Chapter 48 Skin Integrity & Wound Care Flashcards Preview

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Flashcards in Chapter 48 Skin Integrity & Wound Care Deck (93):
1

What is the largest organ in the body?

The skin

2

Skin the largest organ in the body constitute the___% of the total adult weight

15 %

3

The skin is a _____ _____ against disease - causing organisms.

protective barrier

4

The skin functions are:

Pain
Temperature
Touch

5

The skin synthesizes

Vitamin D

6

Nurse responsibilities regarding skin are:

* assess & monitor skin integrity
* Identify problems
* Planning, implementing, & evaluating interventions to maintain skin integrity.

7

Aspects to assess dark skin

* difficult to detect cyanosis.
* be aware of situations that produces changes in skin tone such us inadequate lightning.
* examine body sites with least melanin (under arm).
*evaluate pigmented skin color specific changes.

8

The factors that contribute to skin breakdown are:

*Impaired sensory perception
*impaired mobility
*alteration in level of consciousness.
* shear
* Friction
* Moisture

9

Body fluids that has high risk skin breakdown:

Gastric Drainage.
Pancreatic Drainage.

10

Body fluids that has moderate risk for skin breakdown

Bile, stool, urine, ascetic fluid, purulent drainage.

11

Impaired skin integrity related to unrelieved, prolonged, pressure referred to:

pressure ulcer or pressure sore
decubitus ulcer,
bed sore

12

Localized injury to the skin and other underlying tissue, usually over a bone prominence

Pressure ulcer

13

Nurse should assess pressure ulcers at regular intervals using systematic parameters:

* Wound healing
*plan appropriate interventions
* evaluate progress.

14

Pressure in combination with friction results in

Pressure ulcer

15

what would you document about a pressure ulcer:

*Depth of tissue involve (stage)
* Type and % of tissue in wound bed
* wound dimensions
* exudate description
* Condition of surrounding skin.

16

Stage of Ulcer non blanchable redness of intact skin, painful, warmer or cooler than adjacent tissue. Firm or soft

Pressure Ulcer stage 1

17

stage of ulcer partial thickness skin loss or blister involving epidermis, dermis or both/ Shiny, dry shallow ulcer

Pressure ulcer stage 2

18

Stage of ulcer that is Full-thickness skin loss (Fat visible) tissue loss

Pressure Ulcer Stage 3

19

Stage of ulcer Full-thickness tissue loss with (Exposed bone, muscle, or Tendon.)

Pressure ulcer stage 4

20

What is the major cause of the formation of a pressure ulcer?

-Pressure Intensity
-Pressure Duration
-Tissue Tolerance

21

Risks for pressure ulcers:

Nutrition
-Impaired sensory perception
-Impaired mobility
-Alteration in the level of consciousness
-Presence of a cast
- Secondary to an illness
-Shear
-Friction
-Moisture

22

What nurses should do to prevent pressure ulcer?

Skin care
-Positioning
-Use of support surfaces

23

Disruption of the integrity and function of tissues in the body.

A wound

24

T or F. Non 2 wounds are the same

true

25

what are complications regarding wounds?

-Hemorrhage
-Hematoma:
-Infection (second most common HAI)
-Dehiscence:
-Evisceration: protrusion of visceral organs through a wound opening.

26

there are 2 types of dressing:

1. Clean
2. Sterile

27

Who is at risk for a pressure ulcer development?

-Any patient experiencing decreased mobility
-Decreased sensory perception
-Fecal or Urinary Incontinence
-Poor nutrition

28

Normal Capillary pressure ranges between:

15 to 32 mm Hg

29

Tissues receive oxygen and nutrients and eliminate metabolic wastes through_____.

Blood

30

Any factor that interferes with ____ flow in turn interferes with cellular metabolism and the function of life of the cells.

Blood

31

Prolonged, intense pressure affects cellular metabolism by decreasing or obliterating blood flow, resulting in tissue ______ and ultimately tissue death.

ischemia

32

If the pressure applied over a capillary exceeds normal capillary pressure and the vessel is occluded for a prolonged period of time, what can occur?

Tissue ischemia.

33

If the patient has reduced sensation and cannot respond to discomfort of the ischemia, what will be the result?

If the patient has reduced sensation and cannot respond to discomfort of the ischemia, what will be the result?

34

After a period of tissue ischemia, if the pressure is relieved and the blood flow returns, what color does the skin turn?

Red. Hyperemia (redness)

35

Blanching occurs when the normal red tones of the light-skinned patient are ____.

Absent

36

Evaluate an area of hyperemia by pressing a finger over the affected area. If it blanches (turns lighter in color) and the erythema returns when you remove your finger....

the hyperemia is transient and is an attempt to overcome the ischemic episode, thus called blanching hyperemia

37

If the erythematous area does not blanch (non blanching erythema) when you apply pressure....

Deep tissue damage is probable.

38

Clinical implications of pressure

1. Evaluating the amount of pressure (checking skin for reactive hypermia)
2. Determining the amount of time that a patients tolerates pressure (checking to be sure after relieving pressure that the affected area blanches.)

39

Systemic factors such as ___ ___ ___ affect the tolerance of the tissue to externally applied tissue.

Poor nutrition
- Hydration status
-Low BP

40

is the sliding movement of skin and subcutaneous tissue while the underlying muscle and bone are stationary.

Shear force

41

Example: _____ _____ occurs when the head of the bed is elevated and the sliding of the skeleton starts, but the skin is fixed because of friction with the bed.

Shear force

42

Force of two surfaces moving across one another such as the mechanical force exerted when skin is dragged across a coarse surface such as bed linens.

Friction

43

What is the difference between shear and friction injuries?

Friction injuries affect the epidermis or top layer of the skin, Shear do not.

44

The denuded skin appears red and painful and is sometimes referred to as "sheet burn."

Friction

45

A friction injury usually occurs in:

Patients who are restless
-Those whose skin is dragged rather than lifted from the bed surface during position changes.

46

Immobilized patients who are unable to perform their own hygiene needs depend on the nurse to?

Keep the skin dry and intact.

47

Skin moisture originates from:

-wound drainage
-excessive perspiration
-fecal or urinary incontinence

48

Can you stage an ulcer covered with necrotic tissue?

No, because the necrotic tissue is covering the depth of the ulcer. Necrotic tissue must be debrided or removed to expose the wound base to allow for assessment.

49

Definition for an ulcer that is unstageable/unclassified

in which the base of the wound cannot be visualized and a definition of tissue injury in which the depth of the injury is unknown.

50

Depth of tissue involvement is?

Staging

51

red, moist, tissue composed of new blood vessels.

Granulation tissue

52

Soft yellow of white tissue is a slough

(stringy substance attached to wound bed)

53

Black or brown necrotic tissue is ____. Thick layer of dead dry tissue that covers a pressure ulcer or

eschar

54

Measure depth of an ulcer in the wound bed with?

Cotton-tipped applicator

55

Wounds are usually easily cleaned and repaired. Wound edges are clean and intact.

Acute wound

56

Continued exposure to insult impedes wound healing.

Chronic wound

57

Primary intention (healing process) Like a surgical incision.

Healing occurs by epithelialization; heals quickly with minimal scar formation.

58

Secondary Intention (wound edges not approximated) Like pressure

Wounds heal by granulation tissue formation, would contraction, and epithelialization.

59

Tertiary Intention (wound left open for several days, then wound edges are approximated)

Closure of wound is delayed until risk of infection is resolved.

60

Wound exudate should describe:

-the amount
-color
-consistency
-odor of wound drainage

61

Excessive exudate indicates the

infection

62

Skin surround the wound asses for:

Redness
-Warmth
-Maceration
-Edema (swelling)
*Presence of any of these factors indicates wound deterioration.

63

What differentiates contaminated wounds from infected wounds?

Amount of bacteria present.

64

A patient who is at risk for dehiscence

- poor nutritional status
- infection
- obesity

65

When this appear, the nurse should places sterile towels soaked in sterile saline over the extruding tissues to reduce the chances of bacterial invasion and drying of the tissues. Surgical emergency.

When evisceration occurs

66

Braden scale six subscales:

1. sensory perception
2. moisture
3. activity
4. mobility
5. nutrition
6. friction/shear

67

To keep nutritional maintenance we required

1500 kcal/day

68

Physiological processes of wound healing depend on:

-protein
-vitamins (especially A & C)
-trace minerals zinc and copper

69

Protein formed from amino acids acquired by fibroblasts from protein ingested in food.

Collage

70

To synthetize collagen we need:

Vitamin C

71

The vitamin that reduce the negative effect of steroids on wound healing is

Vitamin A

72

Wound remodeling & immune function. Tissue repair and growth.

Protein

73

antioxidant

Vitamin E

74

wound closure, epithelialization, inflammatory response, angiogenesis, collagen formation. *can reverse steroid effects on skin and delayed healing.

Vitamin A

75

Collagen synthesis, capillary wall integrity, fibroblast function, antioxidant

Vitamin C

76

Collagen formation
Protein Synthesis
Cell membrane & host defenses

Zinc

77

Essential fluid environment for all cell function

Fluid

78

Calories provide the energy source needed to support....

the activity of wound healing.

79

When repositioning an immobile patient, the nurse notices redness over a bony prominence. What is indicated when a reddened area blanches on fingertip touch?

Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode.

80

Which type of pressure ulcer is noted to have intact skin and may include changes in one or more of the following: skin temperature (warmth or coolness), tissue consistency (firm or soft)

Stage I

81

When obtaining a wound culture to determine the presence of a wound infection, from where should the specimen be taken?

Wound after it has first been cleaned with normal saline

82

After surgery the patient with a closed abdominal wound reports a sudden "pop" after coughing. When the nurse examines the surgical wound site, the sutures are open, and pieces of small bowel are noted at the bottom of the now-opened wound. Which corrective intervention should the nurse do first?

Cover the area with sterile, saline-soaked towels and immediately notify the surgical team; this is likely to indicate a wound evisceration

83

Which description best fits that of serous drainage from a wound?

Clear, watery plasma

84

For a patient who has a muscle sprain, localized hemorrhage, or hematoma, which wound care product helps prevent edema formation, control bleeding, and anesthetize the body part?

Ice bag

85

Which skin care measures are used to manage a patient who is experiencing fecal and urinary incontinence?

Using an incontinence cleaner, followed by application of a moisture-barrier ointment

86

A dressing that forms a gel that interacts with the wound surface is called

hydrocolloid dressing

87

Which of the following is an indication for a binder to be placed around a surgical patient with a new abdominal wound?

Reduction of stress on the abdominal incision

88

When is an application of a warm compress indicated? (Select all that apply.)

To relieve edema;
To improve blood flow to an injured part

89

What is the removal of devitalized tissue from a wound called?

Debridement

90

Name the three important dimensions to consistently measure to determine wound healing.

Width, Length, and Depth

91

What does the Braden Scale evaluate?

skin integrity risk

92

that the tissue over the sacrum is dark, hard, and adherent to the wound edge. What is the correct stage for this patient's pressure ulcer?

Unstageable

93

Name one intervention and the rationalization to use that intervention to reduce the likelihood of a shear injury to a patient.

transfer device can pick up a patient and prevent his or her skin from sticking to the bed sheet as he is repositioned. A second intervention would be to position the patient with the head of the bed to be elevated at 30 degrees, which prevents him or her from sliding. A third intervention would be to educate the patient and his or her caregiver on the importance of not sliding on the sheets when repositioning.