Skin Flashcards
(100 cards)
1
Q
5 functions of skin
A
- protection
- thermoregulation
- sensation
- metabolism
- Communication
2
Q
2 parts of skin that help with protection
A
melanin and sebum
3
Q
How does skin help with metabolism?
A
synthesis of vitamin D
4
Q
What is the most prevalent skin related issue in healthcare
A
pressure ulcer
5
Q
Newborn and infant skin changes
A
- reduced ability to thermoregulate
- more susceptible to rashes, blistering, chafing
6
Q
Toddlers and preschooler skin changes
A
- sunscreen
- playing causes injuries
7
Q
School age and adolescent skin changes
A
- lice/scabies/impetigo
- acne
- sunscreen
8
Q
Adult and older adult skin changes
A
- dry skin more common
- wrinkling and poor skin turgor
- slower healing
9
Q
3 Mechanical forces that damage skin?
A
-pressure, friction, sheering
10
Q
Wound type- injury such as knife, gunshot, burn, or surgical incision, heals within 6 months
A
acute
11
Q
wound that persists beyond usual 6 month healing time or recurs with new injury to area
A
chronic
12
Q
open wound
A
break present in the skin; tissue damage present
13
Q
closed wound
A
no break seen in the skin, but soft tissue damage evident
14
Q
clean surgical wound
A
closed surgical wound that did not enter GI/Resp/Genituourinary system
-low infection risk
15
Q
clean/contaminated wound
A
wound entering GI/Resp/Genituourinary system
-infection risk
16
Q
contaminated surgical wound
A
open, traumatic wound; surgical wound with break in asepsis
-high infection risk
17
Q
infected surgical wound
A
wound site with pathogens present
-signs of infection
18
Q
What is pressure?
A
localized damage to skin or underlying tissue over bony prominence as a result of pressure or pressure in combination with shear
19
Q
Stage I Pressure Ulcer
A
- skin intact
- nonblanchable redness (stays red when you press it)
- painful or different feel to rest of skin
- will feel cool in temperature
20
Q
Stage II pressure ulcer
A
- shallow OPEN ulcer with PINK wound bed
- no sloughing/no eschar
- PARTIAL thickness loss of dermis
- skin shear, tape burn, maceration, excoriation
- will feel warm
21
Q
Stage III pressure ulcer
A
- FULL thickness tissue loss
- may have slough or eschar
- NO bone tendon muscle exposure
- UNDERMINING or TUNNELING possible
22
Q
Stage IV pressure ulcer
A
- EXPOSED bone tendon muscle
- may have slough or eschar
- tunneling or undermining
23
Q
tunneling
A
-narrow passageway in soft tissue of open wound going down
24
Q
undermining
A
area of tissue deconstruction under the edge of wound opening
25
eschar
dea tissue, bacterial debris, dark in color
26
What is an unstageable pressure ulcer?
- wound cannot be visualized
| - base is covered in slough or eschar
27
Tool for pressure ulcer screening
Braden Scale
28
What is in protective creams to help healing and prevention?
-zinc, vitamin A,D,E
29
____ rather than ____ when repositioning patient in bed
lift, pull
30
small spot like freckle or petechia
| -circumscribed, flat, non palpable changes in skin color
macule, primary lesion
31
larger than macule like vitiligo,flat, non palpable changes in skin color
patch, primary lesion
32
up to 0.5 cm like elevated nevus, palpable elevated solid mass
papule, primary
33
flat elevated surface larger then 0.5 cm, often formed by coalescence of papules
plaque, primary
34
larger than 0.5 cm, deeper and firmer than a paule, palpable elevated solid mass
nodule, primary
35
large nodule, palpable elevated solid mass
tumor, primary
36
somewhat irregular, relatively transient superficial area of localized skin edema like mosquito bite or hive
wheal, primary
37
up to 0.5 cm, filled with serous fluid, circumscribed superficial elevation of the skin formed by free fluid in cavity within skin layers
vesicle, primary
38
>0.5 cm , filled with serous fluid, like 2nd degree burn
bulla, primary
39
filled with pus like acne or impetigo
pustule, primary
40
loss of the superficial epidermis, surface moist but does not bleed ex:moist area after rupture of vesicle from chicken pox
loss of skin surface,secondary
41
dried residue of serum, pus, blood
crust, secondary
42
deeper loss of skin surface, may bleed and scar like from venous stasis or syphlitic chancre
ulcer, secondary
43
think flake of exfoliated epidermis like dandruff, dry skin, psoriasis
scale, secondary
44
linear crack in the skin like from athletes foot
fissure, secondary
45
primary vs secondary skin lesion
primary-arise from normal skin
| seconary-result from changes in primary lesion
46
4 phases of wound healing in order
1. hemostasis
2. inflammatory
3. proliferative
4. maturation
47
what happens in heomstasis part of wound healing?
- vasoconstriction
- platelet aggregation
- clot formation
48
timeline for phases of wound healing for full thickness wound
1. hemostasis- immediate
2. inflammatory- up to day 3
3. proliferative-4-21 days
4. maturation- 21 days to 2 years
49
what happens in inflammatory phase
- vasodilation
| - phagocytosis
50
when does shear occur?
skin stays in place but subq tissue beneath shifts
- might not be visible break in skin
- can result in breakage/stretching of blood vessels--> soft tissue ischemia
51
the presence of _____ causes skin to be ______ resistant to damage from friction and shear
moisture, less
52
granulation tissue, what phase of wound healing
bright red tissue that is a manifestation fo wound healing but is also prone to trauma
- see in proliferative phase of wound healing
- full thickness wound
53
epithelialization tissue, what phase of wound healing
pink in color, temporary protection, begins at wounds edges and moves inwards
- action promoted by moist environment
- partial thickness wound
54
what happens in the proliferative phase
partial thickness wound: epithelialization
| full thickness wound: granulation tissue, contracture
55
When does maturation phase of wound healing occur? what kind of wounds?
21 days to 2 years
| -only happens with full thickness wounds
56
timeline for phases of partial thickness wounds
1. hemostasis- immediate
2. inflammatory- up to day 3
3. proliferative-4-21 days
57
Primary Intention wound
- clean incision
- early suture
- hairline scar
- decreased infection and scarring
58
Secondary Intention wound
- gaping irregular wound
- granulation
- epithelium grow over scar
- increase scarring and infection
59
Tertiary Intention
- wound
- granulation
- closure with wide scar
- delayed closure
- increase scarring, may already have an infection that has to be cleared in order to heal
60
Adhesive strips that hold edges of wound together
steri-strip
61
Thread or metal that holds edges of wound together
suture, staple, clips
62
Used to close wound on parts of the body that do not experience tension or stretching
cyanoacrylte glue
63
Protocol for elastic wraps/bandages/stretch netting
- apply distal to proximal
- ensure it is not too tight
- check distal circulation
64
Complications from wounds
- hemorrhage or hematoma
- infection
- dehiscence
- evisceration
- fistula
65
what is dehiscence?
partial or total reopening of a wounds edges
66
what is evisceration?
protrusion of viscera thru wound opening
| -insides go outside
67
what is a fistula? how is it named?
passage b/w 2 body parts/areas that don't normally connect
| -named for location ex: entercutaneous- goes intestine to epidermis
68
What do you assess on a wound?
type, location, size, classification, base
- drainage
- undermining or tunneling
- infection or pain
- check fxality of drainage system
69
Bloody drainage =
sanginous
70
pale yellow pink drainage =
serosangiunous
71
pale yellow watery fluid drainage
serous
72
Penrose drain
- tube placed in wound
| - no suction
73
Hemovac
- bloody cavity
| - suction
74
Jackson Pratt drain
-gently suction when bulb compressed
75
2 types of drains with suction
hemovac and JP
76
A wound is present, who should assess it first?
Wound, Ostomy, Continence Nurse
77
Who assesses surgical wounds?
- only surgeon removes the dressing
| - surgeon will write orders on how to do the dressing change
78
Alginate
Used for absorption for draining wounds
79
Collagens used for what kind of wound?
partial and full thickness
80
Composites
use multiple products
81
Foams
hydrophilic polyurethane
| -partial and full thickness with small to moderate drainage
82
Hydrocolloids
water resistant gel like wafer dressing
83
hydrofiber
- sodium carboxymethylcellulose
| - very absorptive
84
Hydrogels
-assist in autolytic debridement of necrotic tissue in full thickness wounds
85
Nonadherent dressing function
minimize disruption of new cells
86
silver dressing
- antimicrobial for infected wound
| - need wound care of physician order
87
Transparent film fx
cover the wound but be able to see it
88
What is negative pressure wound therapy?
hydrophobic sponge fills a wound cavity
- cover with transparent dressing
- connect to machine providing negative pressure = no pressure on wound, not even gravity
89
Surgical Debridement
- not done by nurses
| - use of sharp tools to remove debris
90
Enzymatic debridement
-place chemical products on wound to break down debris
91
Autolytic debridement
- occlusive or hydrogel to soften eschar
| - debris gets eroded then irrigated with saline
92
wet to dry dressing is what kind of debridement
mechanical use:
| -pulsating lavage
93
4 types of debridement
- surgical
- enzymatic
- autolytic
- mechanical
94
3 benefits of using heat therapy
- promote healing and suppuration
- decrease inflammation by accelerating inflam. response
- decrease musculoskeletal discomfort
95
When to use heat therapy
- surgical/infected wounds, hemorrhoids, episiotomies
- phlebitis and IV infiltration
- low back pain, menstrual cramps, contractures, arthritis, muscle spasms
96
3 benefits of cold therapy
- controls bleeding
- decrease edema
- relieves pain
97
When to use cold therapy
- fractures, trauma, superficial lacerations, puncture wounds
- sprains, muscle strains, sports injuries
- arthritis, trauma, musculoskeletal injuries
98
When not to use hot or cold therapy
- acute appendicitis/abscess tooth
- broken skin/deep wound
- circulatory impairment
- sensory deficit
- mental status impairment
- age extremes
- metallic implants
99
Diet for wound healing
high protein, vitamin A/C/E, zinc, water, arginine, carbohydrates, fats
100
What are 2 medicationd that can impair wound healing
- anticoag
| - corticosteroids (decrease ability to fight off infection)
