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NRSG 201 > Lab 9 skin and wound integrity > Flashcards

Lab 9 skin and wound integrity Flashcards

1
Q

if the braden scale is less than 18 how often should you reassess the client

A

Every two days or PRN

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2
Q

what is an intentional wound

A

a planned wound that is a result of therapy ie surgical incision

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3
Q

what is an unintentional wound

A

one that is a result of injury

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4
Q

whats the definition of a partial thickness skin tear

A

when there is separation between the epidermis and dermis

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5
Q

what is the definition of a full thickness skin tear

A

separation of the dermis/epidermis from the underlying structure

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6
Q

what are the four ways a wound can be described

A

Clean
clean contaminated
contaminated
infected

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7
Q

what is a clean wound

A

Primarily closed wounds with minimal inflammation where resp GI and GU tracts have not been entered

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8
Q

what is a clean contaminated wound

A

surgical wounds where there is no sign of infection but the resp GI and GU tracts have been entered under a controlled environment

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9
Q

what is a contaminated wound

A

-includes open fresh wounds caused by surgery or accident
-break in sterile technique or exposed to gross spillage
-non purulent inflammation is visible

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10
Q

what is the definition of an infected wound

A

-old traumatic wound with retained dead tissue
-has existing clinical infection
-internal body cavities have been perforated (ie GI tract)

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11
Q

what are the three types of wound repair

A

-Primary intention
-secondary intention
-tertiary intention

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12
Q

What is primary intention wound healing

A

when the tissue surfaces have been approximated and there is little to no tissue loss (ie incision)

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13
Q

What is secondary intention

A

when the wound edges can not be approximated and there is longer healing time

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14
Q

what is tertiary intention

A

wounds that are left open for 3-5 days and than closed

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15
Q

what are the 4 phases of partial thickness wound repair

A

-hemostasis
-inflammatory response
-epithelial proliferation and migration
-re establishment of the epithelial layers

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16
Q

what are the 4 phases of full thickness wound repair

A

-Hemostasis
-Inflammatory phase
-proliferative phase
-remodelling/ maturation phase

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17
Q

what 3 things happen during the homeostasis phase of wound healing

A

-vasoconstriction occurs to stop the bleeding
-platelets aggregate to from clot/scab
-wound edges start to pull in

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18
Q

how soon does hemostasis occur after injury

A

begins immediately after injury

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19
Q

how soon does the inflammatory phase start after injury

A

begins immediately after injury once bleeding is controlled

20
Q

how long does the inflammatory phase last

A

3-4 days after injury

21
Q

what happens during the inflammatory phase

A

WBC and macrophages engulf debris and bacteria and secrete angiogenesis factors that stimulate the formation of granulation tissue

22
Q

when does proliferation phase start and how long does it last

A

starts on day 3 or 4 and lasts for about 24 days

23
Q

what happens during the proliferative phase

A

fibroblasts begin to synthesize collagen and proteoglycan and capillaries grow across the wound which results in granulation tissue

24
Q

when does proliferative phase start

A

starts on day 3-4 after injury

25
how long does the proliferation phase last
lasts 21-24 days
26
when does the remodeling phase begin
begins once the wound is closed
27
how long does the remodeling phase last
can last for up to 2 years
28
what happens during the remodeling phase
fibroblasts continue to synthesize collagen and the collagen arranges itself in a more organized structure
29
What is induration
Redness/hardness spreading to surrounding tissue as part of the inflammatory response
30
What is Ecchymosis
bleeding into the subcutaneous tissue (bruising)
31
what are the 4 types of drainage that a wound can have
serous sanguineous Serosanguineous purulent
32
What does sanguineous drainage look like
Bright red as it is a result of fresh blood
33
when is a hemorrhage of a surgical wound most likely to occur
48 hours after surgery
33
What does serosanguineous drainage look like
thin watery fluid that is slightly red as its a mix of blood and serous fluid
33
how are retention sutures different from normal sutures
that also attach underlying tissues of fat and muscle as well as skin and as a result are much larger
33
What is an indication that a wound may dehiscence or evisceration
if there is an increased flow of serosanguinous drainage into the wound dressing
33
when is wound dehiscence or evisceration most likely to occur
4-5 days after operation
33
what should a nurse do if dehiscence or evisceration occurs
apply saline soaked sterile dressing place client in bed with knees bent call surgeon
33
what is wound contamination on the wound infection continum
-Wound contains low levels of non proliferating microbes -Wound healing is not impeded
33
What is a wound colonization
wound does have proliferating microbes but there is no host reaction yet
33
what is the main difference between sterile glove technique and no tough clean glove technique
in sterile glove only the sterile glove will ever touch the wound whereas in no touch clean glove only sterile instruments are used to tough the wound
33
how long are surgical dressing usually left on for after surgery
usually left on for the first 48 hours
34
True or false A sterile field becomes contaminated if it comes into contact with moisture from above or below the sterile surface
True
34
how often would you change a dressing on a superficial wound such as a skin tear and why
usually every 5-7 days because you want to decrease the risk of tearing the skin again
34
after a bottle of saline is opened how long is it considered sterile for
it is considered sterile for 24 hours

NRSG 201 (12 decks)

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