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Skin and Wounds Flashcards

(97 cards)

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1
Q

Epiderms

A

superficial layer

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2
Q

Dermis

A

gives skin elecastisity

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3
Q

Subcutaneous Tissue

A

reserve calories

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4
Q

Older Patients

A

thinner, weaker, dryer

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5
Q

Intrinsic Factors for Ulcers

A

aging, nutrition, stroke, decreased mobility

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6
Q

Extrinsic Factor for Ulcers

A

friction, shearing, moisture, hygiene and positioning

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7
Q

Braden Scale

A

pressure injury risk; < 18- risk for pressure injury

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8
Q

Braden Scale Catergories

A

Sensory/Perception
Moisture
Activity
Mobility
Nutrition
Shear and Friction

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9
Q

Closed Wound

A

no break in the skin such as bruised over a closed fracture

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10
Q

Open Surgical Wound

A

a break in the skin

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11
Q

Acute Wound

A

can be surgical incision, goes through 3 stages of healing in short time without complication

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12
Q

Chronic Wound

A

when natural healing process is slower with healing occurring from inside out

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13
Q

Clean Wound

A

uninfected wound that has minimal inflammation, can be open or closed

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14
Q

Clean Contaminated Wound

A

an incision that is higher risk of infection, might require antibiotics
ex ostomy

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15
Q

Contaminated Wound

A

traumatic or surgical wound where there is a break in sterility

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16
Q

Infected Wound

A

overgrowth of microorganisms

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17
Q

Colonized Wound

A

Presence of proliferating bacteria without a host response

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18
Q

Infection

A

invasion of proliferated microorganisms into surrounding tissue causing a host response

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19
Q

Superficial Thickness

A

just involving epidermis, can be due to friction

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20
Q

Partial Thickness

A

through epidermis but not through dermis

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21
Q

Full Thickness

A

through dermis and maybe into subq tissue

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22
Q

Penetrating

A

when a foreign body has pierced through the skin damaging underlying tissue

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23
Q

Abrasion

A

superficial scrape

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24
Q

Abscess

A

collection of puss or drainage: pocket of infection

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25
Contusion
bruising or localized infection; "goose egg"
26
Crushing
heavy object falling onto someone
27
Incision
intentional opening
28
Laceration
where skin is cut or torn
29
Puncture
foreign object has punctured the skin
30
Tunnel
area inside the wound where a specific area has extended
31
Undermining
where skin surrounding opening remains intact but underlying tissue is eroded
32
Stage 1 Ulcer
area of redness that doesn't blanch
33
Stage 2 Ulcer
Small break in skin, partial thickness into epidermis or dermis; appears pinkish red, may have yellow slough over it
34
Stage 3 Ulcer
down to subq tissue and can see the fat, can be down to muscle but not through muscle
35
Stage 4 Ulcer
Full thickness into muscle, may be able to see tendon or bone
36
Unstagable
full thickness, covered in slough or eschar so you cant see it
37
Granulation Tissue
pink to red, beefy red, looks like raw sugar, good sign of healing
38
Epithelial Tissue
healthy pink to pearly white tissue
39
Clean Non-Granulating Tissue
pink shiny moist tissue which is healthy
40
Eschar
necrotic tissue which is leathery and could be brown, black or gray
41
Slough
dead tissue which looks white yellow or tan; common in tan wounds
42
Maceration
when moisture causes the skin to become pale and wrinkled, can be caused by wet dressings left on skin for too long
43
Blistering
small bubble on skin filled with serum
44
Erythema
Reddness
45
Epiboly
wound with rolled or curled under edges that may be dry or calloused
46
Adhesive Strips/Steri-strips
used for low tension small wounds, such as skin tear, fall off on their own
47
Sutures
Stitches
48
Absorbant Stitches
internal, deeper layers
49
Nonabsorbent Stitches
external, superficial; nurse removes these every other
50
Retention Sutures
heavy, nonabsorbent plastic, usually tied over a buttress for skin
51
Staples
used on legs, arms and head, leaves a scar so not used on a face
52
Dermabond
used on face and for smaller wounds
53
Serous Drainage
straw-colored, from serum portion of blood
54
Sanguineous
bloody drainage, new is bright red, and old is brownish red
55
Seroussanguineous
mixture of serous and sanguineous
56
Purulent
thick, yellow white or green puss
57
Purosanguineous
Purulent with some blood
58
Penrose Drain
looks like a straw and is flexible
59
Jackson-Pratt Drain
bulb drain where suction is applied by emptying the cap and compressing the bulb; seen after masectomy or abdominal surgery
60
Hemovac
use suction via a spring; we empty the drain and them compress it to restart suction
61
Primary Intention
surgical incision that is closed and well approximated; will heal quick
62
Secondary Intention
cannot be closed and must heal from inside out ex pressure injury
63
Tertiary Intention
closing the wound at a different date
64
Intermediate Phase
cleansing/clotting, days 1-5, PEST
65
Proliferative Phase
granulation, 5-21 days, when collagen is starting to build
66
Maturation
epithelialization, 6 months, where cartilage is remodeling and scar tissue is building
67
Fistula
passage between 2 body cavities that doesn't belong, common is between vagina and anus
68
Hemorrhage
massive blood loss; biggest risk is 24-48 hours after surgery
69
Internal Bleeding
you cant see it, decreased BP, Increased HR
70
External Bleeding
you can see it, can be in drain
71
Dehiscence
when the wound ruptures; obese patients are more at risk
72
Evisceration
when internal organs pop out; cover with sterile dressing and call MD
73
Negative Pressure Wound Therapy
woundvac, stimulates granulation and decreases edema
74
Hyperbaric Oxygen Therapy
stimulate blood vessels and white cells to promote healing; used in osteomyelitis
75
Debridement
removal or dead tissue
76
Graft or Flap
skin graft are used in burns, flap grafts are used in mastectomies or when large amount of tissue is lost
77
Sharp
where surgery is performed to remove dead tissue
78
Wet to Dry
pulling out dry gauze that takes daed tissue with it
79
Hydrotherapy
"powerwashing" to remove dead tissue
80
Enzymatic
gel that dissolves dead tissue
81
Autolysis
our body naturally dissolves dead tissue, band aids help this
82
Biotherapy
done with maggots or leeches
83
Primary Dressing
covering the wound
84
Secondary Dressing
placed over primary dressing
85
Taping
can be irritating
86
Absorbant Dressings
made of cotton
87
Alginates
absorbable dressing, allows autolytic debridement
88
Antimicrobial
cream or dressing ex; silver dressing
89
Foam
used in wound vac
90
Gauze
used for wet to dry
91
Hydrocolloids
duoderm, serves as an extra skin layer, used in stage 2 pressure ulcers, change every 48-72 hours
92
Hydrogels
adds moisture to wounds
93
Transparent Films
tegaderm, seen over IV sites
94
Prealbumin
most accurate indicator, if low indicates poor wound healing
95
ESR
if high it can indicate inflammatory reaction
96
PT, PTT, INR
if high there will be increased bleeding
97
Wound Culture
dont touch Q tip to drainage

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