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NS1881 > Week 4 Skin Integrity and Wound Assessment > Flashcards

Week 4 Skin Integrity and Wound Assessment Flashcards

1
Q

Skin functions

A
  • Protects
  • Regulates
  • Receives sensation
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2
Q

Factors affecting skin integrity

A

Resistance to injury of skin and mucous membranes varies among people
- Age
- Amount of underlying tissues (thin)
- Conditions
- Some medications
- Impaired circulation
- Nutritional state

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3
Q

Adequate ____ is necessary to maintain cell life

A

Circulation

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4
Q

Skin gland secretions peak during

A

Adolescence and continues until about 50

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5
Q

Age related skin changes

A
  • Skin more easily injured
  • Less capacity to insulate
  • Sensation is reduced
  • skin becomes drier
    -ealing time delayed
  • Uneven pigment
  • Loss of skin elasticity
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6
Q

Loss of epidermis only

A

Superficial

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7
Q

Involves the dermis and epidermis

A

Partial thickness

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8
Q

Involves the epidermis, dermis, subcutaneous fat, muscle, and sometimes bone

A

Full thickness

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9
Q

How many phases are there of wound healing?

A

3

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10
Q

Inflammatory phase

A

Phase 1 (0-3 Days)

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11
Q

Proliferative phase

A

Phase 2 (3-24 Days)

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12
Q

Maturation phase

A

Phase 3 (24-365 Days)

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13
Q

Contributing factors to impaired healing

A
  • Unstable diabetes mellitus
  • Venous or arterial disease
  • Ageing
  • Infection
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14
Q

Maceration

A

pH of skin

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15
Q

Oedema

A

Inadequate O2 and blood

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16
Q

Necrosis

A

Dead tissue which must be removed

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17
Q

Wound not progressing through stages of healing in a timely manner

A

Chronic wound

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18
Q

Chronic wounds due to___ factors

A

Intrinsic and extrinsic

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19
Q

Exudate

A
  • Contains nutrients, energy and growth factors for metabolising cells
  • Contains high quantities of WBCs
  • Cleanses the wound
  • Maintains a moist environment
  • Promotes epithelisation
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20
Q

Exudate
Clear, straw coloured

A

Serous (normal)

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21
Q

Exudate
Clear, pink

A

Haemoserous (normal)

22
Q

Exudate
Red

A

Sanguinous (trauma to blood vessels)

23
Q

Exudate
Yellow, grey, green

A

Purulent (Infection)

24
Q

A technique which aims to prevent pathogenic microorganisms from being introduced to susceptible sites by hands, surfaces/equipment

A

Aseptic

25
Q

Preventing contamination of susceptible sites by hands, surfaces/equipment

A

Non-touch

26
Q

Identifying the risk of contamination and choosing the right field and technique

A

Technique

27
Q

Technically simple, short in duration (<20 min) involving relatively few and small key sites and parts

A

Standard ANTT

28
Q

Main general aseptic field and non-sterile gloves

A

Standard ANTT

29
Q

Technically complex surgery involving extended time periods with large open key sites or large or multiple key parts

A

Surgical ANTT

30
Q

Main critical aseptic field, sterile gloves and barrier precautions

A

Surgical ANTT

31
Q

Open wounds, including insertion and puncture sites

A

Key SITES

32
Q

Parts of procedure equipment coming into direct or indirect contact with other key parts, any liquid infusion or key sites

A

Key PARTS

33
Q

Clinical manifestations of wound infection

A
  • Localised heat
  • Erythema
  • Fever
  • Odour
    -Increased exudate
  • Increased pain
  • Slow healing
  • Cellulitis
34
Q

Wound cleansing

A
  • Normal saline used
  • Cleanses bacteria from wound
  • Assists debridement
  • Adhere to ANTT principles
35
Q

When should you swab a wound for testing?

A

After cleansing, but before antibiotics

36
Q

Used when Key parts/sites are large or numerous and can’t be easily
protected by covers or caps or can’t be handled with a non-touch technique

A

Critical aseptic field

37
Q

The phases of wound healing occur in the following order:

A

Inflammatory, Proliferative, Maturation.

38
Q

Most superficial layer of the skin and provides the first barrier of protection from the invasion of substances into the body

A

Epidermis

39
Q

Connective tissue layer between the epidermis and subcutaneous tissue

A

Dermis

40
Q

Removal of infected and necrotic tissue

A

Debridement

41
Q

The partial or total rupturing of a sutured wound

A

Dehiscence

42
Q

Loss of the superficial layers of the skin

A

Excoriation

43
Q

Dead tissue in wound usually cream or yellow in colour

A

Slough

44
Q

Material, such as fluid and cells, that has escaped from blood vessels during the inflammatory process and is deposited in tissue or on tissue surfaces

A

Exudate

45
Q

Young connective tissue with new capillaries formed in wound healing process

A

Granulation tissue

46
Q

A collection of blood in a tissue, an organ or a space due to a break in the wall of a blood vessel.

A

Haematoma

47
Q

Indicates freedom from infection or pathogenic material.

A

Asepsis

48
Q

Aims to prevent pathogenic organisms, in sufficient quantity to cause infection, from being introduced into susceptible body sites by the hands of staff, surfaces of equipment.

A

Aseptic technique

49
Q

Smaller parts of equipment that must be protected and kept sterile during an aseptic procedure

A

Micro critical aseptic field

50
Q

Simple aseptic field where there may be a small number of key parts and small key sites

A

General aseptic field

NS1881 (10 decks)

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