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42 Cards in this Set
- Front
- Back
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Skin assessments
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intact
redness itching or rashes dry/flaky smoothness color temperature |
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function of the skin
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temperature maintenance
fluid balance protection first line defense againt microorganisms |
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wound healing: inflammatory phase
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tissue injury stimulats the clotting cascade to form a clot
blood vessels constrict initially but then dilate which begins the swelling phase wbc's then arrive to ingest bacteria and cellular debris |
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wound healing: proliferative phase
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begins 2 to 3 days after the injury
granulation tissue: new tissue, foundation for scar development this phase may take weeks depending on the size of the wound |
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Wound Healing: remodeling phase
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final stage of healing
collagen is remodeled making the wound stronger and more like surrounding tissue |
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factors that affect wound heaing
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age
circulation nutritional status condition of the wound patient overall health |
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wound complications
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infection
hemorrhage dehiscence and evisceration fistula formation |
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macule
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flate, color change only
freckle, hypergpigmentation |
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papule
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solid, elevated
mole, wart |
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vesicle
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clear fluid filled
herpes, chicken pox, dermatitis |
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cyst
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indermis or subq layer
subq cyst |
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nodule
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solid, elevated, hard deeper that a papule
xanthoma, fibroma |
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wheal
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raised, erythematous
mosquito bite, allergic reaction |
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pustule
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turbid fluiud in cavity
impetigo, acne |
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serous: wound drainage
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clear, watery drainage
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sanguineous: wound drainage
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red blood cells
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serosanguineous: wound drainage
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mix of serous and sanguineous
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purulent: wound drainage
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wbc's, debris, yellow or green, foul odor
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Stage 1 Pressure ulcer
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intact skin but redness does not go away after pressure release
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Stage 2 Pressure ulcer
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appears as an abrasin, blister or shallow crater
going into the dermis |
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Stage 3 Pressure Ulcer
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damage extends down to subq tissue but not through fascia
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State 4 Pressure Ulcer
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damage may extend into muscle, bone, tendons and joints
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Common sites for Pressure Ulcers
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sacrum
coccyx trochanter calcaneous |
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Pressure Ulcer Prevention
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turn q2hrs
pillows under the heels encourage OOB and ambulation keep their bottom dry |
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fissure
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linear crack or break fro the epidermis to dermis, dry or moist
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scale
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excess, dead epidermal cells produced by abnormal keratinitaion and shedding
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scar
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abnormal formation of connective tissue that replaces normal skin
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ulcer
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loss of the epidermis and dermis, crater-like, irregular shape
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atrophy
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depression in skin resulting from thinning of the epidermis or dermis
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excoriation
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area in which epidermis is missing exposing the dermis
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alopecia
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loss of hair
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angioma
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tumor consisting of blood or lymph vessels
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carotenemia
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yellow discoloration of skin, no yellowing of sclerae, most noticeable on palms and soles
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comedo
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keratin, sebum microorganism, and epithelial debris withing a dilated follicular opening
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hirsutism
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male distribution of hair in women
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intertrigo
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dermatitis of overlying surfaces of the skin
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hypertrophy
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increase in the size of cells without cell division
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hyperplasia
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increase in the number of cells resulting from increased cellular division
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atrophy
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decrease in the size of tissue or organ caused by a decreased number of cells or reduction in the sie of the individual cell
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metaplasia
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reversible transformation of one cell type into another
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dysplasia
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abnormal differentation of dividing cells resulting in changes in the size, shape and appearance of the cells
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anaplasia
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cell differentiation to a more immature or embryonic form
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