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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
impaired mobility - affects on respiratory
fluid build up, risk for pneumonia
26
impaired mobility - affects on cardiovascular system
edema or blood clot risk, movement to keep blood flowing
27
impaired mobility - affects on musculoskeletal
whole body muscle atrophy, contractures, weakened bones
28
impaired mobility - affects on urinary elimination
incontinence, pooling of urine (stasis), increased risk of UTI
29
impaired mobility - affects on integumentary
huge risk factor. encourage self movement
30
impaired mobility - physiological effects
loss of independence, depression, isolation, behavioural changes, sleep-wake disturbances, altered coping patterns
31
friction
two surfaces rubbing against each other
32
how does moisture affect skin tissue
incontinence , decreased skin resistance to other physical factor
33
shear
tissue over bone is moving, force exerted against the skin, while the skin remains stationary and bone moves
34
what factors affect skin tissue
friction, moisture, and shear
35
what factors affect skin integrity
nutrition, infection, age
36
cachexia
generalized malnutrition
37
nutrition
if you have a protein deficiency, soft tissue becomes vulnerable to breakdown
38
infection
a fever increases metabolic needs of the body which puts hypoxic tissue at risk and an increase of moisture
39
diaphoresis
increased moisture
40
what happens to the skin with age
structures changes - decrease in dermal thickness - increase in skin tears
41
what can you do to decrease the risk of skin breakdown
- 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
tissue ischemia
occurs when capillary blood flow is obstructed by pressure
43
reactive blanching hyperaemia *****
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
non blanching reactive hyperaemia ***
indicates tissue damage. redness stays
45
skin assessment
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
SIRA/Braden scale
skin integrity risk assessment used for predicting pressure ulcer risk
47
acute wounds
wound from trauma or a surgical incision. usually easily cleaned and repaired. orderly and timely healing process
48
chronic wounds
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
stages of pressure ulcer
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
steps of wound healing
injury - hemostasis - inflammation phase - proliferative phase - remodelling stage - wound healed
51
wound action
blood cells vessels constrict - bleeding stops - removal of debris begins - plus damaged vessels q
52
inflammatory phase
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
proliferative phase
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
remodelling phase
one year or more - maturation of the wound - closure of defect
55
fact about scar tissue
scar tissue is only 80% as strong as normal tissue
56
primary intention
wound edges well approximated, healing occurs by epithelization, heals quickly with minimal scar formation
57
secondary intention
wound heals by granulation tissue formation, wound contraction and epithelialization
58
tegaderm
film dressing for wounds
59
macerated
wound is too wet underneath
60
tertiary intention
closure of wound is delayed until risk of infection is resolved
61
linear or flap tear
can be repositioned to cover the wound bed
62
partial flap loss
can't be repositioned to cover wound
63
total flap loss
exposing entire wound bed
64
sanguineous
bright red, active bleeding
65
treatment of wounds
- reduce risk factors - improve nutritional status - cleanse with normal saline - cover, protect and cushion the area
66
what to do for dressing changes
- 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
documentation for wound care
- 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
skin care aids
improve circulation, decrease pressure, provide comfort
69
compression (TED) stockings
- 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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