8 Skin Integrity & Wound Care Flashcards

Flashcards reviewing key concepts from a lecture on skin integrity and wound care.

What percentage of our body weight does the skin account for?

About 15%

Name three functions of the skin.

Protection against microorganisms, dehydration, damage to inner organs, UV light; sensory organ; allows movement; endocrine activity; window to overall health

What system is the skin part of?

The integumentary system

Name the three layers of the skin.

Epidermis, Dermis, Hypodermis

What cells produce melanin?

Melanocytes

Name three pigments that create skin color.

Melanin, carotene, hemoglobin

What factors influence healthy skin integrity?

Age, genetics, perfusion, overall health/medications, lifestyle, diet

List five signs of impaired skin integrity.

Pain, inflammation, color changes, edema, pruritic/itchy skin, dry/scaly skin, thin/fragile skin, exudate/drainage, necrosis

Name three causes of injury to skin integrity.

Physical trauma, thermal factors, chemical injury, infection, nutritional imbalances, fluid imbalances, altered circulation/perfusion, age, weight loss, poor nutrition, personal hygiene behaviors

What are the four classifications of wounds?

Clean, clean-contaminated, contaminated, dirty/infected

Describe a superficial wound.

Involves the epidermis

Describe a partial thickness wound.

Involves the epidermis and dermis

Describe a full thickness wound.

Involves the epidermis, dermis, and subcutaneous tissue/connective tissue, potentially bone/muscle

Describe primary intention wound healing.

Wound edges pulled together with minimal/no tissue loss, using sutures, staples, steristrips, or glue.

Describe secondary intention wound healing.

Wound edges don’t come together and need dressing products to promote granulation; takes longer to repair, scarring is greater, higher risk of infection.

Describe tertiary intention wound healing.

A wound left open or reopened due to severe infection, closed later when infection resolves; delayed healing times and increased scar tissue.

What are the three phases of wound healing?

Inflammatory, Proliferative, Maturation/Remodeling

Describe what happens during the inflammatory phase of wound healing.

Vasodilation occurs allowing white blood cells into the wound; hemostasis and phagocytosis occur.

Describe what happens during the proliferative phase of wound healing.

Epithelialization, angiogenesis, collagen formation, and contraction occur.

Describe what happens during the maturation/remodeling phase of wound healing.

Fibroblasts continue to synthesize collagen to strengthen the wound.

List three complications of wound healing.

Hemorrhage, infection, dehiscence, evisceration

List three factors affecting wound healing.

Age, nutrition, lifestyle, medications, underlying health

List 4 aspects of wound assessment.

Type, location, pain, size, degree of tissue injury, color of wound base, drainage

What are the four types of wound exudate/drainage?

Sanguineous, serous, serosanguinous, purulent

What is another name for pressure wounds?

Bedsores or decubitus ulcers

Name two external causes of pressure wounds.

Prolonged pressure, friction, shear force, and moisture

Name two internal causes of pressure wounds.

Malnutrition, anemia, age, cognitive impairment, vascular or other disease states

List three external risk factors for pressure wounds.

Prolonged pressure/immobility, friction, shearing, moisture

List three internal risk factors for pressure wounds.

Malnutrition, vascular disease, irregular body temp, cognitive impairment, anemia, older age, prolonged anesthesia, malignancy, substance use

Name the two risk assessment scales.

Norton and Braden Scale

Describe a Stage 1 pressure wound.

The skin is intact with nonblanchable erythema.

Describe a Stage 2 pressure wound.

There is partial-thickness skin loss involving the epidermis and/or dermis.

Describe a Stage 3 pressure wound.

A full-thickness loss of skin extends to the subcutaneous tissue but does not cross the fascia beneath it.

Describe a Stage 4 pressure wound.

Full-thickness skin loss extends through the fascia with considerable tissue loss. There may be muscle, bone, tendon, or joint involvement.

Describe an unstageable pressure wound.

The depth is unknown because slough or eschar obscures the extent of tissue damage.

List three interventions for prevention of pressure wounds.

Skin inspection, check cushions relieve pressure, mattress type can relieve pressure, moisturize/hydrate skin, consider nutrition, ensure correct dressing for wounds, encourage movement, barrier creams, nutrition/hydration, etc.

What should the nurse monitor for when caring for pressure wounds?

Signs of infection, wound culture results, blood count and inflammatory markers, temperature, odor, exudate

Describe appropriate dressings for a Stage I pressure wound

Apply occlusive barrier over the wound and a vitamin-enriched cream to the skin every shift.

Name three methods of wound debridement.

Autolytic, biological, chemical, surgical

Describe a superficial partial-thickness burn injury.

The epidermis is destroyed or injured and a portion of the dermis may be injured.

Describe a deep partial thickness burn injury.

Involves the destruction of the epidermis and upper layers of the dermis and injury to the deeper portions of the dermis.

Describe a full thickness burn injury.

Involves total destruction of the epidermis and dermis and, in some cases, the destruction of the underlying tissue, muscle, and bone.

What is the Rule of Nines used for?

A quick way to estimate the extent of burns in adults through dividing the body into multiples of nine and the sum total of these parts is equal to the total body surface area injured.

Name three changes caused by burns.

Hypovolemia, decreased cardiac output, edema, electrolyte imbalances, hyponatremia, hyperkalemia, hypothermia, infection/sepsis