Exam 2 - Wound and Integument Flashcards
(145 cards)
1
Q
what are the types of bacterial infection?
A
folliculities cellulitis furnucle and carbuncles erysipelas impetigo
2
Q
what are the types of viral infections?
A
HSV 1 HSV 2 HERPES ZOSTER VARICELLA WARTS (HPV)
3
Q
what nerves does shingles usually effect?
A
trigeminal and dorsal root ganglia
4
Q
what are the types of fungal infections?
A
tinea
candidias
5
Q
what are the types of parasitic infections?
A
scabies
bed bugs
pediculosis
6
Q
what are the types of inflammation?
A
eczema
dermatitis
7
Q
what are the 3 types of skin cancer?
A
basal cell
squamous cell
melanoma
8
Q
what are the manifestations of a furnuncle?
A
boils
red
tender
many or just one
9
Q
what is the manifestations of folliculitis?
A
single or groups
papules
pustules
little to no discomfort
10
Q
what are the manifestations of cellulitis?
A
redness warmth edema tenderness pain fever
11
Q
what are the clinical manifestations of impetigo?
A
red macules
thin walled vesicles
honey yellow crusts
12
Q
how is impetigo caused?
A
group A beta hemolytic streptococcus
13
Q
what are the clinical manifestations of HSV 1
A
Cold sore
14
Q
what are the clinical manifestations of HSV 2
A
warts on genitals with pain and weeping
vesicles
15
Q
what are the clinical manifestations of herpes zoster?
A
intense pain vesicles following nerve route malaise GI disturbances never crosses mid line!!!
16
Q
what might be a manifestation of tinea?
A
circle (ring worm) scaling peeling patches itching pain
17
Q
what are some manifestations of candidias?
A
itching
discharge (white)
burning
18
Q
what are the manifestations of pediculosis?
A
itching
brown and black mites
whitish nits
19
Q
what are the manifestations of scabies?
A
itching worse at night
linear lesions
20
Q
what are some manifestations of bed bugs?
A
itching
mosquito bite like sore
21
Q
what are the types of inflammation skin conditions?
A
seborrhea
psoriasis
pruritus
contact dermatitis
22
Q
what is seborrhea dermatitis
A
dandruff
23
Q
what is seborrheic keratosis?
A
skin keeps growing on skin in a darker pigment than usual. usually in more of geriatrics
24
Q
what is psoriasis
A
excessive turnover of epidermal cells
25
what is pruritus
severe itching of the skin
26
what is contact dermatitis
skin rash that comes with contact with an irritant
27
what are the manifestations of psoriasis
```
plaques with distinct borders
dryness
red
white
scaly
come and go
```
28
what are the manifestations of seborrhea
itchy
dry
flaky
29
what are the manifestations of pruritus
itching
dry
red
30
contact dermatitis manifestations
```
itching
burning
erythema
edema
papules
vesicles
oozing
weeping
```
31
what is the distribution of dermaphyotis or tinea infections?
anywhere
32
what is the distribution of candidias?
skin fold areas or mucous membranes
33
what is the distribution of folliculitis and furuncles?
hair bearing skin
34
what is the distribution of impetigo?
face
35
what is the distribution of cellulitis?
usually lower legs, and around wounds
36
what is the distribution of inflammatory skin disorders?
really anywhere
37
what is the distribution of viral skin conditions?
face, genitals, along nerve endings, posterior and anterior trunk.
38
what is the treatment for bacterial infections
antibiotics, washing, compress
39
what is the treatment for viral infections (hsv 1 and 2)
topical/oral antiviral, vaccines, sitz bath, pain meds, cold compress
40
what is the treatment for shingles?
anaglesics, corticoid steroids, oral antiviral
41
what is the treatment for warts?
topical salicylic acid or cryotherapy
42
what is the treatment for fungal infections
topical antifungals
43
what is the treatment for parasitic infections (8)
```
wash clothes
dye hair
combing
pyrethin OTC
permethrin comp OTC
lindane
malathion
benzyle benzoate
```
44
what is the treatment for inflammatory skin conditions (5)
```
avoid irritant
avoid heat
antihistamines
steroids
no cosmetics
```
45
what does not cure inflammatory skin conditions?
corticosteroids
46
what is malathion used for?
parasitic infectionsq
47
what is benzyl benzoate used for?
parasitic infections
48
what is pyrethrin used for?
parasitic infections
49
what exactly treats seborrhea?
sulfur or hydrocortisone treatments
50
```
corticosteroids
nonsteroidals
coal or wood tar products
intralesionsal therapy
anthralin
medicated shampoos
retinoids
```
all topically treat what?
psoriasis
51
what is PUVA
combo of psoralen and UV A rays
52
what does PUVA treat
psoriasis with photochemotherapy
53
methotrexate
cyclosporin
oral retoinds
gold salts
all treat what systemically?
psoriasis
54
what is cellulitis?
inflammation of skin and subcutaneous tissue
55
what are some nursing implications for treating cellulitis?
raise limbs
clean wounds
bed rest
56
where is MRSA found?
nose, perineum and skin
57
how to prevent spread of MRSA
use sterile technique
hand hygiene
use PPE
educate
58
malignant
cancerous
59
benign
not cancerous
60
what are the 3 skin cancers?
basal cell
squamous cell
melanoma
61
what are skin cancer risk factors?
light skin
uv rays
arsenic
some gamma and x rays
62
what is the incidence of skin cancer
1 million per year
| 90% being basal cell or squamous
63
what is the treatment for basal cell and squamous cell skin cancer?
excision, surgery, tissue destruction by heat, radiation, freezing
64
what is the treatment for melanoma?
surgery to remove lymphnodes and deep excisions, vaccines sometimes
65
what is the prognosis for basal and squamous cell?
virtually curable
66
what is the prognosis for melanoma?
less than 5 years when metastasized
67
pruitus
itching
68
uticaria
wheal; hives; welt
skin rash
may be allergic reaction
69
what are the 3 phases of wound healing?
inflammative
proliferative
maturation
70
describe the inflammation process of wound healing
first 3-5 days of injury
clot formation
plasma and wbc migrate into wound
71
describe the proliferative process of wound healing
```
4th day to 4 wks
fibrin creates scaffold
fibroblasts create collagen
capillaries become a new blood vessel
scar tissue
```
72
describe the maturation process of wound healing
3 wks to 1 year
collagen reorganizes for more strength
scar thins and pales
scar becomes firm and nonelastic
73
partial thickness
loss involving epidermis and sometimes dermis
74
full thickness
destruction of epidermis, dermis and subcutaneous
75
friction
rubbing against surface (just pressure)
76
shear
sliding (pressure and gravity)
77
what do you do in the event of venous insufficiency
blood pools, no ted hose, raise legs!
78
who experiences arterial insufficiency?
diabetic and smokers
79
primary wound
surgical straight edges
80
secondary wound
not good edges, has to build new tissue
81
tertiary wound
open, muscle bone layer, surgically close
82
dehiscence
wound edges break apart
83
evisceration
organs pertrude
84
adhesions
scar tissue
85
stenosis
narrowing around surgical wounds
86
keloids
excessive scar
87
excessive contractures
healing becomes too tight
88
epibole
rolled edge and curled under
89
peri wound
surrounding tissue
90
indurated
firm or hard
91
denunded
loss of epidermis caused by exposure to urine feces, body fluid, wound exudate, friction
92
excoriated
scratch
93
erosion
loss of epidermis
94
tunneling
pathway that extends any direction from wound through subcutaneous tissue
95
undermining
tissue destruction underlying intact skin
96
what causes underminding
shearing
97
slough tissue
yellow, green, gray, wet
98
eschar
dark thick hard (scab)
99
granulation tissue
new tissue that replaces dead, beefy red
100
what is a scant wound
moist tissue that has no measurable drainage
101
what does the braden scale consist of?
```
moisture
sensory perception
activity
mobility
friction or shear
nutrition
```
102
how does the braden scale work?
higher the number, the less risk they are
103
deep tissue injury
pressure related injury to subcutaneous tissues underneath intact skin
104
why is deep tissue injury important?
because it can turn into a stage 3 or 4 pressure ulcer
105
what are the types of debridement
autolytic
mechanical
sharp
chemical
106
what is autolytic debridement
natures way!
107
what is mechanical debridement
scrubbing (wet to dry dressings)
108
what is chemical debridement
enzymes
109
what is sharp debridement
scrape out
110
how does physical therapy help with wounds
whirlpool treatments loosen debris
111
how does drug therapy help wounds
control bacterial growth
112
how does nutrition help wounds
proteins, vitamins and water help rebuild
113
how does electrical simulation help wounds
increase granulation and blood vessel growth
114
how does hyperbaric o2 treatment help wounds
increase abc and oxygen helps heal
115
how does a wound vac help wounds
it drys out wound constantly
116
what is the intervention of surgical debridemtn?
removing necrotic tissue and grafting
117
what are indicators of infection for a wound?
```
increase in wbc
increase in wound size and depth
positive blood culture
purulent or malodorous drainage
fever
```
118
what should the nurse watch for to prevent infection
increase in pain
tenderness
redness
edema
119
when should a wound management plan be reevaluated?
7-10 days
120
what are the 4 categories of clean?
1-4
121
what is stage 1 of clean
not infected operated wound, done sterile
122
what is stage 2 of clean
clean but contaminated - infected part was operated on
123
what is stage 3 of clean
contaminated - open fresh and unintentional
124
what is stage 4 of clean
dirty infected - old traumatic or surgical would that is infected
125
what is a macule
freckle
126
what is a vesicle or bulla (bigger)
small fluid filled
| bulla is more than 1 cm
127
what is a pustule
solid elevated lesion that is less than 1 cm
128
cyst
semi solid that can sometimes move and is surgically removed
129
papule
sole elevated (mole)
130
provides a moist surface that interacts with exudate in order to form a gelatinous mass and helps debridement. it also eliminates dead space
alginate dressing
131
alters the wound bed and decreases risk of infection
antimicrobials
132
assists with stopping bleeding and helps recruit cells into the wound and stimulate proliferation
collagen
133
combine dressing physically for multi function
composities
134
thin and non adherent that is placed on an open wound bed to protect tissue from direct contact
contact layer
135
provide moist healing, doesn't adhere to the skin, helps granulize and epithelialize wounds
foam
136
absorb exudate, produce a moist environment that helps healing, protect wound from contamination, foreign debris and prevents shearing. can stay in place for days
hydrocolloid
137
liquefy necrotic tissue or slough. rehydrate the wound bed and fill dead space.
hydrogel
138
minimize adherent to wound and manage exudate
specialty absorptive
139
moist healing under the dressing and helps soften the necrotic tissue. helps with deep wounds and speeds up debridement
wound fillers
140
provide protection against contamination, and friction. maintains a clean moist surface that facilitates cellular migration and allows for assessment
transparent
141
wounds for superficial wounds
transparent
| hydrocolloid
142
wounds for eschar
hydrogel
| enzymatic debridement
143
exudative wound dressings
alginate
hydrofiber
foam
144
granulating or epithelializing wounds
hydrocolloid
| foams
145
fibrinous wound beds or slough
hydrogels
