Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Module 3 > Skin Integrity > Flashcards

Skin Integrity Flashcards

1
Q

what is primary prevention focusing on in tissue integrity

A

patient education and prevention… (who can we educate them on how not to get a wound)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

what is secondary prevention on tissue integrity

A

after the wound happens (not good education) what can we do while they have a wound and to get it healed

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

what is tertiary prevention on tissue integrity

A

who do we prevent them from coming back to us, more education, teach how to take care of wound and how to clean it at home

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

what are clinical manifestation of compromised tissue integrity

A

itching, burning, pain, excessively dry skin, peeling skin, draining wound-something in wound, pressure ulcers, tear in skin, depression, changes in skin color, fluid and lights imbalance

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

what are wounds classified by

A

cause and depth of tissue affected

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

what are the 2 causes of a wound

A

surgical or nonsurgical, acute or chronic

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

what are the depths of tissue affected

A

superficial, partial thickness, full thickness

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

acute=

A

less than 6 months

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

superficial=

A

epidermis is affected

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

partial thickness=

A

through epidermis to dermis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

full thickness=

A

anything from sub Q down to muscle, bone

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

what are age related changes of tissue integrity

A 
skin becomes fragile
delayed wound healing
dec in Vit D production
susceptible to dry skin
dec in sensory percep
risk hypo/hyperthermia
dec in elasticity
dec in perspiration
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

what are the (primary) healing of a primary intention

A

initial (inflammatory phase)
granulation phase
maturation phase

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

incision with blood clot, edges approximated with suture, fine scar

A

primary intention

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

irregular large wound with blood clot, granulation tissue fills in wound, large scar

A

secondary intention

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

contaminated wound, granulation tissue, delayed closure with suture

A

tertiary intention

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

want this to heal from the inside out so it does not leave a big air pocket

A

secondary intention

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

delayed primary intension so opened back up to heal

A

tertiary intention

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

not going to heal from the inside out because wound not big enough (neatly approximated) surgical incision or paper cut

A

primary intention

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

fibrin clots, erythrocytes, neutrophils, cellular debris come to surface

A

initial inflammatory response

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

wound is pink and vascular, surface epithelium at the wound edges begin to regenerate,

A

granulation phase

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

may start 7 days after injury occurs and can continue for several months or years, collagen fibers are organized and remodeling occurs (scaring)

A

maturation phase

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

wounds from trauma, infection, ulceration, can not suture back, more exudate

A

secondary intention

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

why are secondary intention more at risk for infection

A

because have to leave open

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

how is secondary intention classified as

A

color (red, yellow, black)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

superficial or deep wound that is clean and pink in appearance (serosanguinous drainage)

A

red wound (stage 2 pressure ulcer, skin tear, second degree burn)

27
Q

presence of slough or soft necrotic tissue (liquid semi solid ivory to yellow green may be present) slough should be removed and drainage absorbed

A

yellow wound

28
Q

why should any form of slough be removed

A

it is non viable tissue and oxygen can not reach wound bed to help regeneration

29
Q

necrotic tissue, risk for infection

A

black wound (full thickness, stage 3&4 pressure ulcer)

30
Q

what are the signs of shock

A

rapid pulse, cool clammy skin, pale skin, rapid breathing, pupils dilated, N/V, weakness, fainting

31
Q

how should you measure a wound

A

head to toe
side to side
depth

32
Q

what therapy helps heal from the inside out

A

negative pressure wound therappy

33
Q

what does negative pressure wound therapy do

A

suction removes drainage and speeds up healing process

34
Q

why would you monitor lytes when pt is on negative pressure wound therapy

A

pulls off so much fluid and can cause lyte imbalance

35
Q

allows 02 to diffuse into serum, instead of RBCs delivering the 02

A

hyperbaric oxygen therapy

36
Q

what is the foundation for good wound healing

A

high fluid intake, get high in protein, carbohydrates, vit B and C along with MODERATE fat intake

37
Q

what lab values do you want high in wound healing

A

albumin

38
Q

what are risk factors for pressure ulcers

A

prolonged pressure, poor hygiene, poor nutrition, incontinence, breaks in the skin

39
Q

pressure exerted on the skin when it adheres to the bed and the skin layers slide in the direction of body movement

A

shearing force

40
Q

two surfaces rubbing against each other

A

friction

41
Q

what are the contribution factors of pressure ulcers

A

shearing force, friction and moisture

42
Q

non blanchable reddened area (SKIN IS INTACT)

A

stage 1 PU

43
Q

partial thickness loss of dermis, shallow open ulcer with pink wound bed, WILL HAVE LOSS OF SKIN (intact or ruptured serum filled blister)

A

stage 2 PU

44
Q

full thickness skin loss or necrosis of sub Q tissueDOES NOT INVOLVE bone, facia, or tendons, will have slough, exudate

A

stage 3 PU

45
Q

Full thickness loss can extend to MUSCLE, BONE, or TENDONS, tunneling

A

stage 4 PU

46
Q

purple or maroon localized area of discolored intact skin or blood filled blister (looks like bruise)

A

Deep tissue injury

47
Q

what is an unstageable ulcer and what should not be removed

A

full thickness tissue loss with a base covered in slough and or eschar. DO NOT want to remove STABLE ESCHAR because it is protecting it

48
Q

what are the signs of infection

A

leukocytosis, fever, increased ulcer size, odor, or drainage, necrotic tissue, pain

49
Q

what are complications of PU

A

recurrence (most common)
cellulitis
chronic infection
osteomyelitis

50
Q

a braden scale of 23 is _______ and a scale of 6 is _______

A

none; severe

51
Q

what are good ways for ulcer prevention

A

teaching, mobilization, skin care, nutrition

52
Q

inflammation of sub Q tissues and often follows a break in the skin

A

cellulitis

53
Q

cellulitis starts ______ is hot, red, painful and can ______ if not treated

A

locally; spread

54
Q

what type of pt can not heal cellulitis quickly

A

diabetic and hypertensive pt

55
Q

what are the clinical signs of cellulitis

A

hot, tender, erythematous, edematous, diffuse borders, skin looks SHINY, skin can have red spots, blisters and skin dimpling

56
Q

flaking, weeping, tears from swelling, fever, pain, altered gait, malaise, and chills are all manifestations of

A

cellulitis

57
Q

when a pt has chills, malaise, and fever what are we worried about

A

sepsis

58
Q

who should you treat cellulitis

A

MOIST heat
elevation and immobilization
systemic antibiotic therapy if long term

59
Q

silvery scaling plaques on reddish colored skin, is BENIGN and NOT contagious

A

psoriasis

60
Q

seen on elbows knees, palms, soles and fingernails (is an autoimmune disorder)

A

psoriasis

61
Q

what happens when a person scratches their psoriasis spots?

A

could cause a secondary infection due to a break in skin

62
Q

clinical manifestations of psoriasis

A

itching
burning
pain

63
Q

what type of psoriasis mimics RA

A

psoriatic arthritis

64
Q

goal for psoriasis is to reduce _____ and suppress rapid turnover of ______ cells. there is ____ a _____, but _____ is possible

A

inflammation; epidermal; no cure; control

Module 3 (10 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions