Skin Integrity And Wound Healing

Front 1

A type of acute wound created intentionally as part of surgical treatment

Back 1

Incision

Front 2

Body response to an acute or chronic wound through this complex restorative process called?

Back 2

Wound healing

Front 3

Avascular, skin outer layer. It specialized in forming hair, nails, and glandular structures?

Back 3

Epidermis

Front 4

What is the thin, outermost layer of the epidermis (stratum corn run or horny layer) is CONTINUOUSLY SHEDDING?

Back 4

Desquamation

Front 5

What is vascular, thickest skin layer and contains lymphatic vessels and nerve tissues?

Back 5

Dermis

Front 6

This is a major cell of the dermis that produces proteins collagen and elastin?

Back 6

Fibroblast

Front 7

What tissue consist of primarily of fat and connective tissues that support the skin?

Back 7

Subcutaneous tissue

Front 8

A wound that involves loss of epidermis and possibly partial loss of the dermis?

Back 8

Partial-thickness wound

Front 9

A wound that extends through the dermis to involve subcutaneous tissue and possibly muscle and bone?

Back 9

Full-thickness wound

Front 10

What is the enfolding of the epidermis into underlying dermis (hair, nails, eccrine sweat glands, apocrine sweat glands, and sebaceous glands)

Back 10

Skin appendages

Front 11

What are widely distributed throughout the skin and help transport sweat to outer skin surface?

Back 11

Eccrine glands

Front 12

What are found primarily in the axilla and genital area? (Body odor)

Back 12

Apocrine sweat glands

Front 13

What is found in the greatest concentration over the head and upper chest and SECRETES SEBUM, which lubricates the skin's outer layer?

Back 13

Sebaceous glands

Front 14

What gives the skin an acidic pH, which retards the growth of microorganism?

Back 14

Sebum

Front 15

What inhibits the growth of pathogens that are present on the skin?

Back 15

Staphylococcus, streptococcus, yeast

Front 16

What helps the skin regulate body temperature and adjust to external temperature changes??

Back 16

Dilation and constriction of blood vessels in the dermis

Front 17

What produces shivering to help body maintain its temperature in cool environment?

Back 17

Vasoconstriction

Front 18

What are the characteristics of normal skin?

Back 18

Temp-warm
moisture-dry to touch
texture and thickness-smooth
Odor-free of odor

Front 19

What are horny, slow growing proliferation of the keratinizing cells of the epidermis? May itch and bleed if traumatized.

Back 19

Kerotoses

Front 20

What are some changes in older adult skin ?

Back 20

Sebaceous and sweat glands are less active=dry skin

Loss of elastin fibers and collagen changes=Wrinkling and poor skin turgor

Circulation is reduced, healing is slower=nails thicker, more brittle

Dry, scaling skin=Pruritus

Front 21

What are senile lentigines?

Back 21

Age or liver spots, pigmentation changes that occur on sun-exposed areas

Front 22

4 factors that required to have adequate skin perfusion? Alteration in any factors can lead skin to be ulcerated.

Back 22

1) heart must pump ADEQUATELY
2) volume of circulating blood must be SUFFICIENT
3) arteries and veins must be PATENT and FUNCTIONING well.
4)local capillary pressure must be HIGHER than external pressure

Front 23

What can produce ulceration that are refractory to healing?

Back 23

Impaired arterial or venous function in LOWER EXTREMITIES

Front 24

An inflammation of the skin, accompanied by pain, itching, redness, and blisters?

Back 24

Dermatitis

Chronic-thickening, scaling, and increased pigmentation

TREATMENT-eliminate exposure to allergen, topical meds

Front 25

What are chemical and mechanical irritants? (Allergy)

Back 25

Mechanical-rubbing against irritant (wool)

Chemical-skin creams, detergent, latex gloves, poison ivy

Front 26

A non malignant, chronic disorder that greatly increases the rate of skin production?

Back 26

Psoriasis
Can be triggered by stress, infection, or environmental factors
Common sites-elbows, knees, scalps, and soles

Front 27

An injury to the skin from friction of the skin rubbing against a hard surface can result in?

Back 27

Abrasion
Falls onto hands, elbows, or knees=most common

Front 28

An open wound or cut affecting only the upper layer or subcutaneous tissue underneath known as?

Back 28

Laceration

Front 29

Penetration of the skin or underlying tissue from a sharp or pointed object known as? The disadvantages if this type of wound is that the underlying structure may sustain?

Back 29

Puncture
gross contamination with debris and pathogens
Common causes: nails, pins, tacks

Front 30

What is superficial, pinkish or red with no blistering; mild sunburn?

Back 30

Partial thickness burn (1st degree)

Front 31

What type of burn that appears pink, red, pale, ivory, or light yellow-brown that are usually moist with blisters? (Ex. Exposure to steam)

Back 31

Moderate to deep partial-thickness burns (2nd degree)

Front 32

What burn may vary from brown or black to cherry red or pearly white? Appears dry and leathery, Bullae or blisters may be present

Back 32

Full-thickness burn (3rd degree)

Front 33

What are caused by contact with various heat sources, including flames, hot liquids, hot surfaces, an steam?

Back 33

Thermal burns

Front 34

What is it when the skin rubs together against a firm surface, such as wrinkled bedding, small abrasion may occur, increasing possibility of ulcer formation?

Back 34

Fricion

Front 35

Injury as a result of sliding down the bed, causing the underlying tissue to torn?

Back 35

Shear

Front 36

Injury, such as knife, gunshot, burn, or surgical incision; heals within 6 months?

Back 36

Acute

Front 37

A wound that persists beyond usual healing time or recuts without new injury in the area?

Back 37

Chronic

Front 38

A break in the skin, tissue damage present?

Back 38

Open wound

Front 39

When there is no break seen in the skin, but soft tissue damage evident?

Back 39

Closed wound

Front 40

A closed wound; bleeding in underlying tissues from blunt blow; bruising?

Back 40

Contusion

Front 41

A wound that entered the gastrointestinal, respiratory, or genitourinary systems; infection risk?

Back 41

Clean/contaminated

Front 42

An open, traumatic wound; surgical wound with a break in asepsis; high infection risk?

Back 42

Contaminated

Front 43

A wound site with pathogens present; signs of infections?

Back 43

Infected wound

Front 44

What extrinsic factors that decrease tissue tolerance and increase the likelihood of pressure ulcer development?

Back 44

Moisture, friction, and shearing force
(Other contributing factors: malnutrition, age, and low arteriolar pressure)

Front 45

A pressure ulcer that is intact with nonblanchable that involves persistent redness to a defined area in light skin client's and a persistent discoloration of red, blue or purple in dark skin client's describes?

Back 45

Stage 1 ulcer

Front 46

A superficial ulcer that manifest as an abrasion, shallow crater or blister, without slough, shiny or dry shallow?

Back 46

Stage II Ulcer

Front 47

Full thickness skin loss involving damage or loss of subcutaneous tissue that may extended down to, but not throughout, underlying fascia describes? May include tunneling and undermining but not bone or tendon exposed

Back 47

Stage III Ulcer

Front 48

A full thickness skin loss with extensive tissue damage causing necrosis and destruction to muscle, bone or supporting structures describes? Exposed skin and palpable

Back 48

Stage IV ulcer

Front 49

A full thickness ulcer that is covered by slough?

Back 49

Unstageable

Front 50

Many conditions, such as excessive heat, communicable disease, allergy, or emotional distress can cause?

Back 50

Rash, general term for temporary skin eruption
Macular rash-level with skin surface
Papular rash-solid elevation above skin surface. Generalized rash-covers most of body areas Localized rash-limited to specific areas

Front 51

A loss of structure or function of normal tissues? (Ex. Scales, crusts, and fissures)

Back 51

Lesions, describe by their shape, arrangements, and distribution

Front 52

The four phases of wound healing?

Back 52

1)hemostasis- begin at moment of injury (12-24 m)

Front 53

The four phases of wound healing?

Back 53

1)hemostasis- begin at moment of injury (12-24 months)

Front 54

The four phases of wound healing?

Back 54

1)hemostasis- begin at moment of injury, onset vasoconstriction, platelets aggregation, and clot formation 2) inflammation phase-vasodilation and phagocytosis (clean wound). 3)proliferation phase. 4)maturation-# fibroblast decreases, collagen synthesis stabilizes (3 wks to 2 yrs)

Front 55

The four phases of wound healing?

Back 55

1)hemostasis- begin at moment of injury, onset vasoconstriction, platelets aggregation, and clot formation 2) inflammation phase-vasodilation and phagocytosis (clean wound). 3)proliferation phase. (4 days to 21 days) 4)maturation-# fibroblast decreases, collagen synthesis stabilizes (3 wks to 2 yrs)

Front 56

A total or partial disruption in wound edges? May occur if suture or staples removed before wound is healed adequately.

Back 56

Dehiscense

Front 57

Who are at risk for dehiscence?

Back 57

Obesity, poor nutritional status, and increased stees

Front 58

What should you do if the dehiscence occur?

Back 58

Notified physician, protect open wound with saline moistened dressing until wound treatment plan based on wound assessment is developed

Front 59

A protrusion of viscera(organ) through the wound opening?

Back 59

Evisceration

Front 60

What is the difference in proliferation phase in partial and full thickness wound??

Back 60

In partial thickness wound, proliferation phase, epidermal cells, appears pink, reproduce and migrate across the surface of the wound in process called (epithelialization)
In full-thickness wound, the proliferation phase begins with development of granulation tissue, appears beefy, red, and granular and consist of matrix of collagens embedded with macrophages, fibroblast, capillary buds.

Front 61

A wound with minimal tissue loss, clean surgical incision, edges approximated, granulation tissue not visible, scarring is minimal?

Back 61

Primary intention wound healing

Front 62

A wound with full- thickness tissue loss, such as deep laceration, burns, and pressure ulcers, open wound filled with granulation tissue. Scarring is more prevalent. This is??

Back 62

Secondary intention (contracture and epithelialization)

Front 63

This wound is deep, not sutured immediately, a delay ensues between injury and wound closure?

Back 63

Tertiary intention (delayed closure)

Front 64

What happens when you have protein deficiency and you undergo surgery?

Back 64

You are more susceptible to experience infections because of the decreased leukocyte functions

Front 65

What systemic factors cause delay in wound healing?

Back 65

Nutrition (protein deficiencies), circulation, oxygenation(decreased arterial oxygen tension and hemoglobin levels), and immune cellular function(corticosteroid)

Front 66

What individual factors delay wound healing?

Back 66

Age
obesity
smoking-(tissue oxygenation impaired, formation thrombi-block small vessel)
medication-(decrease thrombi formation=bleeding into wound)
stress-(release catecholamines-cause vasoconstriction= decrease blood flow)

Front 67

When a patient with large drainage wounds or loss of large amount of skin the nurse should?

Back 67

Monitor the fluid balance, with appropriate fluid replacement as indicated. (Electrolyte rich fluid lost in burns and large open wounds)

Front 68

A swelling or mass underneath the skin surface, often bluish?

Back 68

Hematoma, if large: May require evacuation or surgical removal to promote optimal wound healing