Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

fundamentals of nursing > ch 33 skin integrity & wound care > Flashcards

ch 33 skin integrity & wound care Flashcards

You may prefer our related Brainscape-certified flashcards:
Nursing Pharmacology flashcards NCLEX-RN® flashcards Nursing Mental Health flashcards Nursing Fundamentals flashcards Nursing Safety & Infection flashcards Nursing Adult Health flashcards NCLEX-PN® flashcards Nursing Management of Care flashcards Nursing Pediatrics flashcards Nursing Maternity flashcards
1
Q

abscess

A

collection of infected fluid that has not been drained

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

biofilm

A

a thick grouping of microorganisms

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

debridement

A

cleaning away devitalized tissue & foreign matter from a wound

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

dehiscence

A

separation of the layers of a surgical wound; may be partial, superficial, or a complete disruption of the surgical wound

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

dermis

A

layer of the skin below the epidermis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

desiccation

A

dehydration; the process of being rendered free from moisture

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

epidermis

A

superficial layer of the skin

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

epithelialization

A

stage of wound healing in which epithelial cells form across the surface of a wound; tissue color ranges from the color of “ground glass” to pink

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

erythema

A

redness of the skin

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

eschar

A

thick, leathery scab or dry crust that is necrotic and must be removed for adequate healing to occur

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

evisceration

A

protrusion of viscera (organs) through an incision

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

exudate

A

fluid that accumulates in wound; may contain serum, cellular debris, bacteria, & wbc

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

fistula

A

an abnorm passage from an internal organ to the skin or from one internal organ to another

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

friction

A

occurs when 2 surfaces rub against each other; the resulting injury resembles an abrasion & can also damage superficial blood vessels directly under the skin

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

granulation tissue

A

new tissue that is pink/red in color & composed of fibroblasts & small blood vessels that fill an open wound when it starts to heal

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

hematoma

A

localized mass of usually clotted blood

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

ischemia

A

deficiency of blood in a particular area

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

maceration

A

softening through liquid; overhydration

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

negative pressure wound therapy

A

NPWT

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

pressure injury

A

1) localized damage to the skin & underlying tissue that usually occurs over a bony prominence or is related to the use of a (medical or other) device
2) any lesion caused by unrelieved pressure that results in damage to underlying tissue; formerly known as pressure ulcer

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

purulent drainage

A

comprised of wbc, liquefied dead tissue debris, & both dead & live bacteria

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

sanguineous drainage

A

the initial discharge produced after an injury or an open wound where the skin is broken

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

scar

A

connective tissue that fills a wound area

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

serosanguineous drainage

A

mixture of serum & rbc

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

serous drainage

A

composed of clear, serous portion of the blood & from serous membranes

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

shear

A

when tissue layers move over the top of each other, causing blood vessels to stretch and break as they pass through the subcutaneous tissue

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

subcutaneous tissue

A

underlying layer that anchors the skin layers to the underlying tissue of the body

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

vasoconstriction

A

the narrowing (constriction) of blood vessels by small muscles in their walls

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

vasodilation

A

the dilatation of blood vessels, which decreases blood pressure

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

what are the functions of the skin

A

protection
body temp reg
psychosocial
sensation
vit d produc
immunologic
absorption
elimination

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

resistance to injury is affected by…

A

age, amt of underlying tissues; & illness

32
Q

children less than 2 yo

A

-thinner & weaker skin
-easily injured & subj to infection, increased risk for dehydration

33
Q

older adults

A

-circulation & collegen formation impaired
-decreased elasticity
-increased risk of tissue damaged from pressure

34
Q

_____ _____ during illness causes dehydration & predisposes skin to breakdown

A

fluid loss

35
Q

_____ causes increased risk for excoriation & open wounds

A

jaundice

36
Q

intentional wounds

A

e.g. surgical incisions

37
Q

unintentional

A

traumatic

38
Q

neuropathic/vascular

A

occur when a patient with the poor neurological function of the peripheral nervous system has pressure points that cause ulceration through the epidermal and dermal tissue layers

39
Q

pressure-related wounds

A
40
Q

classification of wounds

A

-open vs closed
-acute vs chronic
-partial thickness, full thickness, or complex

41
Q

contusion

A

bruise

42
Q

abrasion

A

superficial injury

43
Q

laceration

A

e.g. a cut caused by glass (no skin is missing)

44
Q

puncture

A

a type of cut that is made when a sharp object, like a nail, goes through the skin and into the tissue underneath (e.g . bite)

45
Q

penetrating

A

occurs when a foreign object pierces the skin and enters/remains in the body creating a wound

46
Q

avulsion

A

a forcible tearing off of skin or another part of the body, such as an ear or a finger

47
Q

irradiation

A

impact of energetic particles or photons

48
Q

venous ulcer

A

leg ulcers caused by problems with blood flow (circulation) in your leg veins

49
Q

arterial ulcer

A

a painful, deep sore or wound in the skin of the lower leg or foot due to lack of blood flow to the area

50
Q

diabetic ulcer

A

open sore or wound that occurs in approx 15% of pts with diabetes, and is commonly located on the bottom of the foot

51
Q

wound healing principles

A

-careful hand hygiene
-systemic process
-adequate blood supply
-wound is clean
-extent of damage and state of health
-proper nutrition

52
Q

hemostasis (wound healing stage)

A

-immediate after injury
-blood vessels constrict and clotting begins
-exudate is formed, causes swelling & pain
-increased perfusion, causes heat & redness
-platelets stimulate other cells to migrate to injury

53
Q

inflammatory phase

A

-lasts 2-3 days
-wbcs move to the wound, ingest debris, release growth factors to attract fibroblasts
-exudate cont to form and accumulate
-generalized body response to the injury

54
Q

proliferation phase

A

-lasts for several weeks
-new tissue is built by fibroblasts to fill the wound space
-capillaries grow across the wound space
-thin layer of epithelial cells forms across the wound
-granulation tissue forms a foundation for scar tissue

55
Q

maturation phase

A

-final stage (3 weeks after injury months-years)
-collagen is remodeled
-new collagen is deposited, compressing the blood vessels, which creates scar tissue
-scars do not sweat, grow hair, or tan

56
Q

local factors affecting wound healing

A

-pressure
-desiccation (the removal of moisture from something)
-maceration (the process of skin softening and breaking down due to prolonged contact with moisture that is usually not present on the skin)
-trauma
-edema
-infection
-excessive bleeding
-necrosis
-presence of biofilm
-primary vs secondary intention

57
Q

systemic factors affecting wound healing

A

-age
-circulation & oxygen
-nutritional status
-wound etiology
-health status
-immunosuppression
-medication use
-adherence to treatment plan
-didn’t heal acronym

58
Q

wound complication

A

-infection
-hemorrhage (the release of blood from a broken blood vessel, either inside or outside the body)
-dehiscence
-evisceration
-fistula formation (abscess)

59
Q

mechanisms in pressure injury development

A

-external pressure
-friction or shearing forces
-microclimate

60
Q

stages of pressure injuries

A

stage 1: nonblanchable erythema of intact skin
stage 2: partial-thickness skin loss w exposed dermis
stage 3: full-thickness skin loss, not involving underlying fascia
stage 4: full-thickness skin & tissue loss
unstageable: obscured full-thickness skin & tissue loss, eschar
deep tissue pressure injury: persistent non-blanchable deep red, maroon, or purple discoloration

61
Q

preventing pressure injuries

A

-assess daily
-cleanse
-protect (from excess moisture)
-minimize friction/shearing forces
-positioning, turning
-support surfaces
-nutritional supplements
-improve mobility & activity

62
Q

serous

A

clear, thin, & watery fluid

63
Q

serosanguineous

A

thin & watery w light red or pink hue

64
Q

sanguineous

A

bright red, fresh blood (may be hemorragic)

65
Q

purulent

A

thick, opaque & odorous build-up from infection

66
Q

wound dressing for maintaining moisture

A

tegaderm transparent film

67
Q

wound dressing for absorbing moisture

A

-hydrocolloid dressing
-alginate dressing
-foam dressing (mepilex)

68
Q

wound dressing for adding moisture

A

hydrogels

69
Q

types of wound dressings for securement

A

-roller bandages (kerlex, ACE wrap); should be spiral or figure-8 wrapped to avoid compression
-binders (abdominal, chest)

70
Q

pressure injury drsg changes are usually a _________ procedure

A

sterile

71
Q

remove old dressing

A

-assess the wound, measure
-note the drainage, type of tissue to wound bed, etc…

72
Q

cleanse the wound

A

-new gauze for each wipe
-clean to dirty - center of wound to the outside w each wipe
-irrigation w normal saline (NS), if ordered
-dry in same manner w gauze

73
Q

open systems wound drains

A

penrose drain (a soft, flexible rubber tube that drains fluid away from a wound)

74
Q

close systems wound drains

A

-jackson-pratt drain (closed-suction medical device that is commonly used as a post-operative drain for collecting bodily fluids from surgical sites)
-hemovac drain (drainage tube, larger and can hold more fluid than jp drains)
-negative pressure wound therapy (wound vac)

75
Q

applying heat

A

-dilates perpipheral blood vessels
-increases tissue metabolism
-reduces blood viscosity & increases capillary permeability
-reduces muscle tension
-helps relieve pain

76
Q

applying cold

A

-constricts peripheral blood vessels
-reduces muscle spasms
-promotes comfort

77
Q

safety of application of hot or cold treatments

A

-15-20 min at a time
-never apply excess pressure
-never place the body on top of material, rather place the material on top of the body area

fundamentals of nursing (14 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions