It is normal to experience pain in a surgical incision wound for approx how many days? (Sudden increase in pain & changes in appearance of the wound need to be reported immediately.)
This is a measure of the client's protein reserves (measured in the blood): if this is decreased, the client will have decreased resources of protein for wound healing.
Partial or complete baldness or loss of hair. Can be caused by illness, malnutrition, meds & chemo. Can be treated w/Rogaine, but when the drug is stopped, the hair growth stops.
formation of new blood vessels, begins within hours after the injury. New endothelial cells build a new vessel.
Benign vascular tumor involving skin & subcutaneous tissue; most are congenital. Commonly known as birthmarks. Can be strawberry birthmarks or dark red/purple patches (port-wine angiomas).
These glands are found in the axillae, anal region, scrotum & labia major. They secrete an organic substance that is odorless until it mixes with skin bacteria.
These are categorized as "Above the Surface" skin condition. Thinning of the skin surface and loss of markings. Ex: Striae (stretch marks), aged skin.
BASAL CELL CARCINOMA
This is the most frequent type of skin cancer, arises from basal cell layer of epidermis. Sun exposure, poor tanning ability & facial x-rays for acne are risk factors. Metastasis is rare. Surgical removal cures this type of cancer.
BASAL CELL CARCINOMA
This is the most common form of skin cancer. Found on face & upper torso, scaly in appearance, waxed rolled edges, depressed center. Metastasis is rare. Surgical removal cures this type of cancer.
These are white lines across the nail, seen with acute severe illness, malnutrition or trauma.
This is the same as a vesicle (accumulation of fluid between the upper layers of skin, containing serous fluid), only greater than 0.5 cm. Ex: Contact dermatitis, large second-degree burns, bullous impetigo & pemphigus
CAUSE, CLEANLINESS & DEPTH
These (3) are commonly used classification systems for wound classification.
Most of the long-term skin damage from sun exposure occurs during_____, because the ability of the skin to tan is not fully developed until the teenage years.
this occurs (in the nails) when long-standing hypoxia is present, particularly with cyanotic heart disease & advanced COPD. Will have a nail angle of at least 180 degrees.
Heat is transferred from warmer surfaces to cooler ones. Ex: cool washcloth. This type of heat loss is called what?
These are categorized as "Above the Surface" skin condition. Dried serum, blood or pus on the surface of the skin. Ex: Impetigo, acute exzematous inflammation.
Bluish discoloration of the skin and mucous membranes observed in lips, nail beds, & earlobes
This is an encapsulated fluid-filled or semi-solid mass in the sub-Q tissue or dermis. EX: Sebaceous cyst, epidermoid cyst.
aka Inflammatory Phase (of wound healing): this occurs immediately after injury & lasts 3-4 days. Hemostasis & inflammation occurrs during this phase.
This is dense, irregular connective tissue composed of collagen & elastic fibers, blood & lymph vessels, nerves, sweat & sebaceous glands & hair roots.
APPEARANCE & DRAINAGE
When assessing this in a wound, you include: General description of color of wound & surrounding area & present phase of healing. You also document the amount, color, location, odor & consistency of any drainage.
These are found in the skin, over most of the body surface. They produce sweat and help in the cooling process.
This is a layer of squamous epithelial cells. Most of the cells are keratinocytes that produce a tough, fibrous protein called keratin.
This is categorized as a "Below the Skin Surface" condition. Loss of epidermis. Ex: Ruptured chickenpox vesicle.
This is categorized as a "Below the Skin Surface" condition. Loss of epidermal layers exposing the dermis. Ex: Abrasion.
This may vary in composition, but has similar functions. Dilution of toxins, Transport of leukocytes and plasma proteins & Transport of bacterial toxins, dead cells, debris & other products of inflammation away from the site.
This is categorized as a "Below the Skin Surface" condition. Linear crack in the epidermis that can extend into the dermis. Ex: chapped hands or lips, athlete's foot.
Repair (of a wound) begins as this type of tissue and grows inward from surrounding healthy connective tissue. This is filled with new capillaries.
This is composed of dead epidermal cells that begin to grow & divide in the base of the hair follicle. As they push toward the surface, they become keratinized and die.
This protects the scalp from ultraviolet rays, cushions blows to the head. Prevents foreign particles from entering eyes and nostrils & external ear canal.
Cessation of bleeding, occurs by vasoconstriction of large blood vessels in the affected area. Platelets aggregate to form a platelet plug & stop the bleeding. Results in formation of fibrin & fibrinous meshwork and forms clot and initial wound closure.
This is a nonspecific cellular response to tissue injury & involves both vascular & cellular responses. Stimulates release of histamine (from mast cells) serotonin & completment & kinins. Results in increased blood flow & leakage of serous fluid into surrounding tissues. Transports leukocytes to area to participate in phagocytosis. Removes debris of battle.
What are the most important cells in the Reconstructive (proliferative) phase. These cells synthesize and secrete collagen.
Localized collection of blood underneath the tissue. Appears as a reddish blue swelling or mass.
This is detected when the surgical dressing becomes saturated with sanguineous drainage.
This is abnormal and may indicate a slipped surgical suture, a dislodged clot, or erosion of a blood vessel. Swelling in the area around the wound or affected body part AND the presence of sanguineous, bloody, drainage from the surgical drain may indicate internal bleeding. Risk is greatest during the first 24-48 hours after surgery.
aka Sanguineous Exudate. This has a large component of RBC's because of capillary damage. This is usually present with severe inflammation. Color is bright red verses dark red. This reflects whether the bleeding is fresh or old.
this presents with decreased blood pressure, rapid thread pulse, increased respiratory rate, diaphoresis, restlessness & cool clammy skin.
Bacterial wound contamination is one of the most common causes of altered wound healing. This is referred to as:
This may happen and become apparent 2-11 days postoperatively. It slows the healing by prolonging the inflammatory phase of healing.
Age, oxygenation, smoking, diabetes, nutrition, hemorrhage & infection are all factor that affect what?
This is an external covering of the body. It performs the vital function of protecting internal body structures from harmful microorganisms and substances.
These wounds occur during treatment or therapy. Usually made under aseptic conditions. Ex: Surgical incisions & venipunctures.
Yellow discoloration of the skin, sclera, mucous membranes and body fluids that occurs when the liver is unable to fully remove bilirubin from the blood
Abnormal growth of scar tissue that is elevated, rounded, and firm with irregular, clawlike margins. Can be removed surgically, but will most likely come back.
As cells move from deeper epidermal layers to the surface, they undergo a process called _____ in which they become filled with keratin, thus hardening the outer layer of epidermal cells.
This creates a barrier that repels bacteria & foreign matter and is impermeable to most substances.
This is also known as "spoon nails", is a sign of iron deficiency anemia, malnutiriton or trauma of the nail bed. The nails are thin & concave.
These should be identified according to type and described regarding color, size & location. Also amount, color, odor & appearance of any drainage that might be present.
These are categorized as "Above the Surface" skin condition. Layers of skin become thickened and rough as a result of rubbing over a prolonged period of time. Ex: chronic contact dermatitis.
HANDS & FEET
What parts of the body, subjected to friction & pressure, contain larger amounts of keratin, which result in thickened skin & calluses
These are localized changes in skin color of less than 1 cm in diameter. Freckle (Mac has freckles)
This is the final stage of (wound) healing. Begins about 21st day and may continue for up to 2 years. During this phase the scar tissue is remodeled. Scar tissue is weaker than the tissue it replaces.
The epidermis contain specialized cells that produce melanin. What are these cells called?
These increase in number on the hands & face and cause age spots. Gray hair occurs from a lack of it's production.
This type of skin cancer is cancer of the melanocytes. It is the most prevelant. Most serious of the 3 types of skin cancer. Begins as a mole of irregular shape. Larger than 6mm and are not uniform in color. Can metastasize to every organ. Use the ABCD rule. Occurs most often on trunk of males and legs on females.
A = Asymetric (nor normal shape) B = Borders irregular C = Not uniform in color D = Diameter > 6mm. Acronym for cancerous moles is:
This is made of epithelium overlying a layer of loose connective tissue. It secretes mucus.
This is the lining of the oral & nasal cavities, and tubes of respiratory, gastrointestinal, urinary & reproductive systems. They perform absorptive or secretory functions.
Pigmented areas in the skin; commonly known as birthmarks or moles. This is pigmented areas in the skin and are aggregations of melanocytes.
Solid & elevated. Extend deeper than papules into dermis or SubQ tissue. 0.5-2.0 cm. Lipoma, erythema nodosu, cyst, melamoma, hemangioma. (NODULAR CYST)
Macule (freckles) and Patch (vitiligo or pressure ulcer stage 1) are this category of skin condition.
Abnormal paleness of the skin, seen especially in the face, conjunctiva, nail beds, and oral mucous membranes
Solid, elevated lesion less than 0.5 cm in diameter. Warts, elevated nevi, seborrheid keratosis. (Pappy has warts)
Localized changes in skin color of greater than 1 cm in diameter. Vitiligo (white patch), stage 1 of pressure ulcer.
this type of healing occurs in wounds have minimal tissue loss and edges that are well approximated (closed). Wound heals with minimal granulation tissue & scaring. There us minimal blood loss. Ex: Surgical wound.
Discharge resulting from infection; also called pus. Can be yellow, brown or green. Occurs with severe inflammation accompanied by infection. Process of pus formation is called suppuration.
This is a vesicle or bullae that becomes filled with pus, usually describes as less than 0.5 cm in diameter. EX: Acne, impetigo, furuncles, carbuncles, folliculitis.
This can affect the condition of the skin. Skin rashes can be a complication of drug therapy
This is the primary means of heat loss. As body heat increases, the arterioles in dermis dilate, bringing body heat to surface. Waves of heat are released to the environment. To conserve heat, arterioles contract to decrease flow of blood to surface, decreasing heat lost by this method.
aka Proliferative Phase of wound healing. Begins on 3rd or 4th day after injury & lasts for 2-3 weeks. Process of collagen deposition, angiogenesis, granulation tissue development & wound contraction. Can resist normal stress such as tension or twisting after 15-20 days.
These are categorized as "Above the Surface" skin condition. Is flaking of the skin's surface. EX: Dandruff, psoriasis, xerosis
This is categorized as a "Below the Skin Surface" condition. Fibrous tissue that replaces dermal tissue after injury. Ex: from a healed surgical incision.
Oily substance secreted by the sebaceous glands of the skin, that lubricates the skin, helping to keep it soft & pliable.
This type of healing is in wounds with extensive tissue loss & wounds in which the edges cannot be approximated (closed). Would is left open and granulation tissue gradually fills in the deficit. Susceptible to infection. Wet to dry dressings. Ex: Pressure Ulcer
Discharge that is clear with some blood (pink) tinge; seen with surgical incisions. Normal after surgical incisions.
Discharge composed primarily of serum; is a clear watery viscous serum in appearance and has a low protein level. The clear portion of blood. Seen with mild inflammation (blisters)
This is continuous with mucous membranes at external body openings of the resp. tract, digestive system and urogenital tract.
Assessment of this includes integrity, color, temp, moisture, texture, turgor & mobility, sensation & vascularity.
This plays roles in regulation of body temp., functioning as a sensory organ, maintains fluid & electrolyte balance, produces V-D and excretes certain waste products from the body.
This contains receptors for pain, touch, pressure & temperature. Has sensory receptors and provide sensations of comfort & pleasure.
This is one of the most common malignant neoplasms in the US and is the most PREVENTABLE cancer.
SQUAMOUS CELL CARCINOMA
This carcinoma appears as a nodular lesion in the epidermis. Is less common. It can extend into the dermis & metastize to other body tissues, causing death.
SQUAMOUS CELL CARCINOMA
This carcinoma is single crusted & scaled. Is nodular lesion in epidermis. Will go deeper, More likely to metastasize. Treatments are surgery, Chemo & Zinc Chloride.
These are non malignant. Do not require med or nursing interventions. Begin as fatty tissue tumor. Sebaceous cysts, Keloid (abnormal growth of scar tissue, Angioma (birth marks) and Port Wine Patch (on face)
This tissue is primarily connective & adipose (fatty) tissue. It anchors skin to muscles & bones. It plays an important factor in body temperature regulation.
Loss of ____ ______ causes skin sagging & wrinkles. The sebaceous & sweat glands diminishes, resulting in dry skin.
Permanent dilation of groups of superficial capillaries and venules; commonly known as "spider veins"
This type of (wound) healing is also known as "delayed or secondary closure". May occur due to poor circulation or infection. May come about as a result of a surgical wound coming open. Wound left open until risk of (or) infection is resolved.
This is the same as a nodule, only greater than 2 cm. EX carcinoma. NOT basal cell or squamous cell of the skin.
This is categorized as a "Below the Skin Surface" condition. A depressed lesion of the epidermis and upper papillary layer of the dermis. Ex: Stage 2 pressure ulcer
These wounds are unanticipated and are often the result of trauma or an accident. They are created in an unsterile environment & pose a greater risk of infection.
Depigmentation of the skin caused by destruction of melanocytes; appears as milk-white patches on the skin, surrounded by normal skin
These wounds are intentional wounds that were created under conditions in which no inflammation was encountered & the respiratory, alimentary, genitourinary, and oropharyngeal tracts were not entered.
These wounds are intentional wounds that were created by entry into the alimentary, respiratory, genitourinary, or oropharyngeal tract under controlled conditions.
These wounds are open, traumatic wounds or intentional wounds in which there was a major break in aseptic technique, spillage from the gastrointestinal tract, or incision into infected urinary or biliary tracts. They have acute nonpurulent inflammation present.
DIRTY & INFECTED
These wounds are traumatic wounds with retained dead tissue or foreign material or intentional wounds created in situations where purulent drainage was present.
The depth this wound is confined to the epidermis layer, which comprises the four outermost layers of skin.
The depth of this wound involves the epidermis and part of the dermis, which is the layer of skin beneath the epidermis. (Not stages)
The depth of this wound involves the entire epidermis and dermis. Deeper structures such as fascia, muscle & bone may be involved. (Not stages)
when measuring tunneling, you should describe the location of the tunneling as the hands of a clock. The client's head is at the reference point of what time?
DEFENSIVE, RECONSTRUCTIVE & MATURATION
What are the three phases of wound healing. Aka Inflammatory, Proliferative & Maturation Phases.
Varies with skin type & race; pink, tanned, olive & brown, pallor (pale), cyanosis, jaundice, erythema, describes _____ of the skin
TEMPERAURE & MOISTURE
Usually warm & dry, depending on the environmental temp. Cool, cold, moist, clammy or warmer than normal. This describes _____ & _____ of the skin.
Smooth, soft. Thickness varies in different areas. Loose, wrinkled, rough, thickened, thin, oily flaking, scaling. This describes _____ of the skin.
Numbness, tingling, insensitive to pressure & sharp objects. Distinguishes hot & cold, sharp and dull. This describes ____ of the skin.
Clear; no discoloration. Telangiectasia, Petechiae, Eccymosis. This describes ____ of the skin.
This is an accumulation of fluid between upper layers of the skin. Elevated mass contains serous fluid; less than 0.5 cm. Ex: Herpes simplex & zoster, chickenpox, scabies.
Localized edema in epidermis causing irregular elevation that may be red or pale. Insect bite, hive, angioedema.
This is a bacterial infection of skin caused by staph in children. Occurs in warm weather, fall & spring. Vesicles filled w/serum. Face & upper trunk. Light brown crust. While healing, wash linens separately and use separate eating utensils. Treat w/antibiotics, antipyretics and clean with soap & water.
This is an infected hair follicle in the dermis. Redness, swelling & pain. Pustules at the nape of the neck & upper back. More common in the obese or malnourished w/poor hygiene as well as diabetics. Treat w/warm soaks or compresses. Topical Antibiotics & Systemic antibiotics.
aka Herpes Zoster (From Varicella virus). This lies dormant. Will have pain, tingling & burning over peripheral sensory nerves. Found mainly on face, thoracic region (unilateral. Pustules rupture & form a crust. Mild to severe pain. After crusted over, is not contagious. Meds: Zovirax (aclivar) (Shortens clinical coarse). Anti pyretics, analgesics, calamine, Isolation if vesicles are draining. Preg woman should not care for patient. 10 days to 5 weeks. Can come back.
HERPES SIMPLEX I
These are fever blisters & cold sores. Most commonly at corners of the mouth. Can transfer w/direct contact. Burning, tingling. Vesicles painful at times. No cure. Zovirax decreases breakouts.
This med is used for all Herpes outbreaks, shingles, Type ! & Type II, and warts. Is an antiviral med that interferes w/DNA replication. Can be PO, IV or topical. SE's are GI upset, oliguria, protienuria, joint pain, gingival hyperplasia, renal failure.
HERPES SIMPLEX II
These are genital blisters. Will transfer w/direct contact. Can outbreak due to stress. Burning vesicles. No cure. Med: Zovirax
When taking this medication you can take w or w/o food. Shake well if suspension. Increase fluids, do good dental care. If on Oral Birth control, this decreases the effect of the pill
These infections are from the Microsporum audouini organism. Called Tinea (everything). What "Type" of infection - not ringworm, etc.
This is (teeny) ringworm. Superficial infection of the skin. Round, red, scaly, itchy, burns and spreads easily. These lesions have a pale center.
This is caused by the female itch mite. She burs under skin, poops & lays eggs in fecal material. Is an "S" shape. Mostly on hands, wrists, elbows, waistline, & gluteal folds. Vesicles are reddish brown nudules w/excoriation. Itching worse at night.
This is used to treat lice. Is is lindane. Is a scabicide, pediculicide. Stimulates Nervous system of the parasite.
This is an inflammatory condition of skin, when a person comes in contact w/a specific antigen. Types are : Eczema, Contact, Venenata & medicamentosa, & exfoliative.
This is caused by things like poison ivy. The skin reacts to external irritants such as cosmetics, chemicals, detergents or insecticides. Metals, wool or glass fibers & urine or feces. Symptoms include pruritus, burning, erythema. As a Maculopapular rash or a combination of pustules & vesicles develops. Can be spread by scratching the lesions. Treat w/corticosteroid ointment & oral antihistamines.
This dermatitis is aggravated usually by chocolate, orange juice, wheat & eggs. Tiny cracks in the skin allow body fluid to escape so skin hydration is the major treatment. It is a chronic superficial inflammation that evolves into pruritic, red, weeping & crusted lesions.
This dermatitis affects the entire body, not just the skin. Can cause loss of skin surface. Is a severe allergic reaction. Treat w/topical or oral cortical co-steroids, cold compresses, medicated baths, antibiotics & analgesics.
This is a chronic inflammatory, noninfectious autoimmune disease of the skin. More prevalent in Caucasions. Mostly common in scalp, elbows, palms, knees, lower back & soles of feet. Emotional stress, infections, trauma, seasonal and hormonal changes trigger exacerbations of it. Is not curable. Treat w/COAL TAR PREPARATIONS, Corticosteroids & photochemo therapy.
VENOUS STASIS ULCER
This type of ulcer is due to poor venous circulation (veins back up to the heart). Affects lower extremities. There are changes in skin texture, turgor & color. Starts as small open area around or above ankle. Slow healing. May require surgery, skin grafting and possibly amputation. No Standing for long periods of time, Do not cross legs. Use TED hose.
aka bedsores or decubitus ulcers. They are localized areas of tissue necrosis that tend to develop when soft tissue is compressed between a bony prominence and an external surface. Caused by ischemia. Commonly found on heals, sacrum, hips, ischium, pinna of ears & elbows.
The stage of this pressure (decubitus) ulcer presents as: Red area, nomal color comes back within 15-20 minutes.
The stage of this pressure (decubitus) ulcer presents as: Partial thickness, (epidermis & partial dermis). Shallow, pink or red base, yellow or white eschar
The stage of this pressure (decubitus) ulcer presents as: Deep Ulcer, into subcutaneous, to upper part of fascia. White, gray or yellow eschar. Purulent drainage