NPTE: Integumentary (scorebuilder 2008) Flashcards

Venous insufficiency
Terms Definitions
Exudate classification: presents as clear, light color with a thin, watery consistency
serous
Exudate classification: presents as red with a thin, watery consistency
sanguineous

• appears to be red due to presence of blood, or may be brown if allowed to dehydrate
Exudate classification: presents as light red or pink with a thin, watery consistency
serosanguineous
Exudate classification: presents as opaque, yellow or tan color with thin, watery consistency
seropurulent

• may be an early warning sign of impending infection.
Exudate classification: presents as yellow or green with a thick viscous consistency
purulent

• indicative of infection
pressure ulcer staging
• Stage I
observable pressure-related alteration of intact skin.

• may include: change in skin color, temperature, stiffness, or sensation
pressure ulcer staging
• Stage II
partial-thickness skin loss. involves epidermis and/or dermis.

• ulcer is superficial and presents as abrasion, blister or a shallow crater.
pressure ulcer staging
• Stage III
full-thickness skin loss that involves damage or necrosis of subcutaneous tissues. May extend to but not through underlying fascia.

• presents as a deep crater with or without undermining adjacent tissue.
pressure ulcer staging
• Stage IV
full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures.
Wagner Grade 0
no open lesion but may possess pre-ulcerative lesions; healed ulcers; presence of bony deformity.
Wagner Grade 1
superficial ulcer not involving subcutaneous tissue
Wagner Grade 2
deep ulcer with penetration through the subcutaneous tissue; potentially exposing bone, tendon, ligament, or joint capsule
Wagner Grade 3
deep ulcer with osteitis, abscess or osteomyelitis.
Wagner Grade 4
gangrene of digit
Wagner Grade 5
gangrene of foot requiring disarticulation
Superficial burn
involves only outer epidermis. area may be red with slight edema. no scarring.
Superficial partial-thickness burn
involves epidermis and upper portion of the dermis. may be extremely painful and exhibit blisters. minimal to no scarring.
Deep partial-thickness burn
involves complete destruction of the epidermis and majority of dermis. may appear discolored with broken blisters and edema. damages to nerve endings may result in only moderate pain. hypertrophic scars and keloids.
Full thickness burn
involves complete destruction of epidermis and dermis along with partial damage of subcutaneous fat layer. eschar formation and minimal pain. requires grafts and may be susceptible to infection.
Subdermal burn
involves complete destruction of epidermis, dermis, and subcutaneous tissues. may involve muscle and bone. often requires surgical intervention.
Definition: zone of coagulation
the area of the burn that received the most severe injury along with irreversible cell damage.
Definition: zone of stasis
the area of less severe injury that possesses reversible damage and surrounds the zone of coagulation.
Definition: zone of hyperemia
the area surrounding the zone of stasis that presents with inflammation, but will fully recover without any intervention or permanent damage.
Rule of nines:
• Head and neck
9%
Rule of nines:
• Anterior trunk
18%
Rule of nines:
• Posterior trunk
18%
Rule of nines:
• Bilateral anterior arm, forearm, hand
9%
Rule of nines:
• Bilateral posterior arm, forearm, hand
9%
Rule of nines:
• Genital region
1%
Rule of nines:
• Bilateral anterior LE
18%
Rule of nines:
• Bilateral posterior LE
18%
Rule of nines:
• How do children differ?
Child under 1 has 9% taken from the LEs and added to head region. Each year of life, 1% is added back to the LEs.
Topical agents used in burn care:
• Can be used with or without dressing
• silver sulfadiazine
Topical agents used in burn care:
• Is painless
• Silver sulfadiazine
• Silver nitrate
Topical agents used in burn care:
• can be applied to wound directly
• silver sulfadiazine
Topical agents used in burn care:
• broad-spectrum
• silver sulfadiazine
• silver nitrate
• povidone-iodine
mafenide acetate
gentamicin
nitrofurazone
Topical agents used in burn care:
• non-allergenic
• silver nitrate
Topical agents used in burn care:
• effective against yeast
• silver sulfadiazine
Topical agents used in burn care:
• antifungal
• povidone-iodine
Topical agents used in burn care:
• easily removed with water
• povidone-iodine
Topical agents used in burn care:
• penetrates burn eschar
• mafenide acetate
Topical agents used in burn care:
• may be used with or without occlusive dressing
• mafenide acetate
Topical agents used in burn care:
• may be covered or left open to air
• gentamicin
Topical agents used in burn care:
• bacteriocidal
• nitrofurazone
Topical agents used in burn care:
• does not penetrate into eschar
• silver sulfadiazine
• silver nitrate
Topical agents used in burn care:
• discolors, making assessment difficult
• silver nitrate
Topical agents used in burn care:
• can cause severe electrolyte imbalance
• silver nitrate
Topical agents used in burn care:
• removal of dressing is painful
• silver nitrate
Topical agents used in burn care:
• not effective against pseudomonas
• povidone-iodine
• nitrofurazone
Topical agents used in burn care:
• may impair thyroid function
• povidone-iodine
Topical agents used in burn care:
• painful application
• povidone-iodine
• mafenide acetate
• nitrofurazone
Topical agents used in burn care:
• may cause metabolic acidosis
• mafenide acetate
Topical agents used in burn care:
• may compromise respiratory function
• mafenide acetate
Topical agents used in burn care:
• may inhibit epithelialization
• mafenide acetate
Topical agents used in burn care:
• causes resistant strains
• gentamicin
Topical agents used in burn care:
• ototoxic
• gentamicin
Topical agents used in burn care:
• nephrotoxic
• gentamicin
Topical agents used in burn care:
• may lead to overgrowth of fungus and pseudomonas
• nitrofurazone
definition: allograft
temporary skin graft taken from another human, usually cadaver
definition: autograft
permanent skin graft taken from a donor site on the pt.'s body
definition: heterograft
temporary skin graft taken from another species.
definition: mesh graft
skin graft that is altered to create a mesh-like appearance in order to cover a larger surface area.
definition: sheet graft
skin graft is transferred directly from the donor site to the recipient site.
definition: split-thickness skin graft
a skin graft that contains only a superficial layer of the dermis in addition to the epidermis
definition: full-thickness skin graft
a skin graft that contains the dermis and the epidermis
burn location: anticipated deformity:

• anterior neck
flexion with possible lateral flexion
burn location: splinting type:

• anterior neck
soft collar, molded collar, philadelphia collar
burn location: splinting type:

• anterior chest and axilla
axillary or airplane splint, shoulder abduction brace
burn location: anticipated deformity:

• anterior chest and axilla
shoulder adduction, extension, and medial rotation
burn location: anticipated deformity:

• elbow
flexion and pronation
burn location: splinting type:

• elbow
gutter splint, conforming splint, three-point splint, air splint
burn location: anticipated deformity:

• hand
extension or hyperextension of the MCP joints, flexion of the IP jts, adduction and flexion of the thumb, flexion of the wrist
burn location: splinting type:

• hand
wrist splint, thumb spica splint, palmar or dorsal extension splint
burn location: anticipated deformity:

• hip
flexion and adduction
burn location: splinting type:

• hip
anterior hip spica, abduction splint
burn location: anticipated deformity:

• knee
flexion
burn location: splinting type:

• knee
conforming splint, three point splint, air splint
burn location: anticipated deformity:

• ankle
plantarflexion
burn location: splinting type:

• ankle
posterior foot drop splint, posterior ankle conforming splint, anterior ankle conforming splint
selective or non-selective debridement?

• sharp
selective
selective or non-selective debridement?

• enzymatic
selective
selective or non-selective debridement?

• autolytic
selective
selective or non-selective debridement?

• wet-to-dry
non-selective
selective or non-selective debridement?

• wound irrigation
non-selective
selective or non-selective debridement?

• hydrotherapy
non-selective
arterial or venous insufficiency ulcer?

• location: lower one-third of leg
arterial
arterial or venous insufficiency ulcer?

• location: toes, web spaces
arterial
arterial or venous insufficiency ulcer?

• location: dorsal foot
arterial
arterial or venous insufficiency ulcer?

• location: lateral malleolus
arterial
arterial or venous insufficiency ulcer?

• location: proximal to medial malleoulus
venous insufficiency
arterial or venous insufficiency ulcer?

• appearance: smooth edges, well defined
arterial
arterial or venous insufficiency ulcer?

• appearance: lack granulation tissue
arterial
arterial or venous insufficiency ulcer?

• appearance: tend to be deep
arterial
arterial or venous insufficiency ulcer?

• appearance: irregular shape
venous insufficiency
arterial or venous insufficiency ulcer?

• appearance: shallow
venous insufficiency
arterial or venous insufficiency ulcer?

• pain: severe
arterial
arterial or venous insufficiency ulcer?

• pain mild to moderate
venous insufficiency
arterial or venous insufficiency ulcer?

• pedal pulse: diminished or absent
arterial
arterial or venous insufficiency ulcer?

• pedal pulse: normal
venous insufficiency
arterial or venous insufficiency ulcer?

• no edema
arterial
arterial or venous insufficiency ulcer?

• increased edema
venous insufficiency
arterial or venous insufficiency ulcer?

• skin temperature: decreased
arterial
arterial or venous insufficiency ulcer?

• skin temperature: normal
venous insufficiency
arterial or venous insufficiency ulcer?

• tissue changes: thin and shiny
arterial
arterial or venous insufficiency ulcer?

• tissue changes: hair loss
arterial
arterial or venous insufficiency ulcer?

• tissue changes: yellow nails
arterial
arterial or venous insufficiency ulcer?

• tissue changes: flaking
venous insufficiency
arterial or venous insufficiency ulcer?

• tissue changes: dry skin
venous insufficiency
arterial or venous insufficiency ulcer?

• tissue changes: brownish discoloration
venous insufficiency
arterial or venous insufficiency ulcer?

• leg elevation decreases pain
venous insufficiency
arterial or venous insufficiency ulcer?

• leg elevation increases pain
arterial
Dressing: used for partial and full-thickness wounds
• Hydrocolloids
• Foam Dressings
• Alginates
Dressing: used for granular or necrotic wounds
• Hydrocolloids
Dressing: provides a moist environment for wound healing
• Hydrocolloids
• Hydrogels
• Foam Dressings
• Transparent film
Dressing: Enables autolytic debridement
• Hydrocolloids
• Hydrogels
• Foam Dressings
• Transparent Films
• Alginates
Dressing: Offers protection from microbial contamination
• Hydrocolloids
• Alginates
Dressing: Provides moderate absorption
• Hydrocolloids
• Foam Dressing
Dressing: Does not require a second layer
• Hydrocolloids
• Adhesive version of Foam Dressing
• Gauze
Dressing: Provides a waterproof surface
• Hydrocolloids
Dressing: May traumatize surrounding intact skin upon removal
• Hydrocolloids
• Adhesive form of Foam Dressing
• Adhesive form of Transparent film
• Gauze
Dressing: May tend to roll in areas of excessive friction
• Hydrocolloids
• Foam Dressings
Dressing: Cannot be used on infected wounds
• Hydrocolloids
• Transparent films
Dressing: Used for superficial and partial-thickness wounds
• Hydrogels
• Transparent films
Dressing: Used for minimal drainage
• Hydrogels
• Transparent films
Dressing: May reduce pain/pressure
• Hydrogels
Dressing: Can be used as coupling agent for ultrasound
• Hydrogels
Dressing: Minimally adheres to wound
• Hydrogels
Dressing: Potential for dressing to dehydrate
• Hydrogels
Dressing: Cannot be used on wound with significant drainage
• Hydrogels
• Transparent Films
Dressing: Typically requires second dressing
• Hydrogels
• Non-adhesive form of Transparent films
• Alginates
Dressing: Used for varying levels of exudate
• Foam dressings (up to moderate level of absorption)
• Gauze
Dressing: Provides protection and cushioning
• Foam dressings
Dressing: Lack of transparency makes inspection of wound difficult
• Foam dressing
Dressing: Allows visualization of wound
• Transparent films
• Some Hydrocolloids
Dressing: resistant to shearing forces
• Transparent films
Dressing: cost-effective
• Transparent films (over time)
• Gauze
Dressing: Excessive accumulation of exudate can result in maceration
• Transparent films
Dressing: Can be used for wet-to-wet, wet-to moist, or wet-to-dry debridement
• Gauze
Dressing: Can be used on infected or non-infected wounds
• Gauze
• Alginates
Dressing: Can be used alone or in combination with other dressings or topical agents
• Gauze
Dressing: Can modify number of layers to accomodate for changing wound status
• Gauze
Dressing: Adheres to wound
• Gauze
Dressing: Requires frequent dressing change
• Gauze
• Alginates
Dressing: non-occlusive --> increased infection rate
• Gauze
Dressing: Used for pressure wounds or venous insufficiency ulcers
• Alginates
Dressing: moisture-retentive
• Hydrogels
Dressing: High absorptive capacity
• Alginates
Dressing: non-adhering to wound or skin
• Alginates
Dressing: cannot be used on wounds with exposed tendon, joint capsule or bone
• Alginates
Which dressing would you use? minimal drainage pressure ulcer stage II, keep under frequent observation
• Transparent Film
Which dressing would you use? moderate drainage pressure ulcer stage IV, want to observe it.
• Hydrocolloids (a transparent one)
Dressing: Order from most to least occlusive:
• Hydrocolloids • Hydrogels •Semi-permeable foam • Semi-permeable film • Impregnated gauze • Alginates • Normal (traditional) gauze
Which dressing would you use? pt. with diabetes, pressure ulcer on 1st met. head, Stage III, infected
• Alginates
Which dressing would you use? pt. with diabetes, pressure ulcer on 1st met. head, Stage IV, necrotic
• Hydrocolloids
Which dressing would you use? pt. with diabetes, pressure ulcer on 1st met. head, stage IV, infected
• Gauze

• since it's infected, can't used hydrocolloids. since it's stage IV can't use alginates - exposed tissue.
Dressing: Most moisture retentive to least:
• Alginates • Semi-permeable foam • Hydrocolloids • Hydrogels • Semi-permeable films
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Term:
Definition:
Definition:

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