SKIN Wound Flashcards
(76 cards)
1
Q
Function of skin
A
- Protection (melanin and sebum)
- Thermoregulation (sweating, vasodilation, vasoconstriction)
- Sensation (touch)
- Metabolism (synthesis of vit D)
- Communication (nonverbal language)
2
Q
Skin Changes Newborn/ Infant
A
- Reduced ability to thermoreg
- more susceptible to rashes, chafing, blistering
3
Q
Skin changes toddler/ preschool
A
- sunscreen
- playing causes injuries
4
Q
School age/ adolescent skin changes
A
- lice, scabies, impetigo
- acne
- sunscreen
5
Q
Adult and older adult skin changes
A
- dry skin more common
- wrinkling and poor skin turgor
- slower healing
6
Q
What can damage skin?
A
Surgery, burns, mechanical force, cancer causes abnormal growth, health-related (nutrition, circulation, allergy or infection, abnormal growth rate), pressure ulcers (mech friction and shear)
7
Q
Acute wound
A
injury such as knife, gunshot, burn or incision heals within 6 mos
8
Q
Chronic wound
A
Wound that persists beyond usual healing time (> 6mo) or recurs without new injury to the area
9
Q
Open wound
A
Break present in the skin; tissue damage present
10
Q
Closed wound
A
No break in skin is seen but soft tissue damage is evident
11
Q
Clean surgical wound
A
closed surgical wound that did not enter Gi, resp, genitourinary systems; low infection risk
12
Q
Clean/ contaminated
A
wound entering gi, resp, or genitourinary systems; infection risk
13
Q
Contaminated
A
open, traumatic wound; surgical wound with break in asepsis; high infection risk
14
Q
Infected
A
Wound site with pathogen present; signs of infection
15
Q
What is pressure?
A
Localized damage to the skin or underlying tissue, usually over a bony prominence as a result of pressure, or pressure in combination with shear
-heels, sacrum, elbows
16
Q
Stage 1 pressure ulcer
A
- skin is intact
- nonblanchable redness
- May be painful or have diff feel to the rest of the skin
- temp sensation
17
Q
Stage 2 pressure ulcer
A
- Shallow open ulcer with a pink wound bed
- partial- thickness loss of dermis
- skin tears, tape burns, maceration, excoriation with no sloughing
18
Q
Stage 3 pressure ulcer
A
Full thickness tissue loss
- May have slough
- bone,tendon, and muscle not exposed
- undermining and tunneling may be present
19
Q
Stage 4 pressure ulcer
A
- exposed bone, tendon, or muscle
- slough and eschar may be present
- tunneling and undermining
20
Q
tunneling/ undermining
A
tunneling: narrow passageway in soft tissue of an open wound
undermining: area of tissue destruction under the edge of wound opening
21
Q
Unstageable pressure ulcer
A
- Unstageable means that the wound cannot be visualized
- the base is covered with slough or eschar
22
Q
Pressure ulcer screening
A
- Braden scale
- numerical tool that calculates a patient’s risk for developing pressure ulcers
23
Q
Measures to prevent pressure ulcers
A
- turn every 2 hours
- lift rather than drag patients when pulling up in the bed
- specialty mattresses: air in mattress circulates to keep in flat to distribute pressure evenly
- Specialty beds: combine bed with specialty mattress. Can feel almost like a waterbed to prevent pressure
- Nursing: Protective creams or lotions, zinc, petroleum
24
Q
Primary lesions
A
May arise from previously normal skin
-Macule, papule, patch, plaque, nodule, wheal, vesicle, bulla, pustule
25
Secondary lesions
Result form changes in primary lesions
| -Erosion, crust, ulcer, scale, fissure
26
Hemostasis (immediate) phase
- Vasoconstriction, platelet aggregation, clot formation
27
Inflammatory phase
- Up to day 3
- vasodilation
- phagocytosis
28
Proliferative phase
```
Partial thickness (day 4-day 21)
-epithelialization
```
Full thickness ( day 4- day 21)
- Granulation tissue
- Contracture
29
Maturation phase
(21 days - 2 years)
| -Full-thickness only (brownish- yellowish)
30
Primary intention
- clear incision
- early suture
- Hairline scar
31
Secondary intention
- gaping irregular wound
- granulation
- epithelium grows over scar
32
Tertiary intention
- wound
- granulation
- closure with wide scar
33
Measures to keep wound edges close together
- Binder
- Steri-strips: adhesive strip to hold edges together
- Sutures, staples, and clips: thread or metal that holds edges together
- Cyanoacrylate Glue: parts of the body that do not experience tension or stretching
- Elastic wraps, bandages, and stretch netting: apply distal to proximal, ensure it is not too tight, check distal circulation
34
Complications that can occur
- hemorrhage or hematoma
- infection: purulent drainage, inflamed incisional area, fever, elevated leukocyte count
- Dehiscence: partial or total disruption, wound opens up
evisceration: protrusion of viscera through wound opening
- Inside body stuff goes outside
Fistula: passage btwn 2 areas that do not normally connect. name= location
35
Wound assessment?
- Type, size, location, classification, and base
- Drainage
- Undermining and tunneling
- infection or pain
- if connected to a drain, measure output and ensure it works
36
Sanguineous
bloody
37
Serosanguineous
pale- pink yellow
38
Serous
clear yellow watery
39
Drain types
Penrose: tube placed in wound no suction
Hemovac: suction present, bloody cavity
Jackson-Pratt: gentle suction when bulb compressed
40
A wound is present who should assess it?
- Wound ostomy continence nurse (WOCN)
- Specialist in wound care who will assess the wound and come up with a specific dressing change for it
- If it is a surgical wound : only surgeon removes the dressing, the surgeon will write orders on how to do the dressing change, follow that order
41
Alginate Dressing
- Absorption for draining wounds
42
Collagens
- Partial and full-thickness
43
Composites
-Use multiple products
44
Foams
- Hydrophillic polyurethane
| - Partial and full-thickness with small to moderate drainage
45
Hydrocolloids
Water-resistant gel-like wafer dressing
46
Hydrofiber
Sodium carboxymethylcellulose
| -very absorptive
47
Hydrogels
Assist in autolytic debridement of necrotic tissue in full-thickness wound
48
Nonadherent dressings
Minimize disruption of new cells
49
Silver dressings
Antimicrobial for infected wounds
| -bacteria
50
Transparent films
Cover the wound but see it
51
What dressings need an order?
All but transparent dressings
52
How often is a dressing changed?
Determined by wound status, type of dressing, amt of drainage, freq of wound assessment.
53
What supplies are needed?
clean and sterile gloves, tape, syringe with saline flush
54
Does it involve cleaning or irrigation
mainly saline irrigation
55
When do you pack and fill a wound?
when tunneling or undermining is present
56
Neg-pressure wound therapy
Hydrophobic sponge dressing fills a wound cavity
- Cover with transparent dressing
- Connect to a machine that provides negative pressure
57
Surgical Debridement
- Not done by nurses
| - Use of sharp tools to remove debris
58
Enzymatic Debridement
-Place chemical product on wound to break down debris
59
Autolytic
Occlusive or hydrogel
- debris gets eroded then irrigated out with saline
- eschar will be affected by hydrogel
60
Mechanical
Wet-dry dressing
- saline sock gauze pulls exudate
- exudate comes out
61
Heat: Promote healing and suppuration (consolidation of pus)
Results in vasodilation leading to increased blood flow, thus increasing oxygen and nutrients to the area and promoting removal of waste products.
62
Heat: Decrease inflammation by accelerating inflammatory process
Increases capillary wall permeability, increases leukocyte and antibody flow to area, and promotes action of phagocytes
63
Heat: Decrease musculoskeletal discomfort
increases sensory nerve conduction, promotes muscle relaxation, and decreases viscosity of synovial fluid
64
Cold: controls bleeding
Results in vasoconstriction, decreases blood flow, decreases metabolic tissue demands and the supply of oxygen and nutrients
65
Cold: Decreases edema
Decreases capillary permeability; cause vasoconstriction
66
Cold: Relieves Pain
Decreases nerve conduction velocity; induces numbness or paresthesia
67
Acute sudden pain that may indicate abscessed tooth or appendicitis
- Application of heat may cause rupture and spread a systemic infection
68
Broken skin or deep open wounds
subq and visceral tissues are more sensitive to extreme temps
69
Circualtory impairment
cold application constricts, thus decreasing circulation. heat does not disspate well from comprimse areas increasing tissue damage .
70
Sensory deficits
alterations in nerve conduction limit the sensation of temp or pain incresing the likehood of tissue damage
71
Mental status impairment
decreased reliability of reporting pain and altered sensation
72
Age extreme
Young children can not properly thermoregulate and cannot communicate pain or discomfort or alter their enviornment. Elderly may have reduced sensation to pain and often have other impairment that compounds risk. Heat should not be applied to abdomen of a pregnant woman because of fetal growth.
73
Metallic implants
Metal is a good conductor of heat thus increasing the potential for burns since implants cannot be readily removed
74
What diet promotes optimal wound healing
Protien, vit A,C,E, zinc, water, arginine, carbs, fats
75
Meds that are problematic with wound healing
Anticoagulants- increase potential for bleeding
| Corticosteroids- reduced body's ability to fight infection
76
What lifestyle choice decreases fxn hemoglobin, causes vasoconstriction, and impairs tissue oxygenation
smoking
