Help
Options
Didn't know it?
click below
click below
Knew it?
click below
click below
Don't Know
Remaining cards (0)
Know
retry
shuffle
restart
0:00
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.
Normal Size Small Size show me how
Normal Size Small Size show me how
Skin Integrity/Wound
Transitions
| Question | Answer |
|---|---|
| What are the functions of the skin? | Protection, Temperature, Regulation, Psychosocial, Sensation, Vitamin D Production, Immunologic, Absorption, Elimination |
| What are the factors affecting skin integrity? | 1. Unbroken and healthy skin and mucous membranes serve as the first line of defense against harmful agents. 2. Resistance to injury is influenced by the persons age, amount of underlying tissues, and comorbidities. 3. Adequate circulation is necessary to maintain cell life 4. Adequately nourished and hydrated body cells are resistant to injury |
| Mucous Membranes are found where? | Line body cavities that open to the outside of the body, joining with the skin, digestive tract respiratory passages, urinary tract, reproductive tract |
| What is a wound? | A wound is a break or disruption in the normal integrity of the skin and tissues |
| What is the first line of defense against microorganisms? | Intact Skin |
| What systemic reactions does a surgical wound cause? | Increased body temperature Increased heart and respiratory rates anorexia nausea and vomiting musculoskeletal tension hormonal changes |
| What promotes normal wound healing? | Wound is free of foreign material (excessive exudate, dead or damaged tissue cells, pathogenic organisms, embedded fragments of bone, metal, glass, or other substances |
| What is the most effective method for preventing wound infections? | Hand washing |
| What are the phases of wound healing | 1. Hemostasis 2. Inflammatory Phase 3. Proliferation/Repair Stage 4. Maturation/Remodeling Phase |
| Dehiscence | Partial or total disruption of wound layers |
| Scar | avascular collagen tissue that does not sweat, grow hair or tan in sunlight |
| Evisceration | Protrusion of viscera through the incisional areaE |
| Granulation Tissue | New tissue, pink-red in color, composed of fibroblasts and small blood vessels that fill an open wound when it starts to heal |
| Wound | Disruption of the normal integrity of the skin |
| Epithelialization | natural act of healing of dermal and epidermal tissue in which a protective membrane forms over a wound |
| Transparent Film | type of dressing often used over intravenous sites, subclavian catheter insertion sites and noninfected healing wounds |
| Gauze dressings | special gauze that covers the incision line and allows drainage to pass through and be absorbed by the center absorbent layer |
| Primary Intention | Wounds are well approximated with skin edges noted to be tightly together with minimal tissue loss such as a surgical wound |
| Secondary intention | Edges are not well approximated. Wounds are open and require more tissue. Wounds like this are often contaminated |
| Tertiary Intention | Wounds that are left open for several days to allow edema or infection to resolve or fluid to drain and then are closed |
| Hemostasis of wound healing | Occurs immediately after the initial injury primarily to stop the bleeding and activate the white blood cells to fight any invading bacteria |
| The inflammatory phase of wound healing | Leukocytes move to the wound to ingest bacteria and cellular debris. About 24 hours after the injury macrophage move to the area and digest debris for an extended period. Growth factors are also released for growth of the epithelial cells and new blood vessels . The growth factors attract fibroblasts to help fill in the wound |
| Proliferation/Repair Phase | Lasts for several weeks. New tissue is built to fill in the w that stretches through the clotound space through the action of fibroblasts. Fibroblasts form fibrin. Granulation tissue forms the foundation for scar tissue development |
| Maturation/Remodeling phase | Begins 3 weeks after the injury. Collagen is remodeled making the healed wound stronger |
| What vitamins, minerals, and trace elements are needed for effective wound healing? | Vitamin A, Vitamin B, Vitamin C, Vitamin K, Zinc, Copper, Iron, Manganese |
| What are the local factors that can affect wound healing? | Pressure, desiccated, maceration, trauma, edema, infection, excessive bleeding, necrosis, bilfilm |
| What are systemic factors that prolong wound healing? | Age, circulation and oxygenation, nutritional status, wound etiology, medications and other therapies, immunosuppressive, proinflammatory conditions, treatment plan adherence |
| Assessment of > 3 signs/symptoms of wound infection indicating SUPERFICIAL critical colonization | Greater than 3 signs or symptoms of the following: Nonhealing wound Exudative wound Red and bleeding founder's in the wound Smell from the wound NERDS |
| Assessment of>3 signs/symptoms indicating wound infection | STONEES; Size is bigger Temperature increased OS Exposed bone New areas of breakdown Exudate Erethema Edema Smell |
| What wound complications increase the risk for generalized edema and death? | Infection, hemorrhage, dehissence and evisceration, fistula formation |
| List nursing strategies to address age related changes in wound healing | Maintain hydration with IV fluids as prescribed Maintain accurate I+O Use caution when removing tape Maintain adequate caloric intake Diet high in protein, VitA, Vitamin C, and trace elements (copper, zinc) Monitor labs (albumin, total protein) Hand hygiene Surgical sepsis with dressing changes Care of tubes and drains Report increased VS including temp Monitor wound for symptoms of infection Meds as ordered Oxygen as ordered |
| What is a pressure injury? | Localized damage to the skin and underlying tissue that occurs over a bony prominence or is related to the use of a device |
| What are the three mechanisms that contribute to pressure injury development? | 1. External pressure that compresses blood vessels 2. Friction and shearing forces that tear and injure blood vessels and abrade the top layer of skin 3.Microclimate of the skin related to temperature and moisture of the skin |
| What is friction? | Occurs when two substances rub together |
| What is shearing? | One layer of tissue slides over another layer |
| What is microclimate? | Temperature and humidity (moisture) of the skin that comes in contact with a support surface, such as a bed or device |
| List the four types of moisture-associated skin damage | 1. Incontinence associated dermatitis (chronic exposure to urine/stool 2.perspiration based dermatitis 3. Periwound moisture related skin damage due to exudate 4. Peristomal moisture related skin damage that occurs with osteomyelitis output |
| Pressure injury development risks include | Immobility Nutrition Hydration Mental Status Age |
| What is a warning sign of potential pressure injury development? | Blanching |
| Risk factors for pressure injury development include | Poor skin hygiene, diabetes mellitus, diminished sensory perception, fractures, history of corticosteroid therapy, general poor health, immobility secondary to paralysis or injury, Immumosuppression, urinary or fecal incontinence, increased body temperature, microvascular dysfunction, multiple organ system dysfunction syndrome, prior pressure injuries, poor nutrition and hydration, sedation, coma, significant obesity, thinness, smoking, surgery, terminal illness, end of life/dying process |
| What are common sites for development of pressure areas? | Occipital bones, scapula, vertebrae, sacrum, coccyx, calcaneous, frontal bone, mandible, humerus, sternum, tuberosity of pelvis, patella, tibia, ribs illicit crest, greater trocanter of femur, lateral knee, lateral mallelous, medial malleolus sole, ischium, posterior knee |
| This wound stage is evidenced by partial thickness loss of skin with exposed dermis. The wound bed is viable, pink, red, and moist and may present as an intact or ruptured fluid filled blister | Stage Ii pressure injury: partial thickness skin loss with exposed dermis |
| Intact skin with a localized area of non-blanchable erethema | Stage I pressure injury: Nonblanchable erethema of intact skin |
| Full thickness loss of skin: Stage III pressure injury | Full thickness loss of skin in which adipose is visible in the ulcer and granulated tissue and episode (rolled wound edges) are present |
| Full thickness skin and tissue loss with exposed or directly palpable fascia, muscle tendon, ligament, cartridge or bone | Stage IV pressure injury: Full thickness skin and tissue loss |
| Unstagable Pressure Injury | Full thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough and eschar |
Created by:
PRO Teacher
lygervase
Popular Nursing sets