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Flashcards in Skin Integrity Deck (64)
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1

what is primary prevention focusing on in tissue integrity

patient education and prevention... (who can we educate them on how not to get a wound)

2

what is secondary prevention on tissue integrity

after the wound happens (not good education) what can we do while they have a wound and to get it healed

3

what is tertiary prevention on tissue integrity

who do we prevent them from coming back to us, more education, teach how to take care of wound and how to clean it at home

4

what are clinical manifestation of compromised tissue integrity

itching, burning, pain, excessively dry skin, peeling skin, draining wound-something in wound, pressure ulcers, tear in skin, depression, changes in skin color, fluid and lights imbalance

5

what are wounds classified by

cause and depth of tissue affected

6

what are the 2 causes of a wound

surgical or nonsurgical, acute or chronic

7

what are the depths of tissue affected

superficial, partial thickness, full thickness

8

acute=

less than 6 months

9

superficial=

epidermis is affected

10

partial thickness=

through epidermis to dermis

11

full thickness=

anything from sub Q down to muscle, bone

12

what are age related changes of tissue integrity

skin becomes fragile
delayed wound healing
dec in Vit D production
susceptible to dry skin
dec in sensory percep
risk hypo/hyperthermia
dec in elasticity
dec in perspiration

13

what are the (primary) healing of a primary intention

initial (inflammatory phase)
granulation phase
maturation phase

14

incision with blood clot, edges approximated with suture, fine scar

primary intention

15

irregular large wound with blood clot, granulation tissue fills in wound, large scar

secondary intention

16

contaminated wound, granulation tissue, delayed closure with suture

tertiary intention

17

want this to heal from the inside out so it does not leave a big air pocket

secondary intention

18

delayed primary intension so opened back up to heal

tertiary intention

19

not going to heal from the inside out because wound not big enough (neatly approximated) surgical incision or paper cut

primary intention

20

fibrin clots, erythrocytes, neutrophils, cellular debris come to surface

initial inflammatory response

21

wound is pink and vascular, surface epithelium at the wound edges begin to regenerate,

granulation phase

22

may start 7 days after injury occurs and can continue for several months or years, collagen fibers are organized and remodeling occurs (scaring)

maturation phase

23

wounds from trauma, infection, ulceration, can not suture back, more exudate

secondary intention

24

why are secondary intention more at risk for infection

because have to leave open

25

how is secondary intention classified as

color (red, yellow, black)

26

superficial or deep wound that is clean and pink in appearance (serosanguinous drainage)

red wound (stage 2 pressure ulcer, skin tear, second degree burn)

27

presence of slough or soft necrotic tissue (liquid semi solid ivory to yellow green may be present) slough should be removed and drainage absorbed

yellow wound

28

why should any form of slough be removed

it is non viable tissue and oxygen can not reach wound bed to help regeneration

29

necrotic tissue, risk for infection

black wound (full thickness, stage 3&4 pressure ulcer)

30

what are the signs of shock

rapid pulse, cool clammy skin, pale skin, rapid breathing, pupils dilated, N/V, weakness, fainting