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Nursing Concepts > Skin Integrity & Wound Care > Flashcards

Skin Integrity & Wound Care Flashcards

1
Q

tool used to predict pressure sore risk used in conjuction with nursing judgment…low score= high risk…15-18 low risk, 13-14 moderate risk, 10-12 high risk, <9 very high risk

A

Braden Scale

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2
Q

removal of necrotic tissue

A

Debridement

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3
Q

partial or total separation of layers of skin and tissue above the fascia in a wound that is not healing properly (obese pt at high risk, most common in abdominal wounds post-surgery)…BE ALERT WHEN SEROSANGUINEOUS DRAINAGE INCREASES!

A

Dehiscence

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4
Q

thick layer of dead, dry tissue that covers a pressure ulcer or thermal burn; slough present in stage IV ulcers (may be allowed to naturally remove or may be surgically removed)

A

Eschar

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5
Q

occurs when wound layers separate below the fascial layer and visceral organs protrude through the wound opening…medical emergency requiring placement of sterile towels soacked in sterile saline over the extruding tissues to reduce chances of bacterial invasion & drying before surgery

A

Evisceration

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6
Q

surface damage caused by the skin rubbing against another surface that often results in an abrasion

A

Friction

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7
Q

red, moist tissue consisting of blood vessels and connective tissue

A

Granulation Tissue

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8
Q

softening of the skin caused by moisture

A

Maceration

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9
Q

impaired skin integrity resulting from pressure

A

Pressure Ulcer

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10
Q

force exerted against the skin while the skin remains stationary and the bony structures move

A

Shearing Force

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11
Q

healing that occurs in a wound with little or no tissue loss such as a clean surgical incision; the skin edges approximate and risk for infection is minimal

A

Primary Intention

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12
Q

healing that occurs in wounds involving loss of tissue such as a severe laceration or chronic wound; skin edges cannot come together because of the extensive tissue loss and healing occurs gradually

A

Secondary Intention

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13
Q

healing that occurs when a wound is later brought together some type of closure material; occurs in wounds that are fairly deep and contain extensive draining & tissue debris; “delayed primary healing”

A

Tertiary Intention

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14
Q

sensitive vascular layer of skin directly below the epidermis composed of collagenous and elastic fibrous connective tissues that give it it’s strength and elasticity

A

Dermis

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15
Q
A
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16
Q

fluid, cells or other substances that have been slowly discharged from cells or blood vessels through small pores or breaks in cell membranes

A

Exudate

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17
Q

clear, watery plasma drainage

A

Serous Drainage

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18
Q

fresh bleeding drainage

A

Sanguinous Exudate

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19
Q

pale, more watery, combination of plasma and red blood cells, blood-streaked drainage

A

Serosanguinous Exudate

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20
Q

thick, yellow/green/brown drainage indicating presence of dead or living organisms and white blood cells

A

Purulent Exudate

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21
Q

act of forming pus

A

Suppuration

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22
Q

closing together of wound edges in which an injury has been caused on the skin by abrasion

A

Approximated Excoriation

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23
Q
A
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24
Q

occurs when epithelial tissue grows from edges and covers over the granulation (new skin/scar)

A

Epithelialization

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25
Q

abnormal passage from an internal organ to the body surface or between two internal organs

A

Fistula

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26
Q

decreased blood supply to a body part, such as skin tissue, or to an organ, such as the heart

A

Ischemia

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27
Q

the death of tissue in response to disease or injury

A

Necrosis

28
Q

discoloration of the ski nor bruise caused by leakage of blood into subcutaneous tissues as a result of trauma to underlying tissues

A

Ecchymosis

29
Q

present in Stage IV ulcers…a narrow canal underneath surface

A

Tunneling/Undermining

30
Q

abdominal binder used to support large incisions that are vulnerable to stress when the patient moves or coughs

A

Montgomery Straps

31
Q

the process of drying up

A

Desiccation

32
Q

pressure sore/ ulcer

A

Decubitus

33
Q

a soft tube placed in an operative site connected to a small, compressed, plastic bulb to drain blood & inflammatory fluid

A

Jackson-Pratt Drain

34
Q

a thin-walled rubber tubular drain made in various widths for use in surgery

A

Penrose Drain

35
Q

reaction phase of wound healing that begins within minutes of injury and lasts 3-6 days; characterized by vasoconstriction then dilation & slight fever (<101)

A

Inflammatory Phase of Wound Healing

36
Q

phase of wound healing that starts on day 21 and can last long periods of time in which collagen scars gain strength, resume normal appearance becoming smaller, flatter, whiter; can take months-years to complete

A

Maturation/Remodeling Phase of Wound Healing

37
Q

phase of wound healing that starts around day 3 and lasts until day 21 in which macrophages are clear of debris and new blood vessels appear; granulation fills wound and then topped with epithelilization; pink, raised scar forms

A

Proliferative Phase of Wound Healing

38
Q

redness and edema are the first response, bringing WBC to the site (wound appears red & swollen), a scab forms when WBC dry; this response is limited and subsides in less than 24 hours

A

Inflammatory Response

39
Q
A
40
Q

injury precipitates release of chemicals; complement and blood-clotting systems; activates inflammatory process

A

Stage 1 of Inflammatory Process

41
Q

stage characterized by erythema (increased blood flow to the area), redness, and increased warmth

A

Stage 2 of Inflammatory Process

42
Q

stage characterized by capillary permeability with leakage of large quantities of plasma into damaged tissues and non-pitting edema; infection walled-off

A

Stage 3 of Inflammatory Process

43
Q

stage in which damaged tissue is invaded by leukocytes that engulf bacteria and necrotic tissue; purulent exudate (pus) produced

A

Stage 4 of Inflammatory Process

44
Q

stage in which destroyed tissue cells are replaced by identical cells which promotes healing and formation of scar tissue; functional capacity of tissue may be reduced

A

Stage 5 of Inflammatory Process

45
Q

water-loving colloids applied to draining wound that forms gel to provide moisture for wound healing; has limited absorption; not adequate for large amts of exudate

A

Hydrocolloids

46
Q

used with primary dressing to prevent dehydration of wound base; can be used on infected wounds

A

Foam

47
Q

used for wounds with large amts of exudate; conforms to size/shape of base; must be irrigated to remove; not used in wounds with tunneling or sinus tracts

A

Absorption Dressing

48
Q

semi-permeable first dressings used to promote moist wound healing; water vapor passes through reducing periwound maceration; non-absorptive so drainage accumulates

A

Transparent Dressing

49
Q

soft, non-woven fibers made from seaweed, sodium & calcium acids that turns into non-adhesive gel when in contact with exudate; highly absorbent so will dry out wound bed; easy to irrigate out of wound; non-toxic; can control minor bleeding

A

Calcium Alginates

50
Q

dressing with cooling effect that enhances epithilization without reinjuring tissue and does not adhere to wound base; softens slough and necrosis; can be used on infected wounds; can macerate periwound skin

A

Hydrogels

51
Q

4x4’s and roller gauze made of woven & non-woven fibers (cotton, rayon, polyester, combination); fine mesh gauze used in packing; coarse mesh used in debridement dressings; synthetic more absorbent than cotton; may be impregnated with wound products to promote healing

A

Gauze Dressings

52
Q
A
53
Q

Factors that Affect Wound Healing

A

age, mobility, nutrition, hydration, diminished sensation, impaired circulation, medications, moisture on skin, fever, lifestyle

54
Q

vasodilation, reduced blood viscosity, reduced muscle tension, increased tissue metabolism, increased capillary permeability

A

Physiological Responses to Heat Therapy

55
Q

vasoconstriction, local anesthesia, reduced cell metabolism, increased blood viscosity, decreased muscle tension

A

Physiological Response to Cold Therapy

56
Q

Conditions Treated with Heat Therapy

A

arthritis, joint pain, muscle strains, low back pain, menstrual cramping, hemorrhoidal, perianal, vaginal, local abscesses

57
Q

Conditions Treated with Cold Therapy

A

direct trauma, superficial laceration or puncture, minor burn, after injections, arthritis, joint trauma

58
Q

Conditions that Increase Risk for Injury from Heat/Cold Therapy

A

very young or old; open wounds; edema or scar formation; peripheral vascular disease; confusion or unconsciousness; spinal cord injury

59
Q

stage of ulcer characterized by nonblanchable erythema of intact skin where only the epidermis is involved; it is refeversible if the pressure is removed; TREATMENT: RELIEVE PRESSURE

A

Stage I Pressure Ulcer

60
Q

stage of ulcer characterized by partial-thickness skin loss involving epidermis and/or dermis; superficial skin tears; presents as abrasion, blister or shallow crater; may be swollen and painful; TREATMENT: MOIST HEALING ENVIRONMENT (SALINE OR OCCLUSIVE DRESSING)

A

Stage II Ulcer

61
Q

stage of ulcer characterized by full-thickness skin loss with damage or necrosis of subcutaneous tissue that may extend to but not through the underlying fascia; presents as deep crater with or without underminding; may have foul-smelling drainage; TREATMENT: DEBRIDE WITH WET-TO-DRY, SURGERY, ENZYMES

A

Stage III Ulcer

62
Q

stage of ulcer characterized by full-thickness skin loss with extensive destruction, tissue necrosis or damage to to muscle, bone or supporting structures with undermining possible present; TREATMENT: NON-ADHERENT DRESSINGS, SKIN GRAFTS

A

Stage IV Ulcer

63
Q

localized area of purple/maroon discoloration; intact skin or blood blister due to damage of underlying soft tissue from pressure/shear; painful, mushy, boggy, warm/cool in comparison to adjacent tissue

A

Deep Tissue Injury

64
Q

ulcer in which the base is covered in slough and/or eschar and therefore, cannot visually be graded or staged

A

Unstageable Ulcer

65
Q
A
66
Q

Changes in Skin Associated with Aging

A

decreased tears/blink reflex, drying of oral mucosa, thinning of skin, decreased oil production, decreased body mass

67
Q
A

Nursing Concepts (16 decks)

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