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Exam 3 > Skin and Wounds > Flashcards

Skin and Wounds Flashcards

(87 cards)

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1
Q

-Outermost layer of skin
-regenerates every 4-6 weeks

A

Epidermis

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2
Q

outermost layer of the epidermis
-provides protection
-regulates fluids and electrolytes

A

Stratum corneum

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3
Q

-Inner layer of epidermis
-new cells are produced
-keratin, melanin, and langer cells are found

A

Stratum Germanium

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4
Q

-1-5 cells thick
-reduced friction and shearing

A

Stratum Lucidum, Granulosum, and spinosum

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5
Q

-provide skin strength
-Flexibility
-Repair

A

Keratin

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6
Q

-Skin color
-UV protection

A

Melanin

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7
Q

-Digest bacteria
- Immune response

A

Langer cells

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8
Q

-Layer between epidermis and subcutaneous layer
-Contains sebaceous glands, sweat glands, hair/nail follicles, nerves, and lymphatics

A

Dermis

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9
Q

-Anchors the epidermis and dermis together
-Prevents friction/shearing

A

Papillary Dermis (Rete Ridge)

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10
Q

-Layer of adipose tissue
-attaches dermis to muscle and bone
-blood supply to dermis
-Provide insulation and cushion

A

Subcutaneous tissue

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11
Q

-Disruption in skin integrity
- lead to loss of normal skin function

A

Wound

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12
Q

Break in the skin surface

A

Open wound

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13
Q

skin intact and seen with bruising

A

Closed wound

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14
Q

clean wound that is at greater risk of infection

A

clean contaminated wound

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15
Q

wound with bacteria present from trauma, break in sterile technique, or spillage of bacteria latent material (stomach contents) during surgery

A

contaminated wound

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16
Q

wound that shows clinical signs of infection

A

Infected wound

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17
Q

one or more organisms are present on the surface of wound but no other overt sign of infection below the surface

A

Colonized wound

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18
Q

wound that progresses through the phases of wound healing in a rapid and uncomplicated manner

A

acute wound

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19
Q

edges of wounds can be brought together

A

approximated

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20
Q

-fast wound healing
-no to minimal scaring
-edges are approximated

A

Primary intention

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21
Q

-new granulated tissue forms to bottom and sides of wound till wound bed is filled
-open wound
-Scarring
-Takes 6-12 weeks

A

Secondary Intention

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22
Q

-Fails to progress to healing in a timely
-remain open for a long period of time

A

chronic wound

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23
Q

-delay of 4-6 days to begin healing
-scaring
-deep and open wound
-possible necrotic tissue

A

Tertiary Intention

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24
Q

-Healing begins
- first 3-5 days
-Increase of pain, redness, warmth, and swelling
-bleeding is formed into clots (coagulation cascade)

A

Inflammatory phase

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25
- Last several weeks (depends on intention) -Wound bed fills with granulation tissue -new blood vessels develop
Proliferative phase
26
- Remodeling - Collagen continues to be deposited and remodeled -last up to a year -scar tissue is formed and strengthened
Maturation phase
27
new beefy red tissue created to fill wound bed
granulation tissue
28
avascular mass of collagen that gives strength to repaired wound
scar tissue
29
connection with surgical incisions becomes separated during healing process
dehiscence
30
total separation of all tissue layers causing organ protrusion
evisceration
31
indicative of new collagen growth being layed down in the wound
healing ridge
32
abnormal connection between two internal organs or from organ to skin
fistula
33
damage to skin in an area that includes soft tissue damage and usually found over boney prominences
pressure injury
34
minimum pressure required to collapse a capillary
capillary closing pressure
35
injuries resulting from use of medical devices (tubing, sensors, trach ties)
medical device related pressure injury
36
two surfaces rubbing together
friction
37
skin sticks to surface and is forcefully pulled off
shear
38
inflammation or skin erosion caused by prolonged exposure to a source of moisture
moisture associated skin damage
39
condition in which excessive moisture cause softening of the skin
maturation
40
-perineal inflammation and dermatitis caused by contact with urine or feces -damage from moisture is confined to more superficial layers
incontinence related dermatitis
41
redness due to excessive vasodilation caused by pressure
abnormal reactive hypermia
42
area of tissue loss present under intact skin forming a lip around wound
undermining
43
narrower passageway extending outward from edge or the wound
tunneling
44
necrotic tissue
eschar
45
clear, watery drainage from wound
serous
46
pink to pale red drainage that is mix of serous fluid and blood
serosanguineous
47
bleeding drainage
sanguineous
48
removal of necrotic tissue
debridement
49
bacterial load
bioburden
50
closed drainage system in which a soft drain is attached to a bulb like suction device
JP drain
51
open drain that is a flexible piece of tubing that is not sutured into place
penrose drain
52
spring like drainage system
hemovac
53
threads used to bring the edges of a wound together in order to speed wound healing and reduces scar formation
suture
54
What are the factors that affect skin integrity?
-wounds -vascular disease -diabetes -malnutrition -age
55
-superficial layers of skin are removed by medical adhesive -lasts longer than 30 minutes -causes pain, increases infection and wound size, slows healing
medical adhesive related skin injury
56
What factors affect wound healing?
-oxygen and tissue perfusion -diabetes -nutrition -age -infection
57
injuries caused by electricity, chemicals, radiation, extreme cold, friction
burns
58
-damages on the epidermis -pain and redness
superficial burn
59
-damages epidermis and dermis - pain and blisters
partial thickness burn
60
-damages all layers of skin -white, brown, or charred -no sensation -requires surgery
full thickness burn
61
What factors can lead to pressure injury?
-friction/shear -sensory loss/ immobility -moisture -nutrition
62
-non blanchable -intact skin -painful - differs in temp and firmness -abnormal reactive hypermia
stage 1
63
-partial thickness skin loss -exposed dermis -intact or open blisters -shallow and superficial
stage 2
64
- full thickness skin loss but not muscle, bone, connective tissue -undermining and tunneling
stage 3
65
- full thickness skin and tissue loss -see bone, cartilage, muscle
stage 4
66
-obscured full thickness skin and tissue loss -cannot be assessed till eschar is removed
unstageable
67
- nonblanchable - deep red, maroon, or purple -skin intact
deep tissue
68
-uses a scalpel, curette, or scissors -underlying infection, or large amount that needs fast removal -premedicate and caution with bleeding disorders
sharp debridement
69
-remove necrotic tissue but also disturbs viable tissue -wet to dry -whirlepools -painful, harmful to viable tissue, and bleeding
mechanical debridement
70
-topical agents containing enzymes that break down fibrin, collagen, or elastin present in devitalized tissue -slow but effective
enzymatic debridement
71
wounds have innate ability to clean itself of debris and necrotic tissue
autolytic
72
-autolytic -requires moist environment -slowest but most comfortable
occlusive debridement
73
-sterile, medical larvae -secrete enzymes that break down necrotic tissue -most effective
biologic debridement
74
-used to pack all wounds -cover dressings -absorbant for heavy wound drainage
gauze dressing
75
-used for wounds with minimal to no drainage -promotes autolytic debridement -prevents bacteria and fluids
transparent film
76
-Used on clean, uninfected wounds -promotes autolytic debridement
hydrocolloids
77
-used for wounds that are producing moderate to heavy amounts of drainage
foams
78
-used for bleeding and draining wounds
alginates
79
--used for wounds with minimal to no drainage -promotes autolytic debridement -adds moisture to wound
gels
80
drainage that is thick, yellowish green, and four odor
purluent
81
What are the 5 ps of circulation?
- pain -pallor -puleslessness -paresthesia -paralysis
82
culture that is available on the surface of the wound
aerobic
83
culture that is available deeper in the wound
anaerobic
84
dressing that begins at distal portion of a limb and is wrapped around twice
circular wrap
85
wraps for extremities
spiral/reverse spiral
86
wraps for joints
figure eight
87
wraps for head or amputated limbs
recurrent wraps

Exam 3 (2 decks)

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