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Nursing 1 > Skin Integrity > Flashcards

Skin Integrity Flashcards

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1
Q

layers of the skin

A

epidermis, dermis, subcutaneous tissue,

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2
Q

What layer of epidermis is the first line of defense?

A

Stratum corneum

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2
Q

what layer of the epidermis produces new cells

A

stratum germinativum

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2
Q

What layer houses sweat glands and hair follicles?

A

dermis

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3
Q

as we age what skin layer gets thinner and thinner?

A

subcutaneous

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4
Q

how do we classify wounds?

A

what layers it has entered

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5
Q

what factors affect skin integrity

A

surgery, injury, psoriasis, atopic dermatitis, meds, impaired circulation, slow healing

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6
Q

Of the following factors, which would put a client at greatest risk for impaired skin integrity:

Medication, digoxin
Moisture
Decreased sensation
Dehydration

A

decreased sensation

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7
Q

what is maceration

A

breakdown of skin from being wet

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8
Q

what are the stages of skin healing?

A

cleansing & granulation, epithelialization

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9
Q

how long does it take to form granulation tissue?

A

5-21 days

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10
Q

how long does it take to form scar tissue?

A

3-6 months

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11
Q

What is serous exudate?

A

clear, watery

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12
Q

what is sanguoneous drainage?

A

blood

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13
Q

what is serosanguinous drainage?

A

combination of blood and serous

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14
Q

what is purulent exudate

A

pus- thick, white/yellow

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15
Q

what is purosanguineous exudate?

A

red-tinged pus/purulent

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16
Q

what position do you place PT in for wound assessment?

A

neutral

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17
Q

what are some types of wounds

A

abrasions, abscess, contusion, crushing, excoriation (scratching), incision, laceration, penetrating wound, puncture wounds (mechanism goes in & out), tunnel wound

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18
Q

symptoms of internal hemorrhage

A

diaphoretic, anemic, tired

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19
Q

what is a dehiscence

A

separation of edges of a wound
EX; (sutures releasing and wound opening)

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20
Q

what are the signs to look for infection

A

Soft red hens produce furry fluffy chicks

swelling, redness, heat, pain, fever, foul smell, color change

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21
Q

What is an evisceration?

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A

wound opens with internal tissue outside of the body

22
Q

what is a fistula?

Study These Flashcards
A

unnatural opening between two body cavities

23
what wounds would you culture?
any wound with a sign of infection or delayed healing of 2 weeks or <
24
what is the biggest thing to remember about drains?
to document excrement's
25
what is a debridement?
cleaning out dead tissue/slough
26
how do you take care of wounds at home?
Wet – dry it Open – cover it Unclean – clean it Necrotic – Don’t scrub it Dry – Moisten it
27
what are pressure ulcers
Injury to the skin and underlying tissue over a bone
28
How are ulcers staged?
by type of tissue involved
29
can stages go back? can you go from a stage 4-stage 2?
No, they can only heal
30
how can you prevent ulcers?
repositioning at least every 2 hours inspect skin daily assess the injury-Braden scale manage moisture
31
what is the Braden scale?
a scale used for predicting pressure ulcer risk
32
what is a stage 1 pressure injury?
localized non-blanchable redness under a bony prominence only epidermis is affected
33
what is a stage 2 pressure injury?
partial thickness lost of dermis open but shallow red wound bed can be blister or ulcer no bruising/sloughing
34
what is a stage 3 pressure injury?
crater with full thickness sin loss damage or necrosis of SQ tissue viable adipose tissue no bone visible may be very deep
35
what is a stage 4 pressure injury?
full thickness skin loss tissue necrosis damage to muscle/bone exposed bone/tendon/cartilage slough or eschar may be present minimum a year to heal
36
what is a deep tissue injury?
skin is intact but discolored purplish boggy blister
37
what is an unstageable pressure injury?
full thickness skin loss base of wound is not visible
38
collagen
tough fibrous protein
39
blanching
normal red tones of light skin are absent
40
pressure factors that contribute to pressure ulcer development
pressure intensity pressure duration tissue tolerance
41
risk factors that predispose a patient to pressure ulcer formation
impaired sensory perception -impaired mobility -alteration in LOC -shear -friction -moisture
42
granulation tissue
red, moist tissue composed of new blood vessels, which indicate wound healing
43
slough
stringy substance attached to wound bed that is soft, yellow or white tissue
44
eschar
black or brown necrotic tissue
45
hemostasis
injured blood vessels constrict, and platelets gather to stop bleeding; clots form a fibrin matrix for cellular repair
46
potential or actual nursing diagnoses related to impaired skin integrity
risk for infection -imbalanced nutrition: less than body requirements -acute or chronic pain -impaired skin integrity -impaired physical mobility -risk for impaired skin integrity -ineffective tissue perfusion -impaired tissue integrity
47
advantages of a transparent film dressing
-adheres to undamaged skin -serves as barrier to external fluids and bacteria but allows wound surface to breathe -promotes moist environment -permits viewing -does not require secondary dressing
48
functions of hydrocolloid dressing
absorbs drainage through the use of exudate aborbers -maintains wound moisture -slowly liquefies necrotic debris -impermeable to bacteria -self-adhesive and molds well -acts as a perventative dressing for high-risk friction areas -may be left in place for 3-5 days, minimizing skin trauma and disruption of healing
49
advantages of hydrogel dressing
soothing and reduces pain -provides a moist environment -debrides the wound -does not adhere to the wound base and is easy to remove
50
warm, moist compresses
improve circulation, relieve edema, and promote consolidation of pus and drainage
51
warm, moist compresses
improve circulation, relieve edema, and promote consolidation of pus and drainage
52
What can the nurse do for clients with a Braden score of no risk?
educate, evaluate on change of condition
53
What can the nurse do for clients with a Braden score of mild/moderate risk?
reposition promote activity manage individual risk factors educate evaluate change of condition
54
What can the nurse do for clients with a Braden score of high/severe risk?
supplement with small positional shifts seating/posture assessment nutrition assessment educate evaluate change of condition
55
Fstage

Nursing 1 (20 decks)

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