stage 4: full-thickness skin and tissue loss

61
Q

Stages of Pressure injuries: Unstageable

A

Unstageable: obscured full-thickness skin and tissue loss

62
Q

Stages of Pressure injuries: Deep tissue pressure injury

A

Deep tissue pressure injury: persistent nonblanchable deep red, maroon, or purple discoloration

63
Q

Psychological Effects of Wounds

A
  1. Pain
  2. Anxiety
  3. Fear
  4. Impact on activities of daily living
  5. Change in body image
64
Q

Health History

A

Recent changes in skin
Activity and mobility
Nutrition
Pain
elimination

65
Q

Skin Assessment- What is included

A

Inspection and palpation

Systematically—head to toe

Include bony prominences

66
Q

When is skin assessments done?

A

On admission and at regular intervals:

67
Q

On admission and at regular intervals: what intervals

A

Acute care

Long-term settings

Home health care

68
Q

For acute care, when are skin assessments done?

A

Acute care—every shift

69
Q

For long term settings, when are skin assessments done?

A

Long-term settings—weekly for 4 weeks then quarterly

70
Q

For home health care, when are skin assessments done?

A

Home health care—each visit

71
Q

When assessing a wound, what are you looking for in general?

A
  1. Appearance
  2. Drainage
72
Q

What are you assessing for in appearance of wound?

A

Size of wound

Depth of wound

Presence of undermining, tunneling, or sinus tract

73
Q

What are you assessing for in drainage of wound?

A

Serous
Sanguineous
Serosanguineous
purulent

74
Q

Preventing Pressure Injuries

A

Assess at risk patients daily

Cleanse the skin routinely

Maintain higher humidity; use moisturizers

Protect skin from moisture

Minimize skin injury from friction or shearing

Proper positioning, turning, transferring

Appropriate support surfaces

Nutritional supplements

Improve mobility and activity

75
Q

What are the purposes of wound dressings?

A

Provide physical, psychological, and aesthetic comfort

Prevent, eliminate, or control infection

Absorb drainage

Maintain moisture balance of the wound

Protect the wound from further injury

Protect the skin surrounding the wound

Debride (remove damaged/necrotic tissue), if appropriate

Stimulate and/or optimize the healing response

Consider ease of use and cost-effectiveness

76
Q

Types of Wound dressings?

A

Those that maintain moisture

Those that absorb moisture

Those that add moisture

77
Q

What are the steps for changing the dressing?

A

Prepare the patient

Use appropriate aseptic techniques

Hand hygiene before and after

Adhere to standard and transmission-based precautions

Remove the old dressing

Cleanse the wound

Apply a new dressing

Secure the dressing

78
Q

Cleaning a Pressure Injury/Wound steps

A

Clean with each dressing change

Use new gauze for each wipe and clean from top to bottom and/or from the center to the outside

Use 0.9% normal saline solution to irrigate and clean the injury

Once the wound is cleaned,
dry the area using a gauze sponge in the same manner

Report any drainage or necrotic tissue

79
Q

What kind of saline solution should you use when cleaning a pressure injury/wound

A

Use 0.9% normal saline solution to irrigate and clean the injury

80
Q

Types of bandages- NOT GOING TO BE ASKED ON TEST JUST STUDY IF YOU HAVE TIME

A

Roller bandages
Circular turn
Spiral turn
Figure-of-eight turn

81
Q

Types of Binders

A

Slings
Abdominal binders
Chest binders
T-binders

82
Q

Types of Drainage Systems

A
  1. Open systems
  2. Closed systems
83
Q

Types of Drainage Systems: Open systems

A

Penrose drain

84
Q

Types of Drainage Systems: Closed systems

A

Jackson-Pratt drain

Hemovac drain

85
Q

Color Classification of Open Wounds

A

R= red

Y= yellow

B= Black

Mixed wound- contain components of RY &B wounds

86
Q

Color Classification of Open Wounds: R

A

R= red- protect

87
Q

Color Classification of Open Wounds: Y

A

Y= yellow- cleanse

88
Q

Color Classification of Open Wounds: B

A

B= black- debride

89
Q

Color Classification of Open Wounds: Mixed wound

A

Mixed wound- contains components of RY&B wounds

90
Q

Topics for home health care teaching

A

Supplies
Infection prevention
Wound healing
Appearance of the skin/recent changes
Activity/mobility
Nutrition
Pain
Elimination

91
Q

Factors Affecting the Response to Hot and Cold Treatments

A

Method and duration of application

Degree of heat and cold applied

Patient’s age and physical condition

Amount of body surface covered by the application

92
Q

How long should you leave a heating pad on?

A

Heating pad no more than 20 minutes.

93
Q

Effects of Applying Heat

A

Dilates peripheral blood vessels

Increases tissue metabolism

Reduces blood viscosity and increases capillary permeability

Reduces muscle tension

Helps relieve pain

94
Q

Effects of Applying Cold

A

Constructs peripheral blood vessels

Reduces muscle spasms

Promotes comfort

NURS 402: Lecture (17 decks)

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