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Foundations EXAM 1 > Skin Integrity And Wound Healing (EXAM 1) > Flashcards

Skin Integrity And Wound Healing (EXAM 1) Flashcards

1
Q

Impaired skin integrity

A
  • expensive to treat
  • may not be covered by insurance
  • lengthens hospital stay
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2
Q

Skin layers

A
  1. Epidermis- top (dermal-epidermal junction separates the top 2 layers)
  2. Dermis
  3. Subcutaneous layer
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3
Q

Factors influencing skin integrity

A
  • nutrition
  • tissue perfusion
  • infection/fever
  • age (newborns/children) , elderly
  • immobility (impaired)
  • diminished sensation/cognition
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4
Q

Impaired circulation

Arterial vs Veous

A

Vascular system brings blood and O2 to tissues and it also removes waste.

Impaired Venous system–> produces edema –> resulting in ulceration and skin breakdown

Impaired Arterial circulation –> produces pain –> results in ischemia & necrosis

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5
Q

Medication types for wound healing

A

Immunosuppressants
Corticosteroids
NSAIDS
Anticoags

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6
Q

Moisture in skin

A

Leads to maceration-softening of the skin and ^ likelihood of breakdown

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7
Q

Lifestyle factors that affect skin

A
  • tanning
  • hygiene habits (homeless, dementia, low cognition)
  • regular exercise
  • nutritious diet
  • smoking
  • body piercing and tattoos
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8
Q

Types of wounds:
Length of time
Condition
Depth

A

Acute- short, heal spontaneously w/o complications via 3 phases of wound healing (inflammation, proliferation & maturation)

Chronic- long time to heal, wounds typically colonized w/multiple types of bacteria

Condition: clean, clean- contaminated, Contaminated

Depth: Superficial, partial thickness, full thickness (look in book and add definition)

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9
Q

Wound Healing: (3 types)

A
  1. Primary intention: (ex: surgical incision. Very clean and suture from inside out)
  2. Secondary intention: extensive and involves considerable tissue loss. Edges cant be brought together. Granulated from bottom up to heal on it’s own. Leave scar
  3. Tertiary intention: Resolution has occurred. Wound edges can be brought together (approximated). EX: bigger surgical wounds that may be infected
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10
Q

Wound Healing Process

A
  1. Hemostasis- blood/plasma leak into wound
  2. inflammation
  3. Proliferative- regeneration (healing phase)
  4. Remodeling/maturation phase- week 2-3
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11
Q

Dehiscence vs Evisceration

A

Dehiscence: seperation or splitting open of layers of the surgical wound

Evisceration: Larger wounds where when the incision opens back up the intestines or insides come outside of body.

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12
Q

Types of wound closures:

A

Adhesive strips: steri-strips. close low tension wounds like skin tears, lacerations, wound already closed at subcutaneous level

Sutures: stitches, most common type of wound closure.
Absorbent suture: used deep in tissue and dissolve
Nonabsorbent stitches: in superficial tissue and require removal

Staples
Wound Vac
Surgical Glue

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13
Q

Wound Drainage: Exudate types (5)

A
  1. Serous- from clean wounds, watery-straw, serum
  2. Sanguineous- bloody. Bright if new, dark if older
  3. Serosanguineous- combo
  4. Purulent- thick, maladorous pus
  5. Purosanguineous- red tinged pus
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14
Q

Pressure Ulcers- pressure sores, decubitus ulcer, or bedsore

A

Key variable: ISCHEMIA and PRESSURE
* large amt. of pressure for a short amt. of time, OR light pressure for a long period of time.

Pathogensis:

  • Pressure intensity
  • Blanching
  • Pressure duration
  • Tissue tolerance
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15
Q

Contributing Factors of Pressure Ulcer Formation

A

Time & Pressure + Tissue Tolerance
Friction & sheering
Mobility & activity compromise
Nutrition/age/circulation/underlying health

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16
Q

A flush of blood flow to an ischemic area that makes the skin redden

A

Normal reactive hyperemia

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17
Q

Excessive vasodilation of tissue with induration (hardening- fibrous elements)

A

Abnormal reactive hyperemia

18
Q

Stages of Pressure Ulcers (STAGE 1)

A 
Intact skin
Not blanchable
Painful
Firm/soft
Warm or cool
Discoloration return after 30 minutes of pressure relief
19
Q

Stages II Pressure Ulcer

A 
Open but very shallow
Red/pink wound bed
Partial thickness loss of dermis layer 
No slough of skin tissue 
May be intact or open/ruptured 
May look like a serum-filled blister
20
Q

Stage III pressure ulcer

A

Deep crater with Full thickness skin loss
Damage or necrosis of subcutaneous tissue
May extend down to but NOT through underlying fascia
No visible bone or tendon

21
Q

Pressure Ulcer Stage IV

A

Full thickness with exposed bone and tendon
Necrosis and muscle damage
Slough or Escher may be present
Blink tracking underneath the epidermis (tunneling)

22
Q

Suspected deep tissue Injury (additional pressure ulcer info)

A

An area of skin that is intact but discolored or bruised looking.
Painful
Boggy or have a blister present

23
Q

Unstageable Pressure Ulcer (additional pressure ulcer formation)

A

Full thickness Skin loss
Base of wound is obscured by slough tan (dead tissue that keeps the wound closed)
Need to open up and debride in order to know what’s goin on underneath

24
Q

Risk factors for Pressure Ulcer Development (Braden scale)

A 
Impaired sensory perception
Impaired mobility/activity 
Moisture and repeated injections to 1 area
Nutrition
Shear and friction
25
Q

most common sources of moisture on skin:

A

incontinence and fever

26
Q

presence of microorganisms in the wound

A

contamination

27
Q

all chronic wounds are considered contaminated bc the bacteria is ___

A

colonized

28
Q

when bacteria begins to overwhelm the body’s defense.

A

critically colonized

-new foul odor, change in color of the wound bed,

29
Q

Clean
Clean-contaminated
Contaminated

A

clean: uninfected w/minimal inflamm. may be open or closed. can be open/closed. Don’t involve GI, resp or GU tracts. little risk of infection

clean-contaminated: surgical incisions that enter the GI, resp or GU tracts. ^ risk of infection

contaminated: open, traumatic or surgical incisions. major break in skin. high risk of infection

30
Q

Infected: bacterial counts in the wound tissue ____

A

> 100k

31
Q

wound depth:

A

superficial: only the epidermal layer. confused by friction, shearing or burning

partial thickness wounds: extend through the epidermis but no through the dermis

Full thickness: extend into the subcutaneous tissue and beyond

32
Q

Staples (wound closures)

A
  • light weight titanium
  • lower risk of infection
    -downfall: edges of wound are more difficult to align
    common sites: arms, legs, abdomen, back, scalp or bowel
33
Q

Norton scale of pressure ulcer risk factors:

A
  1. Physical condition
  2. Mental condition
  3. Activity
  4. Mobility
  5. Continence
34
Q

Types of wound dressing:

  • hydrocolloid
  • hydrogel
  • Wound V.A.C.
A

Hydrocolloid: protects the wound from surface contamination

Hydrogel: maintains a moist surface to support healing

Wound V.A.C.: uses negative pressure to support healing

35
Q

Types of bandages

A

Rolled gauze, elasticize knit, elastic webbing, flannel, and muslin

36
Q

Locations of binder application

A

Breast
Abdominal
Sling

37
Q

Dry scab of necrotic tissue

A

Escher

38
Q

Dead tissue shedding from the ulcer

A

Sloughing

39
Q

Removal of dead tissue to promote healing of tissue

A

Debridement

40
Q

What does heat therapy do?

A

^ blood flow to the area: ^ O2, nutrients, and removal of waste products

  • relieves stiffness
  • if large area monitor for decreased BP
41
Q

Cold therapy does what in the body?

A
  • local anesthetic
  • vasoconstriction
  • reduces cell metabolism
  • slows bacteria growth
  • decrease edema

Foundations EXAM 1 (9 decks)

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