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NUR 231 Exam 2 > chap 32 > Flashcards

chap 32 Flashcards

1
Q

epidermis

A

outermost portion of skin

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2
Q

function of epidermis

A

protective layer

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3
Q

dermis

A

second layer of skin

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4
Q

what does the dermis contain?

A
  • connective tissue
  • collagen
  • nerves
  • hair follicles
  • immune cells
  • blood vessels
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5
Q

subcutaneous tissue

A

anchors skin layers to underlying tissues

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6
Q

what does the subcutaneous tissue contain?

A
  • adipose tissue

- connective tissues

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7
Q

function of subcutaneous tissue

A

stores fat, heat insulator, cushion

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8
Q

functions of skin

A
  • protection
  • temp regulation
  • person identity
  • sensation
  • vitamin D production
  • immunologic
  • absorption
  • elimination
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9
Q

four stages of wound healing

A
  • hemostasis
  • inflammatory phase
  • proliferation phase
  • maturation phase
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10
Q

hemostasis

A
  • immediate

- blood clotting

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11
Q

inflammatory phase

A
  • 2-3 days
  • WBC enters
  • macrophages release growth factors
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12
Q

proliferation phase

A
  • several weeks
  • fibroplastic connective tissue
  • beefy red
  • bleed easy
  • granulated tissue
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13
Q

maturation phase

A
  • 3 weeks after-years
  • collagen
  • scar forms
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14
Q

factors affecting wound healing

A
  • pressure
  • desiccation
  • maceration
  • trauma
  • edema
  • infection
  • excessive bleeding
  • necrosis
  • biofilm
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15
Q

pressure

A

persisten pressure disrupts blood flow

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16
Q

desiccation

A

when skin is dry, causes crust to form and delays healing

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17
Q

maceration

A
  • soft due to prolonged exposure to moisture
  • “prune”
  • risk for skin tears
  • delays healing
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18
Q

partial thickness loss

A

part of dermis is severed

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19
Q

full thickness loss

A

entire dermis is severed

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20
Q

wound complications

A
  • infection
  • hemorrhage
  • dehiscence
  • evisceration
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21
Q

dehiscence

A

partial or total separation of wound layers

-has been stapled or sutured

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22
Q

evisceration

A

wound completely separates w/ protrusion of organ through incision

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23
Q

pressure injuries caused by

A
  • pressure

- friction or sheer

24
Q

risks for pressure injuries

A
  • nutrition and hydration
  • mental status
  • immobility
  • moisture
  • age
25
Q

protein

A

collagen forming and wound remodeling

26
Q

calores

A

fuel for cell energy

27
Q

vitamin C

A
  • collagen synthesis
  • capillary wall integrity
  • immunological function
  • antioxidant
  • fibroblast function
28
Q

vitamin A

A
  • wound closure
  • inflammatory response
  • collagen formation
29
Q

zinc

A
  • collagen formation
  • protein synthesis
  • cell membrane and host defense
30
Q

fluid

A

essential fluid environment for all cell function

31
Q

vital nutrients for wound healing

A
  • protein
  • calories
  • vitamin C
  • vitamin A
  • zinc
  • fluid
32
Q

stage 1 pressure injury

A
  • intact skin
  • non-blanchable
  • painful
  • firm or soft
  • warmer or cooler compared to adjacent tissue
33
Q

stage 2 pressure injury

A
  • partial thickness loss
  • shallow, open ulcer
  • red, pink wound bed
  • “blister-like”
  • no slough
  • shiny or dry shallow ulcer
34
Q

stage 3 pressure injury

A
  • full thickness tissue loss
  • subcutaneous fat may be visible
  • slough may be present
  • no bone or muscle visible
35
Q

stage 4 pressure injury

A
  • full thickness tissue loss
  • bone/muscle/tissue visible
  • slough or eschar may be present
  • tunneling
36
Q

suspected deep tissue injury

A
  • purple or maroon
  • blood-filled blister
  • mushy/boggy
  • warmer or cooler compared to adjacent tissue
37
Q

unstageable pressure injury

A
  • full thickness loss
  • ulcer covered by slough or eschar
  • slough must be removed to promote healing
38
Q

wound assessment

A
  • location of wound
  • note size of wound
  • approximated?
  • drainage
39
Q

primary intention

A
  • surgical incisions
  • well approximated and risk of infection is low
  • minimal scar
40
Q

secondary intention

A
  • not well approximated
  • large open wound
  • filled by scar tissue
  • longer to heal
  • loss of tissue function is often permanent
41
Q

tertiary intention

A
  • delayed primary closure

- wounds open for several days

42
Q

transparent films

A
  • stage 1, partial thickness
  • minimal drainage
  • allows visualization of wound
  • maintain moist wound environment
  • allow exchange of oxygen
43
Q

hydrocolloid

A
  • partial & full thickness wounds
  • stage 2 and 3 pressure injuries
  • reduces friction
  • 3-7 days
44
Q

hydrogel

A
  • partial & full thickness wounds
  • stage 2-4 pressure injuries
  • necrotic wounds
  • minimal exudate
  • on infected wounds
45
Q

alginates

A
  • absorbs exudate
  • partial and full thickness wounds
  • stage 3 & 4 pressure injuries
  • infected & non-infected wounds
  • moderate to heavy exudate
46
Q

foams

A
  • partial & full thickness wounds
  • stages 2-4 pressure injuries
  • surgical wounds
  • absorbs light to heavy amounts of drainage
47
Q

antimicrobials

A
  • partial & full thickness wounds
  • stage 2-4 pressure injuries
  • burns
  • draining non-healing wounds
  • reduce/prevent infection
48
Q

collagen

A
  • partial or full thickness wounds
  • stage 3 pressure injury
  • infected/noninfected wounds
  • primary dressing over grafts & donor sites
  • tunneling wounds
49
Q

contact layers

A
  • partial and full thickness wounds

- shallow dehydrated wounds

50
Q

composites

A
  • partial & full thickness wounds

- stages 1-4 pressure injuries

51
Q

negative pressure wound therapy

A
  • stage 3-4 pressure injuries
  • draining and non-healing wounds
  • stimulates increased blood supply and granulation
52
Q

hemovac drain

A
  • circular device is squeezed flat

- device expands as it fills with fluids

53
Q

jackson-pratt drain

A
  • closed-suction drain

- grenade-shaped bulb

54
Q

heat therapy

A
  • dilates blood vessels
  • increases tissue metabolism
  • reduces muscle tension
  • relieves pain
55
Q

cold therapy

A
  • constricts peripheral blood vessels
  • reduces muscle spasms
  • promotes comfort
  • controls bleeding
  • decreases swelling

NUR 231 Exam 2 (4 decks)

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