Skin Integrity And Wound Care

Front 1

some interesting things about the skin

Back 1

slows down fluid loss
synthesis of vitamin d
a part of blood pressure regulation
excretes lactic acid

Front 2

review of skin

Back 2

epidermis
dermis-very vascular, separates the epidermis from cutaneous adipose tissue, collagen/elastin, sensory nerve fibers
hypodermis- provides insulation, sweat glands

Front 3

history of present illness with skin

Back 3

recent changes
LOCSTAAM
recent exposures
travel history
new meds

Front 4

History of Present Illness for Hair and Nails

Back 4

includes recent changes
LOCSTAAM
nutrition
recent exposures
meds

Front 5

What to consider in Past Medical History for Skin, Hair, Nails

Back 5

any systemic problems,

any problems specific to skin hair, nails

Front 6

family history to consider for skin, hair, nails

Back 6

skin cancers, psoriasis, allergies, infestations

Front 7

Personal and Social History of skin, hair nails

Back 7

self-care habits
exposure to environmental/occupational stress
alcohol/street drug use

Front 8

pallor

Back 8

paleness

Front 9

alopecia

Back 9

loss of hair

Front 10

exudate

Back 10

purulent drainage

Front 11

what is part of palpation assessment of the skin

Back 11

moisture
temperature
texture
turgor
mobility

Front 12

Macule

Back 12

primary skin lesion

flat unelevated patch, 1mm to 1 cm
freckles

Front 13

Papule

Back 13

circumscribed, solid elevation of the skin

Front 14

patch

Back 14

larger than a macule, larger than 1 cm

cafe au lait spot

Front 15

plaque

Back 15

solid raised thing, greater than 1 cm, example is psoriasis

Front 16

wheal

Back 16

reddened, localized collection of edema fluid, irregular in shape, size varies

Front 17

Nodule, Tumor

Back 17

elevated hard mass, tumors are larger than nodule

Front 18

Vesicle

Back 18

circumscribed thin, translucent mass, filled with serous fluid or blood

examples, herpes, chicken pox

Front 19

Bulla

Back 19

larger than a vesicle, like a big blister

Front 20

Pustule

Back 20

vesicle or bulla filled with pus

Front 21

cyst

Back 21

larger and encapsulated fluid filled semi-solid mass

Front 22

scales

Back 22

shedding flakes of greasy, keratinized tissue

dandruff, eczema, psoriasis

Front 23

lichenification

Back 23

rough thickened, hardened epidermis resulting from chronic irritation or rubbing

Front 24

keloid

Back 24

elevated darkened area of scar tissue caused by excessive collagen formation during healing

Front 25

scar

Back 25

FLAT (unlike keloid), irregular connective tissue left after a lesion or wound. New scars may be red or purple, older scars may be silvery or white

Front 26

excoriation

Back 26

linear erosion ie scratches

Front 27

fissure

Back 27

linear crack extending into the dermis

ie cracks at the corner of the mouth

Front 28

erosion

Back 28

wearing away of the superfical epidermis causing a moist, shallow depression. Heal without scarring, scratch marks, ruptured vesicles

Front 29

ulcer

Back 29

deep, irregularly shaped area of skin loss extending into the dermis or subcutaneous tissue, may bleed/scar

ie pressure ulcers, chancres

Front 30

crust

Back 30

dry blood, serum, or pus left on the skin surface when vesicles or pustules burst

Front 31

atrophy

Back 31

translutcent, dry, paerlike sometimes wrinkled skin sruface from thinning or wasting of the skin due to loss of collagen and elastin

examples include aged skin

Front 32

ABCDE's of cancerous moles

Back 32

A-assymetry
B-border (irregular)
C-color (uneven)
D-diammeter (greater than 6mm)
E-elevation or evolving

Front 33

Pathogenesis of Pressure Ulcers

Back 33

pressure intensity leads to tissue ischemia

pressure duration is low pressure over prolonged period or intense pressure over short period

tissue tolerance affected by shear, frictin, moisture, pressure points

Front 34

Tissue ischemia

Back 34

lack of ciruclation, tissue hypoxia

if reddened area blanches that's a good sign. if you press down and color returns their is a decreased probability of tissue damage. this is called blanchable erythema

Front 35

risk factors for pressure ulcer development

Back 35

-impaired sensory perception
-ALOC
-impaired mobility
-shear force: a combination of friction and pressure, occurs when a client assumes a sitting position in bed and ct tends to slide down
friction: force acting parallel to the skin
inadequate nutrition
moisture (often from incontinence)

Front 36

maceration

Back 36

tissue softened by prolonged wetting or soaking

Front 37

Stage 1 Pressure Ulcer

Back 37

no open areas, but persisten purple or red or blue areas of skin

Front 38

Stage 2 Pressure Ulcer

Back 38

Partial thickness skin loss, looks like blister

Front 39

Stage 3 Pressure Ulcer

Back 39

Full thickness skin loss. Damage and or necrosis of subcut tissue. Deep crater

Front 40

Stage 4 Pressure Ulcer

Back 40

Can see muscle or other structures

Front 41

Purpose of the Norton and Braden Scale

Back 41

Use to Assess Risk of Pressure Ulcers

Front 42

Granulation tissue

Back 42

new tissue, young, fragile cells

Front 43

SLough

Back 43

stringy stuff attached to wound bed

Front 44

eschar

Back 44

black necrotic tissue that must be removed for healing

Front 45

exudate

Back 45

note color, amount and consistency

Front 46

determinants of skin integrity

Back 46

open, closed, acute, chronic

Front 47

cleanliness factors of a wound

Back 47

clean, clean-contaminated, contaminated, infected, colonized (when strains become resident flora)

Front 48

process of wound healing

Back 48

primary intenetion-clean surgical edges, primary union
secondary intention, tissue loss, gaping, irregular wound, epithelium heals over scar
tertiary intention-delayed closure, wide scar heales from base of wound out

Front 49

Partial thickness wound repair

Back 49

Shallow, loss of top layer of epidermis and some dermis, healing starts at wound edges, with moisture heals within 4 hours, the tissue is dry and pink

Front 50

Full thickness

Back 50

extends dep into dermis, forms a fibirn matric, wound fills will granulation tissue, epithelialization,woudnd fills will replacement tissue, wound continues to lay down collagen for up toa year

Front 51

Complications of wound healing

Back 51

-Hermmorrhage/shock
Infection
Dehiscence
Evisceration
Fistula formation-passage between two organs or body cavities

Front 52

Factors influencing wounds

Back 52

Nutrition (Anemia, zinc deficiency, hypoproteinemia)
Tissue Perfusion
Infection
Age

Front 53

Assessment of Traumatic Wounds

Back 53

note appearance, amount of bleeding, debris, size, shape, penetrating or superficial

Front 54

nursing diagnosis for wound

Back 54

risk for infection
imbalance nutrition
pain
impaired skin integrity
impaired tissue integrity

Front 55

first aid for wounds

Back 55

hemostatis
clean wound
apply topical med like bacteriocidal
protection

Front 56

wound management

Back 56

prevent and manage
cleanse the wound
debride
mange exudate
protect
education
nutrition