Ch. 36 Flashcards

1
Q

Hematoma

A

Localized collection of blood under the tissues.

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2
Q

Evisceration

A

Separation of wound layers with protrusion of visceral organs.

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3
Q

Approximate

A

wound edges come together

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4
Q

Abrasion

A

Superficial loss of dermis

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5
Q

Shearing force

A

pressure exerted against the skin when the patient is moved.

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6
Q

Cachexia

A

general poor health and malnutrition with weakness and emaciation. loss of adipose tissue.

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7
Q

Debridement

A

Removal of devitalized tissue.

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8
Q

Laceration

A

Torn, jagged damage to the epidermis

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9
Q

Dehiscence

A

Separation of skin and tissue layers.

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10
Q

Fistula

A

Abnormal passage between two body organs or between an organ and the outside of the body.

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11
Q

Example of a contributing for pressure ulcer formation:

A

Shear, friction, moisture on the skin, poor nutrition, cachexia, infection, impaired peripheral circulation, obesity, advanced age.

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12
Q

A clean surgical wound with little tissue loss heals by:

A

primary intention

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13
Q

A severe laceration or chronic wounds heal by:

A

secondary intention

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14
Q

Separation of the layers of the skin with serosanguineous drainage noted.

A

dehiscence

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15
Q

Bluish swelling or mass at the site

A

hematoma/ bleeding

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16
Q

Fever, general malaise, and increased white blood cell count

A

Infection

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17
Q

Decreased blood pressure, increased pulse rate, increased respirations.

A

bleeding/shock

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18
Q

Green, odorous local drainage

A

infection

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19
Q

Visceral organs protruding through abdominal wall

A

Evisceration

20
Q

Wound edges swollen, painful, with redness, extending from the edges outward.

A

infection

21
Q

Wound drainage:Serous

A

Clear, watery plasma

22
Q

Wound drainage: Sanguineous

A

Fresh bleeding

23
Q

Wound drainage: Serosanguineous

A

Pale, more watery, with plasma and red blood cells

24
Q

Wound drainage; purulent

A

Thick, yellow, green, or brown with organisms and white blood cells

25
Q

Steps for obtaining an aerobic wound culture:

A
  1. cleanse the wound and allow to dry.
  2. Moisten swab with normal saline
  3. Swab wound in a 1X1 cm area
  4. Apply pressure to express fluid from wound onto swab.
  5. Return the swab to the culture tube.
26
Q

For wound irrigation, identify the following that are considered as safe guidelines; Syringe size, needle gauge, psi?

A

syringe size:35 mL
Needle gauge: 19 gauge
psi: 8

27
Q

The nurse should be held how far above the wound?

A

1 in (2.5 cm) above the wound.

28
Q

During the irrigation, the nurse notes sanguineous return. The nurse should?

A

reduce the irrigating pressure and notify the health care provider.

29
Q

Identify the steps in caring for a traumatic wound:

A

1) stabilize the pt cardiopulmonary function.
2) promote hemostasis (stop any bleeding)
3) cleanse the wound
4) protect the site for further injury.

30
Q

Tissue Ischemia

A

decreased blood flow to tissue resulting in tissue death, occurs when capillary blood flow is obstructed, as in the case of pressure.

31
Q

Blanchable hyperemia

A

area that appears red and warm will blanch

32
Q

Nonblanchable hyperemia

A

is redness that persists after palpation and indicates tissue damage.

33
Q

Unstageable

A

Full-thickness tissue loss in which the base of the ulcer is covered by slough.

34
Q

A wound with little or no tissue loss such as a clean surgical incision, heals by:

A

Primary intention

35
Q

A wound involving loss of tissue such a severe laceration, heals how?

A

secondary intention

36
Q

Full thickness wound repair:

A

Hemostasis, inflammation, proliferative, remodeling.

37
Q

Hemostasis phase

A

involving a full thickness wound healing by primary intention is hemostasis, the control of bleeding.

38
Q

Inflammation phase

A

establish a clean wound bed and to obtain bacterial balance.

39
Q

Proliferative phase

A

production of new tissue, epithelialization, and contraction.

40
Q

Remodeling phase

A

last up to 1 year, reorganizes collagen to produce more elastic, stronger collagen for the scar tissue.

41
Q

Ecchymosis

A

skin discoloration, or bruising caused by blood leakage into subcutaneous tissues after trauma to underlying vessels.

42
Q

maceration

A

softening of the skin due to moisture

43
Q

Types of dressings:

A

Hydrocolloid, hydrocel

44
Q

Hydrocolloid

A

gelling agents and have adhesive wound surface.

45
Q

Hydrocel

A

available in sheets or gel in a tube. high percentage of water and are indicated for wounds that require moisture, either a wound with granulation (maintaining the moist wound environment needed for healing) or a wound that has high necrotic tissue.