Wound Care

Front 1

What layer is the epidermis?

Back 1

the top layer

Front 2

What is stratum corneum?

Back 2

the thin, outermost layer of the epidermis.

Front 3

What does the stratum corneum consist of?

Back 3

flattened, dead, keratinized cells

Front 4

What is the basal layer?

Back 4

the cells originate from the innermost epidermal layer

Front 5

What do the cells in the basal layer do?

Back 5

divide, proliferate, and migrate toward the epidermal surface.

Front 6

What happens after cells reach the stratum corneum?

Back 6

they flatten and die

Front 7

The constant movement of cells ensure what?

Back 7

replacement of surface cells sloughed during normal desquamation

Front 8

The dermis is what layer?

Back 8

inner layer

Front 9

What does the dermis do for the skin?

Back 9

provides tensile strength, mechanical support, and protection to the underlying muscles, bones, and organs.

Front 10

What is collagen?

Back 10

a tough, fibrous protein

Front 11

What is found in the dermal layer?

Back 11

collagen, blood vessels and nerves

Front 12

What is responsible for collagen formation?

Back 12

fibroblasts

Front 13

What is the only distinctive cell type within the dermis?

Back 13

fibroblast

Front 14

What protects the client from chemical and mechanical injury?

Back 14

Intact skin

Front 15

When the skin is injured, the ___ functions to resurface the wound and restore the barrier against invading organisms.

Back 15

epidermis

Front 16

When the skin is injured, the ___ responds to restore the structural integrity (collagen) and the physical properties of the skin

Back 16

dermis

Front 17

What can alter the skin characteristics and make skin more vulnerable to damage?

Back 17

age

Front 18

What terms are used to describe impaired skin integrity related to unrelieved, prolonged pressure?

Back 18

pressure ulcer, pressure sore, decubitus ulcer, and bedsores

Front 19

What is a pressure ulcer?

Back 19

is defined as localized areas of tissue necrosis that develop when soft tissue is compressed between a bony prominence and an external surface for a prolonged period of time

Front 20

Any resident experience what can be at risk for pressure ulcer development?

Back 20

decreased mobility, decreased sensory perception, fecal or urinary incontinence and/or poor nutrition

Front 21

Tissues recieve ___ and ___ and eliminate metabloic wastes via the ___?

Back 21

oxygen; nutrients; blood

Front 22

What happens when prolonged, intense pressure affects cellular metabolism by decreasing or obliterating blood flow?

Back 22

tissue ischemia and ultimately tissue death

Front 23

Three pressure related factors contribute to pressure ulcer development

Back 23

(1) pressure intensity; (2) pressure duration; and (3) tissue tolerance

Front 24

What causes an older adult skin to be easily torn?

Back 24

reduced skin elasticity, decreased collagen, and thinning of underlying muscle and tissues

Front 25

In an older adult, what two factors may interfere with wound healing?

Back 25

concomitant medical conditions and polypharmacy

Front 26

Older clients have little ___ padding over bony prominences, so they are prone to skin breakdown and heatstroke

Back 26

subcutaneous

Front 27

Reduced ___ intake increases risk for pressure ulcer development and impaired wound healing

Back 27

nutritional

Front 28

Serous

Back 28

clear, watery plasma

Front 29

purulent

Back 29

thick, yellow, green, tan or brown

Front 30

serosanguineous

Back 30

pale, red, watery: mixture of clear and red fluid

Front 31

sanguineous

Back 31

bright red: indicates active bleeding

Front 32

Risk for skin breakdown from body fluids: Low risk

Back 32

saliva; serosangineous drainage

Front 33

Risk for skin breakdown from body fluids: Moderate risk

Back 33

bile; stool; urine; ascetic fluid; purulent exudate

Front 34

Risk for skin breakdown from body fluids: High risk

Back 34

gastric drainage; pancreatic drainage

Front 35

When is blanching seen?

Back 35

when the normal red tones of the light-skinned client are absent.

Front 36

There are two considerations with regard to the duration of pressure.

Back 36

Low pressures over a prolonged time period can cause tissue damage. High-intensity pressure over a short period of time

Front 37

Clinical implications of pressure duration include what?

Back 37

evaluating the amount of pressure (checking skin for reactive hyperemia) and determining the amount of time that a client can tolerate pressure (checking to be sure after relieving pressure that the affected area blanches).

Front 38

Darkly pigmented skin is defined how?

Back 38

skin that "remains unchanged (does not blanch) when pressure is applied over a bony prominence, irrespective of the client's race or ethnicity."

Front 39

Characteristics of Dark Skin at Risk for Skin Breakdown: Assessment Issues

Back 39

Natural or halogen light source best for assessing skin; Fluorescent light source, to be avoided, because it casts a bluish hue, making accurate assessment difficult

Front 40

Characteristics of Dark Skin at Risk for Skin Breakdown: Color

Back 40

Appears darker than surrounding skin; May have purplish/bluish hue

Front 41

Characteristics of Dark Skin at Risk for Skin Breakdown: Temperature

Back 41

Initial warmth when compared with surrounding skin; Later coolness as tissue is devitalized

Front 42

Characteristics of Dark Skin at Risk for Skin Breakdown: Touch

Back 42

Indurated; Edema; Soft, boggy

Front 43

Characteristics of Dark Skin at Risk for Skin Breakdown: Appearance

Back 43

Taut; Shiny; Scaly

Front 44

The ability of tissue to endure pressure depends on what?

Back 44

the integrity of the tissue and the supporting structures

Front 45

The extrinsic factors of shear, friction, and moisture affect the ability of the skin to tolerate pressure:

Back 45

the greater degree to which the factors of shear, friction, and moisture are present, the more susceptible the skin will be to damage from pressure.

Front 46

The second factor related to tissue tlerance pertains to what?

Back 46

the ability of the underlying skin structures (blood vessels, collagen) to assist in redistributing pressure

Front 47

Systemic factors of tissue tolerance

Back 47

poor nutrition, increased aging, and low blood pressure

Front 48

Risk factors for pressure ucler development

Back 48

factors can be directly related to disease, such as decreased level of consciousness, related to the aftereffects of trauma, the presence of a cast, or secondary to an illness, such as decreased sensory input following a cerebrovascular

Front 49

Friction

Back 49

the mechanical force exerted when skin is dragged across a coarse surface such as bed linens

Front 50

Shear

Back 50

the force exerted parallel to skin resulting from both gravity pushing down on the body and resistance between the client and a surface