Skin Integrity And Wound Healing Nursing Fundamentals Craven Ch 29

Front 1

The ______, the skin's outer layer, is avascular and composed of layers of striated squamous epithelial cells

Back 1

epidermis

Front 2

The thin outermost layer of the epidermis is continuously shed in a process called_______.

Back 2

desquamation

Front 3

The major cell of the epidermis is the keratinocytes, producing ______, the primary material in the shed layer cells.

Back 3

keratin

Front 4

The _____, which underlies the epidermis, is the thickest skin layer and is composed of tough connective tissue.

Back 4

dermis

Front 5

_______ _______ underlies the skin. It consists primarily of fat and connective tissue that support the skin.

Back 5

Subcutaneous tissue

Front 6

The _____ and_____ glands are sweat glands.

Back 6

eccrine and apocrine

Front 7

Normally, skin has good elasticity, rapidly returning to its normal shape when pinched between the thumb and forefinger, a quality called _____ _____.

Back 7

skin turgor

Front 8

Skin changes are part of normal aging. As skin ages, it generally becomes thinner because it loses dermal and subcutaneous mass. Sebaceous and sweat glands are less active, dry skin is more common.

Back 8

Wrinkling and poor skin turgor result from loss of elastic fibers and collagen changes in the dermal connective tissue.

Front 9

______(itching) commonly occurs in older adults and is caused mainly by dry, scaling skin.

Back 9

Pruritus

Front 10

________ are horny, slow-growing proliferations of the keratinizing cells of the epidermis.

Back 10

Keratoses-may itch and bleed if traumatized.

Front 11

_____ ______, also called age or liver spots are pigmentation changes that occur on sun-exposed areas.

Back 11

Senile lentigines

Front 12

Adequate skin perfusion requires four factors:

Back 12

1) The heart must be able to pump adequately.
2) The 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 13

Leg and foot ulcers occur from various causes, but the most common are ulcers secondary to _____ ______, arterial insufficiency, and neuropathy.

Back 13

venous insufficiency

Front 14

Venous ______ results from impaired venous return secondary to venus insufficiency or structural alterations in the legs.

Back 14

Dermatitis

Front 15

Pooling of blood leads to _______, vasodilation, and plasma extravasation, all of which results in dermatitis.

Back 15

edema

Front 16

Skin that is continually exposed to moisture softens and becomes ________, increasing its susceptibility to trauma and infection.

Back 16

macerated--skin is wrinkled and lighter in appearance than healthy tissue.

Front 17

_____ or inadequate drying after hygiene, especially in skin folds, can increase moisture and encourage the growth of yeast, leading to rashes

Back 17

Diaphoresis

Front 18

______, an inflammation of the skin, most often produces epidermal and dermal damage or irritation, possibly accompanied by pain, itching, redness, and blisters.

Back 18

Dermatitis-chronic cases produce changes in the epidermis, including thickening, scaling, and increased pigmentation.

Front 19

_______ and_______ organisms are responsible for most bacterial skin infections.

Back 19

streptococcal & staphylococcal

Front 20

_______, which is usually caused by beta-hemolytic streptococci, is the most common bacterial skin infection.

Back 20

Impertigo

Front 21

Cutaneous warts caused by the ________ are one of the most common diseases of the skin, with hands and feet most typically affected.

Back 21

papillomavirus

Front 22

______ ______ infections often occur when normal body flora is disrupted secondary to antibiotic therapy or immunosuppression.

Back 22

Candidal fungal

Front 23

Inflammatory bowel disease, _______, and peripheral vascular disease are examples of diseases that, during exacerbations, can produce impaired skin integrity.

Back 23

pemphigus

Front 24

An _______ results when skin rubs against a hard surface. Friction scrapes away the epithelial layer, exposing the epidermal or dermal layer.

Back 24

abrasion

Front 25

A ________ is an open wound or cut. Affect only the upper layers of skin and subcutaneous tissue and underneath. Permanent damage may result, however, if injury occurs to internal structures such as muscles, tendons, blood vessels, or nerves.

Back 25

Laceration--Accidents involving automobiles, machinery, or knives may result in lacerations.

Front 26

A ______ wound is made when a sharp, pointed object penetrates tissue. Damage to underlying structures or gross contamination with debris and pathogens may result.

Back 26

Puncture wound

Front 27

A ____ ____ _____ burn (1st degree; epidermal) is pinkish or red with no blistering; a mild sunburn is a good example.

Back 27

superficial partial-thickness burns

Front 28

Moderate to ____ _____ burns (second degree; dermal or deep dermal) may be pink, red, pale ivory, or light yellow-brown. They are usually moist with blisters. Exposure to steam can cause this type of burn.

Back 28

Moderate to deep partial-thickness burn

Front 29

A _____ ____ burn (3rd degree) may vary from brown or black to cherry red or pearly white. Thrombosed vessels and blisters or bullae may be present. Sometimes, when fascia, muscle, or bone is extensively damaged

Back 29

Full-thickness burn

Front 30

_____ burns, the most common type, are caused by contact with various heat sources, including flames, hot liquids, hot surfaces, and steam.

Back 30

Thermal burns

Front 31

_____ burns are caused by contact with noxious substances

Back 31

Chemical

Front 32

____ occurs when two surfaces rub together.

Back 32

Friction

Front 33

_____ force occurs when tissue layers move on each other, causing blood vessels to stretch as they pass through the subcutaneous tissue.

Back 33

Shear Force

Front 34

_____ is the major factor in pressure ulcer formation.

Back 34

Pressure.

Front 35

____ ___ is a localized area of tissue destruction caused by compression of soft tissue over a bony prominence and an external surface for a prolonged period of time.

Back 35

pressure ulcer

Front 36

______, or itching, is a common symptom associated with many skin and systematic problems. The majority of diseases that cause itching are inflammatory or allergic. _____ is often the cause of secondary lesions because scratching breaks the skin surface.

Back 36

Pruritus

Front 37

_____ rash is level with the skin surface.

Back 37

Macular rash

Front 38

_______ rash involves solid elevations above the skin surface.

Back 38

papular rash

Front 39

______ rash covers most body areas,

Back 39

generalized rash

Front 40

____ rash is limited to specific areas.

Back 40

localized rash

Front 41

Secondary lesions develop from primary lesions. They consist of:

Back 41

scales, crusts, and fissures. In the acute form of dermatitis, vesicles develop, burst, and ooze, and crusts form

Front 42

Wounds heal through a systematic 4 part series. They 4 parts are:

Back 42

hemostasis
inflammatory
proliferative
maturation

Front 43

1st phase of wound healing is?

Back 43

hemostasis-begins immediately upon wounding with the onset of vasoconstriction, platelet aggregation, and clot formation.

Front 44

2nd phase of wound healing is?

Back 44

inflammatory phase: which lasts up to 3 days. Marked by vasodilation and phagocytosis as the body works to clean the wound to begin the repair process.

Front 45

3rd phase of wound healing is?

Back 45

proliferation phase depends on whether the wound is partial or full thickness, but the four phases remain the same.

Front 46

In partial-thickness wounds, the 3rd phase, the proliferation phase, epidermal cells, which appear pink, reproduce and migrate across the surface of the wound in a process called __________?

Back 46

Epithelialization. When epithelial cells have covered the base of the wound, cells continue to replicate, increasing the number of cellular layers in the epidermis to assume the thickness of normal healthy epidermis.

Front 47

In a full-thickness wound, the proliferation phase begins with the development of _______, which appears as beefy, red, and granular, and consists of a matrix of collagen embedded with macrophages, fibroblasts, and capillary buds. As it is produced, it fills the wound with connective tissue.

Back 47

granulation tissue. -Open full-thickness wounds undergo contracture and epithelialization durint this phase of healing.

Front 48

_____ can be identified by its effect of pulling the wound inward, leading to a decrease in depth and dimension of the wound. The proliferative phase lasts from day 4 after injury to about day 21 in a normally healing full-thickness wound.

Back 48

Contracture

Front 49

Maturation is the final stage of full-thickness wound healing. It begins about 3 weeks after the injury and may last as long as ____ years.

Back 49

2 years. The tissue usually reaches maximum strength in 10 to 12 weeks, but even after complete healing only 70% to 80% of the original strength can be expected.

Front 50

Primary Intention: Wounds with minimal tissue loss, such as clean surgical incisions or shallow sutured wounds, heal by primary intention. The edges of the primary wound are ______ or lightly pulled together.

Back 50

approximated. Granulation tissue is not visible, and scarring is usually minimal. Infection risk is lower when a clean, surgical wound heals by primary intention.

Front 51

Wounds with full-thickness tissue loss, such as deep lacerations, burns, and pressure ulcers, have edges that do not readily approximate. The open wound gradually fills with granulation tissue, Eventually, epithelial cells migrate across the granulation base, completing the cycle. Scarring is more prevalent. Because the wound is open for a longer time, it becomes colonized with microorganisms that may lead to infection.

Back 51

Secondary Intention

Front 52

Healing by ______ intention occurs when a delay ensues between injury and wound closure. This type of healing also is referred to as delayed primary closure. It may happen when a deep wound is not sutured immediately or is purposely left open until there is not sign of infection and then closed with sutures. A deeper and wider scar is common.

Back 52

Tertiary Intention

Front 53

what vitamins are helpful with wound healing?

Back 53

Vitamins A, C, and E; protein; arginine; zinc; and water are especially important in wound healing.

Front 54

When hemoglobin levels are reduced by more than 15%, such as in severe ______, oxygenation is reduced, and tissue repair is altered.

Back 54

anemia

Front 55

_______ drugs, such as corticosteroids, which may be given to prevent rejection of a transplanted organ, also depress the natural defenses against infection and mask the inflammatory response. Immunosuppressive agents also usually suppress protein synthesis, wound contraction, and epithelialization.

Back 55

Immunosuppressive drugs

Front 56

Individual Factors for Wound healing

Back 56

Age
Obesity
Smoking
Medications-prednisone can delay wound closure and increased risk for skin injury.
Stress

Front 57

Local Factors for Wound Healing:

Back 57

Nature of Injury
Presence of Infection

Local Wound Environment(pH should be between 7.0 and 7.6)

Front 58

A ______ is a localized collection of blood. It appears as a swelling or mass underneath the skin surface, often with a bluish color. Large _____ may require evacuation or surgical removal to promote optimal wound healing.

Back 58

Hematoma

Front 59

Symptoms of Infection are:

Back 59

wound are purulent drainage, and inflamed incisional area, fever, and an elevated leukocyte count.

Front 60

________ is a total or partial disruption in wound edges., most commonly used to describe surgical incisions win which the skin has separate but underlying subcutaneous tissue has not parted.

Back 60

Dehiscence-Client describes "incision has given way" physician should be notified and the open area protected with a saline-moistened dressing.

Front 61

______ the protrusion of viscera through an abdominal wound open. Abdominal fascia separate and internal organs protrude. This is a medical EMERGENCY!

Back 61

Evisceration

Front 62

A _____ is an abnormal tube-like passageway that forms between two organs or from one organ to outside the body. May result from illness, such as inflammatory bowel disease.

Back 62

Fistula

Front 63

______ drainage is pale yellow, watery, and like the fluid from a blister.

Back 63

serous drainage

Front 64

_____ drainage is bloody, as from an acute laceration.

Back 64

Sanguineous drainage

Front 65

_______ drainage is pale pink-yellow, thin, and contains plasma and red cells.

Back 65

Serosanguineous drainage

Front 66

______ drainage contains white cells and microorganisms and occurs when infection is present. It is thick and opaque and can vary from pale yellow to green or tan, depending on the offending organism. Presence of undermining/tunneling: Assess the wound edges to check for the presence of dead space or a sinus tract.

Back 66

Purulent drainage

Front 67

______ adhesive semipermeable film dressing.

Back 67

transparent films

Front 68

____ hydrophilic polyurethane used for partial and full-thickness wounds with small to moderate drainage; foams provide absorption and protection.

Back 68

Foams

Front 69

____ hydrophilic colloid particles attached to a backing.

Back 69

Hydrocolloids

Front 70

_____ used to encourage granulation within full-thickness wounds and to provide comfort in tender, partial-thickness wounds.

Back 70

Hydrogels

Front 71

_____ used for absorption; indicated for deep or moderately draining wounds.

Back 71

Alginate

Front 72

______ contain collagen, a major protein in the body used for partial-and full-thickness wounds.

Back 72

collagens

Front 73

______ dressings that combine two or more products to facilitate application and use.

Back 73

composites

Front 74

____ ______: nonadherent dressing that will not stick to wound surface; minimizes disruption of new cells.

Back 74

Contact layers

Front 75

_____ ______: antimicrobial dressings used for infected wounds.

Back 75

Silver dressings

Front 76

______ tape is a pliable, foam-like tape used for compression or pressure dressings.

Back 76

Microfoam

Front 77

______ _____ or ties, used when dressings require frequent changing, are commercially prepared strips of nonallergenic tape.

Back 77

Montgomery straps-help prevent skin breakdown because they eliminate the need to remove tape with every dressing change.

Front 78

_______ is the removal of foreign material or dead tissue from a wound to discourage the growth of microorganisms and to promote wound healing.

Back 78

Debridement

Front 79

______ debridement refers to the use of sharp instruments to debride the wound, ad done during surgery or at the bedside.

Back 79

Surgical or sharp debridement

Physician or providers who specialize perform this procedure.

Front 80

______ debridement refers to the process placing chemical products within the wound to help break down the necrotic debris.

Back 80

Enzymatic debridement

Front 81

______ debridement is the process of removing debris and necrotic tissue using the body's own fluids and cells.

Back 81

Autolytic

Front 82

Wound Support

Back 82

steristrips
sutures, staples and clips
cyanoacrylate glue
ace bandages and wraps
binders

Front 83

A _____ drain is a hollow, fat rubber tube placed directly into the incision or into a stab wound in the incisional area. It allows fluid to drain through capillary action into absorbent dressings.

Back 83

Penrose drain

Front 84

A _____ is placed into a vascular cavity where blood drainage is expected after surgery. Expect bloody drainage and ensure that it remains in the compressed state.

Back 84

Hemovac

Front 85

A _____-_____ or grenade drain permits drainage to collect in a bulb-like device that can be compressed to create gentle suction. Suction is lost when the bulb is expanded because of too much drainage or a leak in the system.

Back 85

Jackson-Pratt