Integumentary 313-327 Flashcards
Erythema
Diffuse redness if the skin from capillary dialation and congestion or inflammation
Ecchymosis
Discoloration occuring below intact skin from trauma to underlying blood vessels and blood seeping into tissues
Desiccated
Drying out or dehydration of a wound
What is hyperkeratosis
Callus
Deep partial-thickness burn
Complete destruction of epidermis
Majority of dermis
What is a laceration
Wound or irregular tear of tissue associated with trauma
What is an unstageable pressure ulcer
Full-thickness loss which base of ulcer is covered by slough in the wound bed
Monofilament testing is to see if the patient is at risk for developing
A neuropathic ulcer
Superficial partial-thickness burn
Epidermis and upper dermis
When would sharp debridement be used
Wounds with large amounts of thick, adherent, necrotic tissue
Cellulitis or sepsis
Indications for hydrogels
Superficial and partial-thickness wounds that have minimal drainage
What is primary intention
Smooth clean edges are reapproximated with sutures, stitches, or staples to facilitate re-epithelialization
Dehiscence
Separation of a wound closed by primary intention
What is a subcutaneous wound
Extends through integumentary tissues
Involve fat, muscle, tendon, bone, etc
What is stage 2 ulcer
Partial thickness tissue loss of dermis presents as shallow open ulcer with red or pink wound bed
Friable
Skin that rapidly tears when palpate
Zone of hyperemia
Has inflammation, but will fully recover without intervention
What is eschar
Hard or leathery, black/brown dehydrated tissue that is firmly attached to the wound bed
Different from arterial insufficiency ulcers, what should be done to the legs for venous insufficiency ulcers
Elevate legs above heart when sleeping
Indications for negative pressure wound therapy
Wounds that can’t be closed by primary intention
Healing for superficial partial-thickness burn time
5-21 days
Tertiary healing is AKA
Delayed primary intention
Indications for hydrocolloids
Partial and full-thickness wounds
What is an abrasion
Wound caused by friction and shear, scraping away superficial surfaces
Wounds that are infected or have loose debris call for
Wound irrigation/pulsatile lavage
Zone of coagulation
Area of burn that is most severe and has irreversible damage
The Wagner Ulcer Classification system is for
Diabetic foot ulcers
Hematoma
Localized swelling or mass of clotted blood confined to a tissue, organ, or space caused by a break in blood vessel
What kinds of wounds heal with secondary intention
Significant tissue necrosis
Irregular wound margins that can’t be reapproximated
Infection
Should autolytic debridement be used for infections
NOPE
Superficial burn
Only outer epidermis
Subdermal burn
Complete epidermis
Complete dermis
Complete subcutaneous tissue
In tertiary healing, what happens when risk factors have been alleviated
Primary intention healing
What is a partial thickness wound
Through epidermis and possibly into (but not through) dermis
What is a superficial wound
Epidermis intact
Non-blistering sunburn
Healing by xxxxx intention permits wounds to close on their own without superficial closure
Secondary intention
Zone of stasis
Less severe injury with reversible damage
Healing for deep-partial thickness burns
21-35 days
What should be avoided with arterial insufficiency ulcers
Unnecessary leg elevation
How does venous insufficiency and or lymphedema contribute to wound healing and why
They slow it down
because
increased tissue pressure from excessive edema impacts perfusion and removal of cellular waste (decreased O2)
What does seropurulent exudate look like
Cloudy or opaque, with yellow or tan color and thin watery consistency
Is the dermis vascularized
Yes
What is wet-to-dry dressing
Application of moistened gauze over necrotic tissue
Dressing dries and then is removed along with necrotic tissue adhered to gauze
What is stage 1 pressure ulcer
Intact skin with non-blanchable redness of localized area over bony prominence
How often should someone with a pressure ulcer be repositioned
Every 2 hours
What is slough
Moist, stringy, or mucinous, white/yellow tissue that tends to be loosely attached in clumps to the wound bed
How long does it take to heal a superficial burn
2-5 days
Wounds deeper than xxx are considered full thickness
4mm
The Braden Scale is for
Pressure ulcers
What is gangrene
Death and decay of tissue resulting from interruption in blood flow to an area of the body
What is seropurulent exudate indicative of
Impending infection and is ALWAYS abnormal
Full thickness burn
Complete destruction of epidermis
Complete destruction of dermis
Partial damage of subcutaneous fat
Disquamation
Peeling or shedding of outer layers of the epidermis
What is a full thickness wound
Through dermis
Into subcutaneous fat
Three zones of injury
Coagulation
Stasis
Hyperemia
For arterial insufficiency ulcers, are heating pads used
No
What kinda of wounds are healed with tertiary intention
Wounds that can develop sepsis or dehiscence
When can an unstageable pressure ulcer be staged
When slough is removed
