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42 Cards in this Set

  • Front
  • Back
Skin assessments
intact
redness
itching or rashes
dry/flaky
smoothness
color
temperature
function of the skin
temperature maintenance
fluid balance
protection
first line defense againt microorganisms
wound healing: inflammatory phase
tissue injury stimulats the clotting cascade to form a clot
blood vessels constrict initially but then dilate which begins the swelling phase
wbc's then arrive to ingest bacteria and cellular debris
wound healing: proliferative phase
begins 2 to 3 days after the injury
granulation tissue: new tissue, foundation for scar development
this phase may take weeks depending on the size of the wound
Wound Healing: remodeling phase
final stage of healing
collagen is remodeled making the wound stronger and more like surrounding tissue
factors that affect wound heaing
age
circulation
nutritional status
condition of the wound
patient overall health
wound complications
infection
hemorrhage
dehiscence and evisceration
fistula formation
macule
flate, color change only
freckle, hypergpigmentation
papule
solid, elevated
mole, wart
vesicle
clear fluid filled
herpes, chicken pox, dermatitis
cyst
indermis or subq layer
subq cyst
nodule
solid, elevated, hard deeper that a papule
xanthoma, fibroma
wheal
raised, erythematous
mosquito bite, allergic reaction
pustule
turbid fluiud in cavity
impetigo, acne
serous: wound drainage
clear, watery drainage
sanguineous: wound drainage
red blood cells
serosanguineous: wound drainage
mix of serous and sanguineous
purulent: wound drainage
wbc's, debris, yellow or green, foul odor
Stage 1 Pressure ulcer
intact skin but redness does not go away after pressure release
Stage 2 Pressure ulcer
appears as an abrasin, blister or shallow crater
going into the dermis
Stage 3 Pressure Ulcer
damage extends down to subq tissue but not through fascia
State 4 Pressure Ulcer
damage may extend into muscle, bone, tendons and joints
Common sites for Pressure Ulcers
sacrum
coccyx
trochanter
calcaneous
Pressure Ulcer Prevention
turn q2hrs
pillows under the heels
encourage OOB and ambulation
keep their bottom dry
fissure
linear crack or break fro the epidermis to dermis, dry or moist
scale
excess, dead epidermal cells produced by abnormal keratinitaion and shedding
scar
abnormal formation of connective tissue that replaces normal skin
ulcer
loss of the epidermis and dermis, crater-like, irregular shape
atrophy
depression in skin resulting from thinning of the epidermis or dermis
excoriation
area in which epidermis is missing exposing the dermis
alopecia
loss of hair
angioma
tumor consisting of blood or lymph vessels
carotenemia
yellow discoloration of skin, no yellowing of sclerae, most noticeable on palms and soles
comedo
keratin, sebum microorganism, and epithelial debris withing a dilated follicular opening
hirsutism
male distribution of hair in women
intertrigo
dermatitis of overlying surfaces of the skin
hypertrophy
increase in the size of cells without cell division
hyperplasia
increase in the number of cells resulting from increased cellular division
atrophy
decrease in the size of tissue or organ caused by a decreased number of cells or reduction in the sie of the individual cell
metaplasia
reversible transformation of one cell type into another
dysplasia
abnormal differentation of dividing cells resulting in changes in the size, shape and appearance of the cells
anaplasia
cell differentiation to a more immature or embryonic form