Unit 6: Skin Integrity and Wounds Flashcards
(48 cards)
What is the outermost layer of the skin called?
Epidermis
The epidermis regenerates every 4-6 weeks.
How many sub-layers does the epidermis have?
Five
The five sub-layers are stratum corneum, stratum lucidum, stratum granulosum, stratum spinosum, and stratum germinativum (basale).
What is thicker than the epidermis and contains sebaceous glands?
Dermis
The dermis also contains sweat glands, hair and nail follicles, nerves, and lymphatics.
What type of tissue is found in the subcutaneous layer?
Adipose tissue
The subcutaneous layer provides insulation and cushioning.
What are the four classifications of wounds based on?
- Skin integrity
- Wound depth
- Amount of contamination
- Healing process
These classifications help in assessing the wound and planning treatment.
What is the duration of the Inflammatory Phase of wound healing?
3 days
This phase involves the coagulation cascade.
What occurs during the Proliferative Phase of wound healing?
Granulation tissue formation
This phase lasts several weeks.
What can affect wound healing?
- Oxygenation and tissue perfusion
- Diabetes
- Nutrition
- Age
- Infection
These factors can significantly impact the speed and effectiveness of healing.
What are the risk factors for pressure injury?
- Intensity and duration of pressure
- Medical devices
- Friction and shear
- Sensory loss or immobility
- Moisture
- Nutrition
Understanding these factors can help in prevention strategies.
What characterizes Stage 1 pressure injury?
Non-blanchable erythema of intact skin
The area may be painful, firm, or differ in temperature.
What is a characteristic of Stage 2 pressure injury?
Partial-thickness skin loss with exposed dermis
This stage may include blisters.
What defines Stage 3 pressure injury?
Full-thickness skin loss with possible undermining or tunneling
This stage indicates a deeper injury.
What is the definition of Unstageable pressure injury?
Full-thickness loss obscured by necrotic tissue (eschar)
The actual depth cannot be determined due to the necrotic tissue.
What does a Deep Tissue Injury present as?
Persistent non-blanchable deep red, maroon, or purple discoloration
This indicates damage to underlying tissue.
What factors are assessed in wound assessment?
- Location and size
- Presence of undermining or tunneling
- Drainage characteristics
- Condition of wound edges and surrounding tissue
- Wound bed condition
- Patient response
These factors are crucial for developing an effective care plan.
What assessment tool is used for pressure sores?
Pressure Sore Status Tool (PSST)
This tool helps in evaluating the severity of pressure injuries.
What is an example of a nursing diagnosis related to skin integrity?
Impaired Skin Integrity – Pressure injury on left buttock due to paralysis
This diagnosis highlights the impact of immobility on skin health.
What are some interventions to preserve skin integrity?
- Turning and positioning every 2 hours
- Skin hygiene to maintain pH balance
Regular repositioning is critical for preventing pressure injuries.
What is the purpose of pressure-reducing surfaces?
Spread out body weight
These surfaces help in reducing the risk of pressure injuries.
What types of debridement are there?
- Sharp
- Mechanical
- Enzymatic
- Autolytic
- Biologic
Each method has its own indications and effectiveness.
What types of dressings can be used in wound care?
- Gauze
- Transparent films
- Hydrocolloid
- Foams
- Alginates
- Gels
The choice of dressing depends on the wound type and condition.
What is the role of drains in wound care?
Reduce infection risk
Drains can be open or closed systems.
What are the benefits of heat and cold applications?
- Reduce pain
- Improve circulation
- Reduce swelling
These applications may require a doctor’s order.
What is necessary for evaluating wound care interventions?
Continuous assessment of intervention effectiveness
Ongoing care plan revisions are necessary as needed.
