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C10- Integumentary Flashcards

(55 cards)

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1
Q

Impaired skin integrity

A

Break or disruption of skin or tissues

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2
Q

Impaired skin integrity causes: (external)

A

Hyperthermia
Hypothermia
Chemical
Mechanical
Humidity/moisture
Radiation
Medication

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3
Q

Impaired skin integrity causes: (Internal)

A

Altered metabolic or nutrition state
Altered circulation
Sensation
Pigmentation
Immune deficit
Altered fluid status

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4
Q

Factors placing a person at risk for skin alterations

A

Age
Changes in health status
Therapeutic measures can cause skin problems
Lifestyle variables

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5
Q

Wound definition

A

Disruption or break in normal integrity of skin

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6
Q

Acute wound

A

Heal within days to weeks
Wound edges are well approximated

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7
Q

Chronic wound

A

Do not progress through the normal sequence of repair
Wound edges often not approximated
Normal healing time is delayed
Often remain in inflammatory phase of healing

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8
Q

Open wound

A

Occur from intentional/unintentional trauma
Skin surface broken (portal of entry for microorganisms)
Bleeding
Tissue damage
Increased risk for infection
Delayed healing

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9
Q

Closed wound

A

Occurs from a blow, force, or strain
Skin surface not broken
Soft tissue damage
Internal injury and hemorrhage may occur

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10
Q

Intentional wound

A

Result of planned invasive therapy or treatment

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11
Q

Wound healing process:

A

Skin reflects condition of body
Adequate blood supply
Proper nutrition

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12
Q

Primary intention

A

Wound edges are well approximated

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13
Q

Secondary intention

A

Edges not well approximated
Take longer to heal and often develop scar tissue

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14
Q

Tertiary intention

A

Wounds left open for several days to allow edema or infection to resolve
Or fluid to drain

Then they are closed

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15
Q

Local factors

A

Factors that occur directly in the wound
Ex: pressure, maceration, trauma, edema, infection, excessive bleeding, necrosis, biofilm

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16
Q

Systemic factors: definition and examples

A

Not related to wound itself but prolong wound healing

Ex: age, circulation and oxygenation, nutritional status, medications, health status, adherence to treatment plan

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17
Q

What type of organ is skin?

A

Sensory organ

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18
Q

Psychological effects of wounds?

A

Pain
Anxiety & fear
Changes in body image

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19
Q

What are the 4 phases of wound healing?

A

Hemostasis
Inflammatory
Proliferation
Maturation/Remodeling

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20
Q

Blood clotting, platelet activity, brief vasoconstriction and increased capillary permeability are actions of which phase of wound healing?

A

Hemostasis

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21
Q

How fast is the inflammatory response?

A

Immediate

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22
Q

Which cells may be activated in the inflammatory phase?

A

Leukocytes
Macrophages
Epithelial cells

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23
Q

What type of reaction does the inflammatory phase produce?

Study These Flashcards
A

Generalized (mild fever, increase WBC, malaise)

24
Q

How long does it take for proliferation to begin? How long does it last?

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A

Within 2-3 days
Lasts 2-3 weeks

25
Common phrase associated with proliferation
“Fill the divot”
26
3 step associated with proliferation
Fibroblasts deposit fibrin Blood flow reinstituted Granulation tissue formed
27
When does Maturation/Remodeling begin? How long does it last?
Begins ~3 weeks Lasts for months or years
28
Maturation/remodeling three steps
Collagen remodeled More collagen deposited (compressing vessels) Scar develops (avascular collagen)
29
Which “intention” takes the longest to remodel?
Secondary intention
30
Color classification system for wound beds (RYB)
Red=protect Yellow=cleanse Black=debride
31
Red wound bed color indicates?
Ready for healing and responding to treatment Granulation tissue Good wound bed
32
Yellow wound bed indicates?
Non-viable tissue needs debridement Slough or tissue with poor blood supply
33
Black wound bed indicates?
Necrotic tissue (eschar) DEBRIDE dead tissue
34
Peri-wound is defined as
Tissue surrounding the wound
35
What are we assessing for peri-wound skin?
Intact? Color? Characteristics -erythema (redness around wound) -induration (increase in fiber elements in tissue) -inflammation
36
Exudate means?
Drainage
37
Terms defining the amount of exudate drainage coming out of the wound
Scant Minimal Moderate Copious
38
Characteristics of exudate
Color Odor Type
39
Serous wound drainage
Clear, watery plasma
40
Purulent wound drainage
Thick, yellow, green, tan, or brown
41
Serosanguineous wound drainage
Pale, red, watery: Mixture of serous and sanguineous
42
Sanguineous wound drainage
Bright red Indicates active bleeding
43
Infection signs and symptoms my occur ________-______ days after inury
2-7 days
44
Infection produces an increase of:
Purulent drainage Increased drainage Pain Redness and swelling (in and around wound) Elevated temp and WBC count
45
Greatest risk for hemorrhage when?
In the first 48 hours after surgery -check wound frequently (2X shift) -look for hematoma
46
Hemorrhage treatment
Apply added pressure on the site and contact provider
47
Dehiscence is?
Partial or total separation of the wound layers -suture line pops open
48
Evisceration is?
Complete separation and protrusion of the viscera and organs through incision
49
Abscess and fistula are formed by:
Collection of infected fluid not draining -abnormal passage/tunnel (organ to skin) This results from delayed healing
50
What four things would a nurse identify during a wound assessment?
Type of wound/cause Appearance of wound Stage of a pressure ulcer wound Wound complications Nurse would also assess (Pain, Vital signs, fever, labs)
51
R.I.C.E. Wound healing
R- rest I- Ice/ immobilization C- compression E- elevation *** oxygenation and infection control ***
52
What are pressure injuries?
Localized damage to the skin and underlying tissue that usually occurs over a bony prominence or is related to the use of a medical device
53
Who is at risk for pressure injuries?
Older adults Spinal cord & brain/neurological injuries
54
Pressure injury assessment
Measure: -size Shape Length and width Unit label (inch, cm, mm) Depth -insert sterile moistened swab into wound Measure depth on swab
55
Nursing management of pressure injuries
Assess/monitor healing process Role of nutrition Pain assessment/management Support surfaces and positioning Cleansing debridement and dressings

Nursing Fundamentals (8 decks)

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