Fundamentals Exam 4 Skin

Front 1

Largest Organ in the body

Back 1

Skin

Front 2

Integumentary system is made up of...

Back 2

skin
subcutaneous layer directly under the skin
appendages of the skin (hair and nails)

Front 3

Body's first line of defense..

Back 3

Skin

Front 4

Epidermis

Back 4

top layer of the skin

Front 5

Dermis

Back 5

second layer of the skin

Front 6

Functions of the skin

Back 6

Protection
Temperature
regulation
sensation
Vitamin D production
absorption
elimination

Front 7

Mucous Membranes

Back 7

Line body cavities that open to the outside of the body, joining with the skin.
Also found in the GI tract, respiratory passages and the GU tracts.

Front 8

Epithelium

Back 8

covers the mucus membrane surfaces and contains cells that secrete mucus.

Front 9

Wound

Back 9

any break in the external or internal surfaces of the body involving a separation of tissue, and caused by external injury or force.

Front 10

Wounds are classified as....

Back 10

Intentional and unintentional
open vs. closed
acute vs. chronic
mechanism of injury
Depth

Front 11

Intentional wound

Back 11

the result of a planned, invasive therapy.

Front 12

Example of an intentional wound...

Back 12

Surgery
IV therapy

Front 13

Unintentional wound

Back 13

accidental wound

Front 14

example of unintentional wounds

Back 14

trauma, burns or injury

Front 15

Intentional wounds are...

Back 15

clean wound edges
controlled bleeding
clean

Front 16

Unintentional wounds are....

Back 16

likely contaminated
jagged wound edges
uncontrolled bleeding

Front 17

Septic or infected wounds

Back 17

are those in which the area is contaminated by bacteria, which can cause suppuration or shedding of tissue.

Front 18

Open wound...

Back 18

can be intentional and unintentional
portal entry for bugs
bleeding, tissue damage, delayed healing

Front 19

Closed wound..

Back 19

Results from a blow, force or strain
Surface not broken
Soft tissue damage, internal injury or hemmorhage may occur

Front 20

Mechanism of Injury for wounds...

Back 20

Incision
Contusion
Abrasion
Laceration
Penetrating wound
Puncture

Front 21

Incision

Back 21

open wound, painful.
deep and shallow

Front 22

contusion

Back 22

closed wound
Involves blow from a blunt object resulting in swelling, discoloration, and ecchymosis (bruising)

Front 23

Abrasion

Back 23

Open wound involving the skin.
Painful
Involves scrapping or rubbing of the skin by friction

Front 24

Puncture

Back 24

open wound which penetrates the skin and underlying tissue.

Front 25

Laceration

Back 25

made by object that tears tissue resulting in irregular wound edges.

Front 26

penetrating wound

Back 26

open wound that penetrates the skin and underlying tissue.

Front 27

Depth of wounds..

Back 27

Partial thickness
Full thickness

Front 28

partial thickness of a wound...

Back 28

confined to epidermal and dermal layers

Front 29

full thickness of a wound...

Back 29

Involving the dermis, epidermis, subcut. tissue and possibly muscle and bone

Front 30

Clean wound

Back 30

an aseptically made wound that does not enter the alimentary, respiratory or genito-urinary tracts.

Front 31

Clean contaminated wound

Back 31

are surgical wounds in which the alimentary, respiratory and genitals or urinary tract has been entered and have no active infection.

Front 32

Contaminated wound

Back 32

wounds exposed to excessive amounts of bacteria, inflamed.

Front 33

Dirty or infected wound

Back 33

wounds containing dead tissue and with evidence of clinical infection. (purulent discharged)

Front 34

Serous wound

Back 34

clear, watery; consists chiefly of serum derived from blood and serous membranes.

Front 35

Purulent wound

Back 35

thick yellow, green, tan, or brown; consists of serum and pus.

Front 36

Pus

Back 36

leukocytes, liquefied living and dead bacteria, dead tissue debris

Front 37

Sanguineous wound

Back 37

bright red, indicative of active bleeding, consists of serum and red blood cells.

Front 38

Serosanguineous wound

Back 38

pale, red, watery mixture of serous and sanguineous. More serum than blood.

Front 39

Phases of wound healing (4)

Back 39

Hemostasis
Inflammatory
Proliferative
Remodeling or Maturation Phase

Front 40

Hemostatis

Back 40

blood vessels constrict, platelets aggregate and bleeding stops, scab forms, preventing entry of infectious organisms.

Front 41

Inflammatory Phase

Back 41

starts immediately after injury and lasts 3-6 days or 4-6 days.
Includes Hemostatsis and Phagocytosis

Front 42

Inflammation

Back 42

increase blood flow to wound resulting localized redness and edema, attracts WBC and wound growth factors. Results in calor (warmth) and rubor (hyperemia)
WBC's arrive--clear debris from wound

Front 43

Proliferative phase

Back 43

extends from day 3 to about day 21 post injury.
-->collagen synthesis-->establishment of new capillaries-->creation of granulation tissue-->wound contraction-->epitheliazation.

Front 44

Remodeling or Maturation Phase

Back 44

Begins after 21 days post injury
Final healing stage may continue for 1 year or more.
Remodeling of scar tissue to provide wound strength.

Front 45

Types of wound healing (2)

Back 45

First intention healing
Second intention healing

Front 46

First/Primary Intention Healing

Back 46

Partial thickness wounds
A clean incision is made with primary closure and minimal scarring and tissue loss.
Expected when the edges of clean surgical incisions are sutured together.
Rapid healing with minimal infection risk.
Tissue loss is minimal or absent if the wound is not contaminated with microorganisms. (skin tear or abrasion)

Front 47

Second Intention Healing

Back 47

Granulation (new tissue)
Accompanies traumatic open wounds with tissue loss or wounds with high microorganism counts.
Goes through a process involving scar tissue formation.
Delayed healing and extensive infection risk.
Heals slowly d/t volume of tissue needed to fill the defect. (contaminated surgical wound, pressure ulcer)

Front 48

Factors affecting wound healing:

Back 48

Developmental considerations (healthy children and adults--first to heal)
Nutrition (protein-test serum protein)
Lifestyle
Medications (steroids)
Contamination and Infection

Front 49

Factors Affecting Skin Integrity...

Back 49

Excess Diaphoresis
Jaundice
Skin disease
CIRCULATION
underlying tissue
Age

Front 50

Local factors that affect wound healing...

Back 50

Pressure
Dessication (dehydration)
Maceration (over-hydrated)
Necrosis (death of tissue)
Trauma
Edema

Front 51

Complications of wound healing..

Back 51

Bleeding
Infection
Dehiscence
Eviseration
Fistula
Pain, anxiety and fear
Changes in body image

Front 52

Bleeding with wound healing..

Back 52

RISK OF HEMORRHAGE IS GREATEST.....DURING THE FIRST 48 HOURS AFTER SURGERY.
Persistent arterial and or venous bleeding.
Emergent Bleeding-apply pressure dressing to wound and monitor vital.
**vital signs are a must when pt. is bleeding**

Front 53

S/S of bleeding

Back 53

decreased BP
Rapid, thready pulse
Restlessness
Diaphoresis
Clammy, pale skin (no circulation)
Oliguria (decrease urine output)

Front 54

Oliguria

Back 54

decrease urine output

Front 55

CULTURE WOUND BEFORE YOU GIVE ANTIBIOTICS...

Back 55

TO KNOW WHAT ORGANISM WE ARE GOING TO TREAT.

Front 56

S/S of infection

Back 56

increased temperature
tenderness/pain around wound site.
Increased WBC's
Inflamed wound edges.
Purulant drainage

Front 57

Dehiscence with possible evisceration

Back 57

may occur 4-5 days post op
Layers below the skin separates/protrusion of viscera
If happens..quickly support the site with a sterile dressing soaked in sterile normal saline.
Position the pt. with knees bent to decrease the pull on the incision.
Notify the MD

Front 58

S/S of Dehiscence

Back 58

Partially or totally disrupted wound edges.
Increase in wound drainage
Sensation that "something gave."

Front 59

S/S of evisceration

Back 59

totally open wound edges
increase in wound drainage
Sensation that something "let go."
Protrusion of viscera and or organs through ruptured wound.
Medical Emergency!!!!

Front 60

Fistula

Back 60

Abnormal passage between 2 organs or between an organ and the outside of the body.

Front 61

S/S of Fistula

Back 61

Chronic drainage
Skin breakdown
--If fistula opens to the skin, and the drainage is gastric or intestinal in nature, it contains digestive enzymes.

Front 62

Wound assessment parameters

Back 62

etiology
loc. of the wound
stage of wound/extent of tissue lost
phase of healing
wound size
presence of undermining, sinus tracts or tunnels
condition of the wound bed
condition of the periwound skin
volume of exudates
presence of pain

Front 63

Pressure Ulcer

Back 63

wound with a localized area of tissue necrosis.
Are costly!!
60% develop in hospitalized pts.

Front 64

Risk Factors for Decubitus Ulcers

Back 64

Immobility
Malnutrition
Incontinence
Persistent pressure on bony prominences
Decreased mental status
Diminished sensation
Advanced age

Front 65

Braden Scale

Back 65

predicts pressure ulcer risk

Front 66

Mechanisms that contribute to pressure ulcer development

Back 66

External pressure that compresses blood vessels.
Friction and shearing forces that tear and injure blood vessels and abrade the top layer of the skin
Ischemia

Front 67

friction

Back 67

occurs when 2 surfaces rub against each other

Front 68

Causes of friction

Back 68

wrinkled sheets
pts. using arms and feet to help with moving up in the bed
when the patient is pulled up in the bed over the sheet (use a draw sheet)

Front 69

Shearing force

Back 69

results when one layer of tissue slides over another layer, separating the skin from underlying tissue.

Front 70

Causes of shearing

Back 70

When the skin sticks to the sheet as the pt. slides down in a chair or bed.
When the pt. is pulled up in the bed over the sheet rather than lifted.

Front 71

Stage I pressure ulcer

Back 71

area of persistent redness in lightly pigmented skin and a red, blue or purple hue in darker pigmented skins

Front 72

Stage II pressure ulcer

Back 72

partial thickness skin loss involving epidermis and or dermis. The ulcer is superficial and presents clinically as an abrasion, blister or shallow crater.

Front 73

Stage III pressure Ulcer

Back 73

Full thickness skin loss involving damage or necrosis of subcut. tissue that may extend down to, but not through, underlying fascia. Requires debridement.

Front 74

Stage IV pressure ulcer

Back 74

Full thickness skin loss with existence destruction, tissue necrosis, or damage to muscle, bone or supporting structures. Sinus tracts may also be associated with Stage IV ulcers.

Front 75

preventing pressure ulcers

Back 75

turn atleast every 2 hours
hygiene and skin care
positioning devices (pillows)
trapeze or bed linen for transfers
special support surfaces.

Front 76

Treating Pressure Ulcers

Back 76

Wound cleansing-whirlpool, irrigation
USE NORMAL SALINE ONLY
provide moist environment to promote re-epithelizaion and healing.
good nutrition (approx. 1.5 grams protein per kg of body wt.)

Front 77

Debridement

Back 77

to remove nonviable tissue

Front 78

Dressings

Back 78

material applied to wound with or without medication to give protection and assist in healing

Front 79

Purpose of dressings

Back 79

to protect the wound from mechanical injury.
To absorb secretions
To prevent contamination from bloody drainage.
To promote Homeostasis
To debride wounds

Front 80

Types of dressings

Back 80

Wet to dry
Dry to dry
Wet to Wet

Front 81

Dry to Dry dressing

Back 81

used primarily for wounds closing by primary intention.
Advantages:
--Offers good protection, absorption, and provides pressure.
Disadvantages:
--Adhere to wound surface

Front 82

Wet to Dry Dressing

Back 82

Used for untidy or infected wounds that must be debrided and closed by secondary intention.
Saturate gauze with sterile NS or an antimicrobial solution for packing the wound.
Cover wet dressings with dry.
Change when dressing dries out.

Front 83

Wet to Wet dressing

Back 83

used on clean, open wounds or on granulating surfaces.
Provides warmth and moisture, which can enhance the local healing processes and assure greater pt. comfort.
Surrounding tissues can be ulcerated
High risk for infection.

Front 84

Drains

Back 84

device or tube used to draw fluids from an internal body cavity to the surface.
Ex...Hemovac, jackson-pratt,penrose drains and t-tube,

Front 85

Binders and Bandages

Back 85

create pressure over body parts.
Immobilize body parts.
Reduce or prevent edema.
secure a splint.
secure a dressing.

Front 86

INFLAMED AND TENDER WOUNDS WITH EVIDENCE OF DRAINAGE AND FOUL ODOR....

Back 86

Monitor for other signs of infection.
--fever
--Elevated WBC count,
Notify MD
Pain control

Front 87

Increased wound drainage...

Back 87

change dressing frequently.
Notify MD
Be aware that wounds bleed more during dressing changes.

Front 88

Hot Therapy

Back 88

Local heat dilates...
Increases...local blood flow, a long with O2 and nutrients

Front 89

Cold therapy

Back 89

Constrict peripheral
Reduces....blood flow to the tissues.