Chapter 37 Skin Integrity And Wound Care Flashcards Preview

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Flashcards in Chapter 37 Skin Integrity And Wound Care Deck (125):
0

Braden scale

Lower score higher the risk

1

Impaired skin integrity resulting from pressure
Localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure or pressure in combination with shear and/or friction

Pressure ulcer

2

Body's largest organ

Skin

3

Primary defense against infection

Skin

4

Disruption in the integrity of the body tissue

Wound

5

Surface damage caused by the skin rubbing against another surface that often results in an abrasion

Friction

6

Loss of the epidermis
Eschar
Abrasion

Abrasion

7

Thick layer of dead dry tissue that covers a pressure ulcer or thermal burn
It may be allowed to be sloughed off naturally or it may need to be surgically removed
Like a scab

Eschar
Abrasion

Eschar

8

A wound with little or no tissue loss such as a clean surgical incision which heals by
Skin edges approximate or close together and risk for infection is minimal
Healing rapidly with minimal scarring
Low risk for infection
Healing occurs in four stages

Primary intention

9

A wound involving loss of tissue such as a severe laceration or a chronic wound such as a pressure ulcer heals by
The skin edges cannot come together because of the extensive tissue loss and healing occurs gradually
Edges widely separated
Large scar occurs
Increased potential for infection
Healing time longer
Healing from bottom up

Primary
Secondary

Secondary intention

10

Pink pebbly tissue
Red moist tissue consisting of blood vessels and connective tissue, covers the wound base
Wound contraction brings the wound together and the wound closes with scar formation
Layers of pink pebbly tissue is new granulation tissue
As layer gets thick it becomes beefy red

Ecchymosis
Granulation

Granulation tissue

11

Cessation of bleeding

Hemastasis

12

Partial or total separation of layers of skin and tissue above the fascia in a wound that is not healing properly

Dehiscence

13

Occurs when wound layers separate below the fascial layer and visceral organs protrude through the wound opening
This is a medical emergency. This happens in abdominal incision where it splits open when you may sneeze or pick up something heavy.
Have patient lay on floor so things will not fall out, take pressure off, sterile equipment, moisten soak in sterile solution and put it in wound and cover do internal organs will not dry out and call surgeon and schedule for surgery. Do not push things back in. Do not put anything on it to bind it.

Evisceration

14

Discoloration of the skin or bruise caused by leakage of blood into subcu tissues as a result of trauma to the underlying tissues

Ecchymosis
Dehescience

Ecchymosis

15

Softening of the skin caused by moisture

Maceration

16

Removal of dead tissue from a wound

Debridement

17

Sensitive vascular layer of the skin directly below the epidermis composed of collagenous and classic fibrous connective tissues that give the dermis strength and elasticity

Dermis
Exudate

Dermis

18

Approximate

To come close together as in the edges of a wound

19

Injury to the skins surfaced caused by abrasion

Excoriation

20

Fluid, cells or other substances that have been slowly discharged from cells or blood vessels through small pores or breaks in cell membranes

Exudate

21

Clear, watery plasma

Serous

22

Fresh bleeding

Sanguineous

23

Pale, more watery
Combination of plasma and red cells
May be blood streaked

Serosanguinous

24

Thick, yellow, green or brown, indicating the presence of dead or living organisms and WBCs

Purulent

25

Abnormal passage from an internal organ to the body surface or between two internal organs

Fistula

26

Skin and subcu layers adhere to surface of bed and muscle and bone slide in the direction of body movement

Shearing force

27

Protective reaction that neutralizes pathogens and repairs body cells

Remodeling
Inflammatory response

Inflammatory response

28

Nonblanchable erythema of the intact skin
Only the epidermis is involved
Reversible if pressure removed
Which stage pressure ulcer

Stage I

29

Partial thickness skin loss involving epidermis and/or dermis
Skin tears
Superficial
Presents as an abrasion, blister or shallow crater
May be swollen or painful
More painful than IV
which stage of pressure ulcer

Stage II

30

Full thickness skin loss with damage or necrosis of subcu tissue that may extend to but not through the underlying fascia
Presents as deep crater with or without undermining
May have foul smelling drainage
Which stage of pressure ulcer

Stage III

31

Full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone or supporting structures
Undermining/tunneling may be present
Which stage of pressure ulcer

IV

32

Decreased blood supply to a body part such as a skin tissue or to an organ such as the heart

Ischemia

33

External factors that increase patients risk for developing an ulcer

Pressure
Shear
Friction
Moisture

34

Internal factors that increase patients risk for a pressure ulcer

Nutrients
Infection
Age

35

What nutrient is needed to maintain skin

Protein

36

Low protein levels cause

Edema or swelling

37

Edema increases the risk for pressure ulcer formation because

Changing pressures in capillary circulation and capillary bed resulting in decreased blood supply and retention of waste products in the edematous tissue

38

Does edema increase or decrease elasticity

Decease

39

Inhibit wound healing

NSAID
Steroids

40

Most common sources of moisture

Incontinence
Fever

41

Exposure of moisture leads to

Maceration

42

Temperature greater than 101
Leads to swearing and maceration
Increases metabolic
Sign of infection
Triggers immune response which uses calories and nutrients

Fever

43

Are these primary or secondary defenses

Skin and normal flora
Mucous membranes
Sneeze, cough, tearing reflexes
Elimination and acidic environments
Circulatory system

Primary

44

Physical barrier
Inhibits growth traps infection

Mucous membranes

45

Trap and propel mucous from lung

Cilia

46

Physical expulsion

Sneeze/cough

47

Flushing mechanism

Tears

48

Primary or secondary defenses

Inflammatory response
Immune response

Secondary

49

White blood cells
Second line of defense
Ingest and destroy microbes

Leukocytes

50

Normal range of leukocytes

Less than 10,000

51

Which stage of inflammatory response

Initial injury precipitates release of chemicals
Activates the inflammatory response

Stage 1

52

Which stage of inflammatory response

Erythema
Produces the characteristic signs of redness and increased warmth

Stage 2

53

Increased blood flow to inflamed area

Erythema

54

Which stage of inflammatory response

Increases capillary permeability with leakage of large quantities of plasma into damaged tissue
Infection is walled off
Nonpitting edema occurs

Stage 3

55

Which stage of inflammatory response

Damaged tissue invaded by leukocytes that engulf the bacteria and necrotic tissue
Produces purple to exudate (pus)

Stage 4

56

Which stage of inflammatory response

Destroyed tissue cells replaced by identical/similar cells and/or fibrous tissue
Promotes tissue healing or formation of scar tissue
Functional capacity of tissue may be reduced

57

Cardinal signs and symptoms of inflammation

Redness - blood accumulation in dilated capillaries
Warmth - the heat of the blood
Swelling - fluid accumulation
Pain - pressure or injury to local nerves

58

Does inflammation equal infection

No

59

Is inflammation a normal response

Yes

60

When the body's defenses are overwhelmed

Infection

61

Setting up for trouble in individuals

Breaks in skin and mucous membranes
Invasive devices
Stasis of body fluids
Inadequate nutrition
Stress
Immune system dysfunction

62

Common sites of infection

Surgical wounds
Urinary tract
Respiratory tract

63

Major cause for hospital morbidity which accounts for 60% of extra hospital days

Surgical wounds

64

Most common nosocomial infection

UTI
Respiratory

Urinary tract

65

Second most common site and associated with most deaths

Respiratory tract

66

Does wound infection double or triple for each hour a patient is in surgery

Doubles

67

Most common mechanism of respiratory infection

Aspiration

68

Major causative agent of a UTI

Caths
Wounds

Catheters

69

Very little tissue loss

Primary
Secondary
Tertiary

Primary

70

Delayed primary

Secondary
Tertiary

Tertiary

71

A wound that just happened

Acute
Chronic

Acute

72

A wound that has been there for two months or longer

Chronic

73

Granulating healing wound

Red
Yellow
Black

Red

74

Pus

Yellow
Red
Black

Yellow

75

Necrosis

Brown
Black

Black

76

What are the four stages of healing

Hemostasis
Inflammatory
Proliferate
Remodeling

77

Also called delayed primary healing
A widely separated wound is later brought together with some type of closure material
Usually fairly deep
Often contains extensive drainage and tissue debris

Tertiary

78

Physiology of wound healing

Vascular response/inflammation (hemostasis and inflammatory)
Proliferation/regeneration
Maturation/remodeling

79

Reaction phase
Begins in minutes and lasts about 3-6 days
Hemostasis
Slight fever
Inflammation

Proliferation
Vascular response
Remodeling

Vascular response

80

Proliferation/regeneration

Day 3-4 to day 21
Macrophage clears area of debris
Begins with appearance of new blood vessels
Fills wound with connective or granulation tissue and top is closed with epithelialization
Fibroblasts synthesize collagen which closes wound (forms scar)
Scar is pink and raised

81

Grows from edges and covers over the granulation
New skin/scar

Epithelial tissue

82

Maturation/remodeling

Starts day 21 and can go long periods
Collagen scar gains strength
Scar remodels resuming normal appearance
Scar becomes smaller, flatter and whiter
Takes months to years to complete

83

Types of exudates

Serous
Sanguinous
Serosanguinous
Purulent

84

Act of forming pus

Suppuration

85

Complications of healing

Infection
Hemorrhage
Dehiscence
Evisceration
Fistulas

86

Used in clean and granulating wounds

Wet to moist

87

Only solution for wound care recommended by Agency for Health Care Policy Research

Normal saline

88

Best agent to use for wound and isotonic

Normal saline

89

Solutions that delay healing

Hydrogen peroxide
Dakin's solution (bleach solution)

90

Solution that slow healing

Acetic acid (vinegar solution)

91

Major no no, removes moisture from wound bed

Betadine

92

Intermittent current to wound bed
Stimulates migration of cells involved in repair
Stimulates granulation
Inhibits bacterial growth
Limited clinical use

Electrical stimulation

93

Oxygen delivered at increased atmospheric pressure
Stimulates fibroblasts, collagen synthesis and epitheliumtunica
Improves blood capacity to carry O2 thus leading to increased oxygenation

Hyperbaric oxygen

94

Sponge inside wound covered with occlusive dressing and connected to negative pressure machine
Eliminates excess exudates
Good for large/deep wounds, heavy exudates and nonhealing wounds

Negative pressure wound treatment

95

Acute wounds in inflammatory phase

Cold or heat

Cold

96

Chronic wound - direct heat contraindicated in arterial insufficiency

Heat

97

Scrub, rub, wet to dry damp dressing, irrigation, whirlpool, maggots

What kind of debridement
Mechanical
Enzymatic
Automatic
Sharp

Mechanical

98

Topical medication, collagenase are enzymes

Enzymatic

99

Body does it to itself
Dressings that contain moisture that make use of the body's enzymes to break down necrotic tissue

What kind of debridement
Mechanical
Enzymatic
Autolytic
Sharp

Autolytic

100

Use of scalpel/scissors
Requires special training

What kind of debridement

Mechanical
Enzymatic
Autolytic
Sharp

Sharp

101

What are some common misconceptions of pressure ulcers

Develop because of poor nursing care
Are preventable
Are caused from pressure alone
Massaging reddened tissue helps prevent
Use of specialty equipment will prevent ulcers indefinitely and independently

102

What would you use with a wound with a lot of drainage

Collagen

103

Does a wound vac limit ambulation

Yes

104

What are the most susceptible areas for a pressure ulcer

Coccyx-sacral area
Heels
Elbows

105

Contributing factors leading to pressure ulcer

Prolonged pressure
Shearing force
Friction
Moisture
Nutrition
Infection
Impaired peripheral circulation
Obesity
Age

106

Abrasion
Two surfaces rubbing against each other
Injury is shallow and without necrosis
Limited to the epidermis (skinned knee, road rash)

Friction

107

Most vulnerable areas with a friction injury

Heels and elbows

108

Suspects deep tissue injury - localized area of purple/maroon discoloration
Intact skin or a blood filled blister that is due to damage of underlying soft tissue from pressure and/or shear
Tissue that is painful, firm, mushy, boggy, or warm/cool in comparison to adjacent tissue

Suspected deep tissue injury

109

Base of the ulcer is covered by slough and/or eschar
A necrotic ulcer, or one with eschar, cannot be graded or staged - depth of wound and tissue type cannot be visualized
Cannot see bottom of wound bed, can't tell stage

Unstageable

110

Which stage related treatment
Relieve pressure

Stage 1

111

Stage related treatment
Moist healing environment

Stage 2

112

Which Stage related treatment
Debride

3

113

Which stage related treatment
Non adherent dressing, skin grafts

4

114

Head of bed position to prevent a pressure ulcer

Lowest possible level

115

Hemostasis and inflammatory

Reaction phase
Begins in mins and lasts about 3-6 days
Blood vessels constrict providing a clot
Vasodilation brings nutrients and WBCs
Blood flow reestablishedafter epithelial cells begin to grow

Phagocytosis
Slight fever less than 101. Normal and product of inflammation. Not infection

116

Day 3 to 4 and lasts 21 days
Macrophages clear area of debris
Begins with appearance of new blood vessels
Fills wound with connective or granulation tissue and top is closed by epithelialization
Fibroblasts synthesize collagen which closes
Scar is pink and raised

Proliferation/regeneration

117

Starts around three week mark and can go on for long periods
Collagen scar gains strength
Scar remodels resuming normal appearance
Scar becomes smaller, flatter and whiter
Takes months/years to complete

Maturation/remodeling

118

Clear water plasma

Serous

119

Sanguinuous

Fresh bleeding

120

Pale, more watery, combination of plasma and red cells, blood streaked

Serosanginuous

121

Thick, yellow, green, brown indicating presence of dead or living organisms and white blood cells

Purulent

122

Complications of wound healing

Infection
Hemorrhage
Dehiscence
Evisceration
Fistulas

123

Reduces skins resistance to pressure and shearing
Originates from
Wound drainage, perspiration, incontinence, vomitus, condensation from equipment

Moisture

124

Causes atrophy and lose subcu tissue
Less tissue present to pad bones
Poor nutrition Often overlooked because of obesity
Fluid/electrolyte imbalance
Anemia: reduced amount 02

Poor nutritional status