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Assessment Final > Skin > Flashcards

Skin Flashcards

(59 cards)

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1
Q

What are the structures of the skin

A

skin
hair
nails
scalp

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2
Q

Skin makes up ___% of total body weight

A

15

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3
Q

Melanin

A

gives color to skin

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4
Q

Epidermis

A

pH4.5-5.5

slightly acidic to protect from bacteria and fungus

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5
Q

Dermis

A

secondary layer of skin

made up of collagen (tensile strength) and elastin (recoil)

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6
Q

What is a pressure ulcer

A

an area of local tissue damage usual developing where soft tissue is compressed between a bony prominence and any external surface for prolonged time periods. It is a sign of local tissue necrosis and death

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7
Q

What are some risk factors for pressure ulcers

A 
excessive exposure and moisture from bodily secretions
impaired metal status
impaired nutritional status
immobility
mechanical forces
shearing and friction
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8
Q

What is the difference between shearing and friction

A

Friction causes removal of the stratum corneum and damage to underlying layers of the skin
Shearing occurs when friction hold the skin in place but gravity pulls the axial skeleton down which results in the pulling of the dermal layers of the skin

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9
Q

Hyperemia

A

occurs when pressure is applied for <30 minutes and resolves in 1 hour

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10
Q

Ischemia

A

Condition in which there is insufficient blood flow to the part of the body

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11
Q

Necrosis

A

death of body tissue. not enough blood going to tissies

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12
Q

Ulceration

A

breakdown of the skin

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13
Q

What are the 4 things you should think about with regard to ulcerations

A

Surface selection
Keep turning
Incontinence management
Nutrition

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14
Q

What is the first indication that a pressure ulcer may be developing

A

blanching of the skin (becoming pale and white)

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15
Q

Braden Scale

A

Scores sensory, perception, moisture nutrition, friction and shear, activity, and mobility.

Lower the score, the higher the risk for a pressure ulcer (score of <18)

Needs to be done consistently and updated frequently

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16
Q

What are facts that affect pressure ulcer development

A 
Wrinkled sheets
Pull of pt over linen surfaces
Immobility
Malnutrution and dehydration
moisture on skin
mental status and sense of recovery
Age
Heep HOB at 30 degrees or less to reduce pressure/fricton or shearing
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17
Q

Stage I pressure ulcer

A

non blanchable erythema
may contain changes in skin temp tissue consistency (firm or boggy feeling), itching (sensation)
may be red, blue, or even purple hues

*It is reversible if pressure is relieived

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18
Q

What re pressure ulcer relieving mechanisms

A

frequent turning
pressure-relieving devices
positioning

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19
Q

Stage II pressure ulcer

A

partial thickness and skin loss
looks like an abrasion, blister or shallow crater

Maintenance of moist healing environment with saline and occlusive dressing (promotes natural healing but prevents the formation of scar)

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20
Q

Stage III pressure ulcer

A

full thickness/loss of skin
damage/necrosis of subcutaneous tissue that can extend as far down as the fascia
may have fowl smelling drainage if it is infected and usually takes months to heal after the pressure is relieved

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21
Q

Stage IV pressure ulcer

A

full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone or supporting structures. Wound may appear small on surface but can have extensive tunneling

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22
Q

What are often associated with Stage IV pressure ulcers

A

Sinus tracts

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23
Q

Eschar

A

thick leathery scab or dry crust that is necrotic and must be removed from a pressure ulcer in order to determine what stage the ulcer is in

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24
Q

Unstageable pressure ulcers

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A

full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, grey) and or/eschar in the wound bed

**True depth and stage cannot be determined until eschar is removed

25
What are things to assess/document when measuring pressure ulcers
location stage drainage types of tissue present Document: size of wound, side - side, top to bottom and depth Determine presence of undermining, tunneling or sinus tracts
26
How do you clean a pressure ulcer
use a dressing change (careful and gentle motion) avoid harmful cleaners use 0.9% NaCl solution to irrigate/clean area use a catheter tip syringe and 35ml/20ml/water pic at lowest setting
27
When dressing an ulcer what do you want to make sure to use
Use dressing that keep the wound moist Wet to Dry dressing are for debridement ONLY make sure dressing absorbs exudate pack the wound cavities loosely - overpacking could increase wound pressure
28
What are some ways to debride a wound
surgically - use scalpel to cut the necrotic skin or eschar from the wound mechanically - wet to dry dressing enzymatically - using a chemical agent that degrades eschar autolytically - covering the pressure ulcer with a gel or hydro colloid allowing the bodes moisture and enzymes to soft the eschar
29
debridement
removal of the devitalized tissue and foreign material so the wound can heal
30
What are the different types of drainage
serous sanguineous serosanguineous purulent
31
Serous drainage
clear and watery
32
Sanguineous drainage
large numbers of RBCs and looks like blood | Indicative of fresh bleeding
33
Serosanguineous drainage
mixture of serum and RBCs (light pink)
34
Purulent
WBCs, liquefied dead tissue debris, dead and live bacteria | thick, musty/foul odor and can be yelled or green
35
What are the 4 things to assess for with a wound
COCA | Color Odor Amount Consistency
36
Intentional wound
result of planned invasive therapy or tx Ex. IV, surgery wound etc. Usually done under sterile conditions so risk for infection is decreased
37
Unintentional wound
accidental and usually caused by trauma, forcible injury (stabbing, gunshot etc.), or burns. Contamination is likely since it occurred in a unsterile environment Bleeding often uncontrolled and would edges are jagged
38
Acute wounds
usually heal within days to weeks and wound edges are well approximated: edges meet closely Risk for infection is lessened
39
Chronic wounds
healing is impeded; wound edges are not well approximated, and increased risk of infection. They remain in the inflammatory stage of wound healing Ex. venous/arterial wounds and pressure ulcers
40
Before treating a wound what is it important to know
the etiology : venous, arterial, surgical, or trauma
41
Abrasions
superficial injury caused by rubbing or scraping of skiing against another surface
42
Laceration
open would with jagged edges
43
Contusions
closed wound; swollen, discolored and painful
44
What are the phases of wound healing?
Hemostasis Inflammatory Stage Proliferative Stage Remodeling
45
Hemostasis phase
tissue injury initiates clotting process which leads to platelet aggregation. This leads to fibrin clot formation which prevents excessive blood loss and body fluids
46
Inflammatory phase
phagocytois occurs; increase of WBC to the area of wound; erythma, edema warmth, increase in temp, general malaise (approx 4-6 days after onset)
47
Proliferative phase
new tissue is built to fill the wound space days after the injury. Granulation tissue (new tissue) forms Starts after 5-7 days
48
Remodeling (maturation) phase
starts about 3 weeks after injury and can continue for months to years. new collagen continues to be formed - leads to scar
49
What are common sites for the development of pressure ulcers
``` occipital bone scapula vertebra sacrum coccyx calcaneus ribs (side lying) iliac crest (side lying) greater trocanter (side lyings) lateral knee, malleolus and medial malleolus (side lying ```
50
Primary intention wound healing
would with little tissue loss, edges approximated. heals rapidly with minimal scarring, low risk of infections healing occurs by direct union of granulating surfaces
51
Secondary intention wound healing
wounds involving loss of tissue, wound edges widely separated, healing occurs by granulation, large scar increases likelihood of infection, longer healing time EX burns, pressure ulcers
52
Tertiary intention would healing
deep wound and is likely to contain extensive drainage and tissue debris. High risk of infection
53
wound dehiscence
surgical wound that tears open along the closure of the wound
54
When changing a dressing for a draining wound
promote comfort maintain skin integrity prevent infection promote healing
55
NPWT - vacuum assisted closure therapy
used for recalcitrant wounds, acute and chronic wounds, pressure ulcers, surgical wounds, skin graft etc. The negative pressure on the wound bed results in mechanical tension on the wound tissues, stimulating cell proliferation, blood flow to the wounds and the growth of new blood vessels
56
Growth factors
applied to the wound bed to bind to cells to promote granulation, cell proliferation and cell migration. Used during the proliferative phase of wound healing in pts with chronic non-healing wounds
57
HBOT (hyperbaric oxygen tx)
placing patients in a pressurized chamber, where they breathe 100% to. Promotes cell proliferation, increased blood flow to wounds and promotes angiogenesis (growth of new blood cells)
58
When is VAC contraindicated
necrosis, malignancy, fistula, or if arteries or veins are exposed in the wound
59
Heat and Cold Therapy
heat accelerates the inflammatory response to promote healing cold constricts blood vessels, reduces muscle spasms, and promotes comfort

Assessment Final (7 decks)

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