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118 - INP > Class 13: Wound Care > Flashcards

Class 13: Wound Care Flashcards

1
Q

abrasion

A

superficial with little bleeding and considered a partial thickness wound (scrape)

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2
Q

blanching

A

occurs when normal red tones of light skinned patients are absent

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3
Q

contusion

A

happens when an injured capillary or blood vessel leaks blood into the surrounding areas. blunt object injury.

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4
Q

erythema

A

redness of skin or mucous membranes caused by hyperemia in superficial capillaries

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5
Q

hyperemia

A

increased blood flow

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6
Q

laceration

A

a jagged, unintentional (non surgical) wound, sometimes bleeds more profusely, depending on depth and location (cut)

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7
Q

penetrating wounds

A

caused by objects that penetrate the body, causing an open wound (deep)

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8
Q

pressure ulcer (pressure injury)

A

localized to skin and underlying tissue, usually over a bony prominence, as a result of shear, pressure or friction

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9
Q

puncture wound

A

usually small, circular wound with edges coming together toward centre.

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10
Q

skin tear

A

traumatic injury caused by friction, or a combination of shear and friction forces strong enough to separate the epidermis from the dermis. can happen easily

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11
Q

approximation

A

skin edges are closed, decreased risk of infection

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12
Q

epithelialization

A

surface of skin is repaired

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13
Q

exudate

A

describes the colour, consistency and odour of wound drainage, and it part of the wound assessment

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14
Q

fibrin

A

formed by clots to later provide a framework for cellular response

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15
Q

granulation tissue

A

red, moist tissue composed of new blood vessels, which indicates progression toward healing

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16
Q

hemostasis

A

injured blood vessels constrict, and platelets gather to stop bleeding

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17
Q

purulent

A

thick, yellow, green, tan or brown

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18
Q

serous

A

clear, watery plasma

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19
Q

serosanguineous

A

pale, red, watery. mix of clear red fluid

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20
Q

impaired mobility - affects on metabolism

A

bone wasting can occur - use weight bearing activities

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21
Q

effects of impaired mobility for infants and children

A

physiological growth and development

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22
Q

effects of impaired mobility for adolescents

A

impact social development/sexuality

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23
Q

effects of impaired mobility for young and middle adults

A

impacts social networks/ work ability

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24
Q

effects of impaired mobility for older adults

A

rapid decrease of independence, and rapid losses

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25
Q

impaired mobility - affects on respiratory

A

fluid build up, risk for pneumonia

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26
Q

impaired mobility - affects on cardiovascular system

A

edema or blood clot risk, movement to keep blood flowing

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27
Q

impaired mobility - affects on musculoskeletal

A

whole body muscle atrophy, contractures, weakened bones

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28
Q

impaired mobility - affects on urinary elimination

A

incontinence, pooling of urine (stasis), increased risk of UTI

29
Q

impaired mobility - affects on integumentary

A

huge risk factor. encourage self movement

30
Q

impaired mobility - physiological effects

A

loss of independence, depression, isolation, behavioural changes, sleep-wake disturbances, altered coping patterns

31
Q

friction

A

two surfaces rubbing against each other

32
Q

how does moisture affect skin tissue

A

incontinence , decreased skin resistance to other physical factor

33
Q

shear

A

tissue over bone is moving, force exerted against the skin, while the skin remains stationary and bone moves

34
Q

what factors affect skin tissue

A

friction, moisture, and shear

35
Q

what factors affect skin integrity

A

nutrition, infection, age

36
Q

cachexia

A

generalized malnutrition

37
Q

nutrition

A

if you have a protein deficiency, soft tissue becomes vulnerable to breakdown

38
Q

infection

A

a fever increases metabolic needs of the body which puts hypoxic tissue at risk and an increase of moisture

39
Q

diaphoresis

A

increased moisture

40
Q

what happens to the skin with age

A

structures changes

  • decrease in dermal thickness
  • increase in skin tears
41
Q

what can you do to decrease the risk of skin breakdown

A
  • pat dry, don’t rub
  • make sure no folds in linens
  • increase fluid intake
  • bed position make sure knees are up to avoid slips
  • hygiene
42
Q

tissue ischemia

A

occurs when capillary blood flow is obstructed by pressure

43
Q

reactive blanching hyperaemia *****

A

this is a normal process that causes the blood vessels to dilate in the injured area and prevents tissue trauma. caused by crossed legs the underneath leg is red and then apply pressure it goes white (moving of blood to area).

44
Q

non blanching reactive hyperaemia ***

A

indicates tissue damage. redness stays

45
Q

skin assessment

A

check the whole body, but pay special attention to bony areas. assess the skin in the morning and evening when dressing or undressing or changing position. check more frequently

46
Q

SIRA/Braden scale

A

skin integrity risk assessment used for predicting pressure ulcer risk

47
Q

acute wounds

A

wound from trauma or a surgical incision. usually easily cleaned and repaired. orderly and timely healing process

48
Q

chronic wounds

A

wound from a vascular compromise, chronic inflammation or repetitive insults to tissue. continued exposure to insult impedes wound healing. not an orderly or timely healing process

49
Q

stages of pressure ulcer

A

stage 1: skin is unbroken but inflamed
stage 2: skin is broken to dermis or epidermis
stage 3: ulcer extends to subcutaneous fat layer
stage 4: ulcer extends to muscle or bone. undermining is likely

50
Q

steps of wound healing

A

injury - hemostasis - inflammation phase - proliferative phase - remodelling stage - wound healed

51
Q

wound action

A

blood cells vessels constrict - bleeding stops - removal of debris begins - plus damaged vessels q

52
Q

inflammatory phase

A

3 days.

  • WBC clean wound of debris and bacteria
  • exudate (wound drainage)
  • pain (due to pressure from swelling, nerve involvement)
  • heat (due to metabolic activity and blood flow)
  • erythema (vasodilation)
  • swelling (increased vessel permeability)
53
Q

proliferative phase

A

3-24 days

  • new blood vessels appear
  • wound fills in with granulation tissue
  • wound contracts (pale and pink)
  • resurfacing of the wound by epithelialization
54
Q

remodelling phase

A

one year or more

  • maturation of the wound
  • closure of defect
55
Q

fact about scar tissue

A

scar tissue is only 80% as strong as normal tissue

56
Q

primary intention

A

wound edges well approximated, healing occurs by epithelization, heals quickly with minimal scar formation

57
Q

secondary intention

A

wound heals by granulation tissue formation, wound contraction and epithelialization

58
Q

tegaderm

A

film dressing for wounds

59
Q

macerated

A

wound is too wet underneath

60
Q

tertiary intention

A

closure of wound is delayed until risk of infection is resolved

61
Q

linear or flap tear

A

can be repositioned to cover the wound bed

62
Q

partial flap loss

A

can’t be repositioned to cover wound

63
Q

total flap loss

A

exposing entire wound bed

64
Q

sanguineous

A

bright red, active bleeding

65
Q

treatment of wounds

A
  • reduce risk factors
  • improve nutritional status
  • cleanse with normal saline
  • cover, protect and cushion the area
66
Q

what to do for dressing changes

A
  • medical asepsis: dressing change
  • meticulous hand washing
  • maintain clean field, clean gloves, sterile supplies
  • use in home care settings, LTC, for chronic or simple wounds
67
Q

documentation for wound care

A
  • date and time
  • describe old dressing, drainage, approximation of wound edges
  • cleansing and solution
  • condition of wound
  • new dressing applied
  • clients tolerance of procedure
68
Q

skin care aids

A

improve circulation, decrease pressure, provide comfort

69
Q

compression (TED) stockings

A
  • maintain internal pressure on muscles of lower extremities
  • promote venous return
  • removed and reapplied at least two times a day
  • stockings must be clean and dry
  • avoid wrinkles
  • requires physicians order

118 - INP (16 decks)

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