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Fundamentals in Nursing - Lecture > Skin Integrity and Wound Care > Flashcards

Skin Integrity and Wound Care Flashcards

1
Q

Any disruption in the integrity of the body
tissue is called a

A

WOUND

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2
Q

Impaired skin integrity, such as wounds,
may occur as a result of

A

TRAUMA or
SURGERY

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3
Q

refers to the
presence of normal skin and
skin layers uninterrupted by
wounds

A

Intact Skin

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4
Q

Body’s largest ORGAN and is
the primary defense against
infection.

A

Skin

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5
Q

Skin Integrity
* Affected by:

A
  • Genetics and heredity
  • Age
  • Chronic illnesses and their
    treatments
  • Medications (rashes)
  • Poor nutrition
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6
Q

Types of Wounds

A
  • Clean
  • Clean-contaminated
  • Contaminated
  • Dirty, infected
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7
Q

Types of Wounds (How they are acquired)

A

Incision
Contusion
Abrasion
Puncture
Laceration
Penetrating wound

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8
Q
  • Sharp instrument (e.g., knife or
    scalpel)
  • Open wound; deep or shallow; once the
    edges have been sealed together as a part
    of treatment or healing, the incision
    becomes a closed wound
A

Incision

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9
Q
  • Blow from a blunt instrument
  • Closed wound, skin appears ecchymotic
    (bruised) because of damaged blood
    vessels.
A

Contusion

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10
Q
  • Surface scrape, either unintentional
    (e.g., scraped knee from a fall) or
    intentional (e.g., dermal abrasion to
    remove pockmarks)
  • Open wound involving the skin
A

Abrasion

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11
Q

Penetration of the skin and
often the underlying tissues by
a sharp
instrument, either intentional or
unintentional
- Open Wound

A

Puncture

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12
Q
  • Tissues torn apart, often from
    accidents (e.g., with
    machinery)
  • Open wound; edges are often jagged
A

Laceration

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12
Q
  • Penetration of the skin and the
    underlying tissues and enters a
    tissue or a cavity (e.g., from a
    bullet or metal fragments)
  • Open wound
A

Penetrating wound

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13
Q
  • Injury to skin and/or
    underlying tissue usually
    over a bony prominence
  • Formerly decubitus ulcers,
    pressure sores, bedsores
  • Preventable
A

Pressure Ulcers

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14
Q

Risk Factors of Pressure Ulcers

A
  • Friction and shearing
  • Force acting parallel to skin
  • Combined friction and
    pressure
  • Immobility
  • Inadequate nutrition
  • Fecal and urinary
    incontinence
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15
Q
  • Tissue softened
    by prolonged wetting
A

Maceration-

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16
Q

Risk Assessment Tools

A
  • Braden Scale for Predicting
    Pressure Sore Risk
  • Norton’s Pressure Area Risk
    Assessment Form Scale
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17
Q

nonblanchable erythema
signaling potential ulceration.

A

Stage Ⅰ

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18
Q

partial-thickness skin loss
(abrasion, blister, or shallow crater)
involving the epidermis and possibly the
dermis.

A

Stage Ⅱ

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19
Q

full-thickness skin loss
involving damage or necrosis of
subcutaneous tissue that may extend
down to, but not through, underlying
fascia. The ulcer presents clinically as a
deep crater with or without undermining
of adjacent tissue.

A

Stage Ⅲ

20
Q

full-thickness skin loss with
tissue necrosis or damage to muscle,
bone, or supporting structures, such as
a tendon or joint capsule. Undermining
and sinus tracts may also be present.

A

Stage Ⅳ

21
Q

fullthickness skin or tissue loss-depth
unknown: Actual depth of the ulcer is
completely obscured by slough (yellow,
tan, gray, green, or brown) and/or
eschar (tan, brown, or black) in the
wound bed.

A

Unstageable/unclassified

22
Q

purple or maroon localized
area of discolored intact skin or bloodfilled blister due to damage of underlying
soft tissue from pressure and/or shear.
Deep tissue injury may be difficult to
detect in individuals with dark skin tones.
Evolution may include a thin blister over
a dark wound bed. The wound may
further evolve and become covered by
thin eschar.

A

Suspected deep tissue injury-depth
unknown

23
Q

Regeneration (renewal) of tissues

A

Wound Healing

24
Q

Phases of Wound Healing

A

nflammatory, Proliferative, Maturation

25
Q

Types of Wound Healing

A

Primary, Secondary, Tertiary

26
Q
  • Immediately after injury
  • Lasts 3 to 6 days
  • Hemostasis
  • Phagocytosis
A

Inflammatory phase

27
Q

process to prevent and stop bleeding

A

Hemostasis

28
Q

process by which a cell uses its plasma membrane
to engulf a large particle, giving rise to an internal compartment
called the phagosome)

A

Phagocytosis

29
Q
  • From post-injury day 3/4 until day 21
  • Collagen synthesis
  • Granulation tissue formation
A

Proliferative phase

30
Q
  • From day 21 until 1 or 2-years
    post injury
  • Collagen organization
  • Remodeling or contraction
  • Scar stronger
  • Keloid
  • Hypertrophic scar with abnormal
    amount of collagen
A

Maturation phase

31
Q
  • Tissue surfaces
    approximated (closed)
  • Minimal or no tissue loss
  • (e.g., clean surgical incision)
  • Formulation of minimal
    granulation tissue & scarring
  • Proliferative phase
A
  • Primary intention healing
32
Q
  • Extensive tissue loss
  • Edges cannot be
    approximated.
  • Repair time is longer.
  • Scarring is greater.
  • Susceptibility to infection is
    greater
A

Secondary intention healing

33
Q
  • Also known as delayed primary intention
  • Initially left open 3-5 days
  • Edema, infection to resolve, or exudate to drain
  • Closed with sutures, staples, or adhesive skin closures
A

Tertiary intention healing

34
Q

Material (fluid, cells)
escaped from blood
vessels during
inflammatory process

A

Exudate

35
Q

3 major types of Exudtae

A
  • Serous
  • Purulent
  • Sanguineous
36
Q
  • Mostly serum
  • Derived from blood and serous
    membranes of the body
  • Looks watery, few cells
  • E . g., fluid in blister from a burn
A

Serous exudate

37
Q
  • Thicker
  • Presence of pus
  • Consists of leukocytes, liquefied
    dead tissue debris, dead and living
    bacteria
  • Color varies with causative organism
A

Purulent exudate

38
Q
  • Large number of R B Cs
  • Indicates severe damage to
    capillaries
  • Frequently seen in open wounds
A

Sanguineous exudate

39
Q

Mixed exudate

A

Serosanguineous
Purosanguineous

40
Q

Clear and blood-tinged drainage

A

Serosanguineous

41
Q

Pus and blood

A

Purosanguineous

42
Q

Complications of Wound Healing

A

Hemorrhage
Hematoma
Infection
Dehiscence
Evisceration

43
Q

Massive bleeding

A

Hemorrhage

44
Q
  • Localized collection of blood under
    skin
  • May appear as reddish blue bruise
A

Hematoma

45
Q

Contamination of a wound surface with
microorganisms

A

Infection

46
Q

Partial or total rupturing of a sutured
wound

A

Dehiscence

47
Q

Protrusion of the internal viscera through
an incision

A

Evisceration

Fundamentals in Nursing - Lecture (9 decks)

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