Mod 2 Assisting With Wound Care Flashcards
Boggy
Wet spongy area
Bony prominence
An area on the body where the underlying bone seems to “stick out” (eg: the elbow)
Coccyx
Also known as the tailbone; the bony tip of the spine
Dermis
The inner layer of the skin that contains the nerve endings, blood vessels, oil glands, and sweat glands
Dynamic
Something that is constantly changing; an interacting living thing
Epidermis
The external layer of cells that make up the skin. It is the protective layer and does not contain blood vessels
Friction
Resistance that skin encounters when it rubs against another surface such as clothing, bedding, or another fold of skin
Integrity
Unbroken, complete, intact
Necrotic tissue
Localized death cells or tissue from injury, disease or lack of ice gum and nutrients to the cells
Non blanchable
A redness that persists when fingertip pressure is applied. Non blanchable skin over a pressure site is a symptom of a stage 1 pressure ulcer
Pathogen
A microorganism capable of producing an illness
Shearing
Shearing force occurs when the skin remains in a fixed position and the underlying tissue slides in the opposite direction
Skin ulcer
Localized injury to skin or underlying tissue
Subcutaneous fat
The tissue lies beneath the dermis skin layer. Subcutaneous fat is a shock absorber, helping to cushion the skin against trauma
Purulent drainage
Thick drainage from a wound or body orfice, which may have a foul odour, purulent drainage is yellow, green or brown and may indicate infection
Sanguineous
Bloody drainage
Serous
Drainage that is clear and water fluid
Serosangunineous
Thin, watery drainage that is blood tinged
What is the difference between a pressure injury and a wound caused from shear force?
A pressure injury occurs when tissue over a bony prominence is squeezed between hard surfaces. The blood supply is compromised and I even and nutrients are cut off from the tissue; as a result the tissue dies
Shear force is caused when the skin sticks to a surface and the underlying tissue and bone slide. The blood vessels are stretched or torn, which decreases the blood supply that nourishes the tissue
During a bed bath for Mrs Oliver you notice red open weeping areas under both her breasts, this is a result of;
Moisture breakdown
What are the phases of wound healing?
Inflammatory phase, proliferative phase, maturation phase
Pressure areas are most commonly found on which part of the body?
Coccyx
A client has Huntington’s disease. The OT has provided her with elbow protectors, what type of skin breakdown was Mrs H at risk for developing?
Friction
Which situation presents a risk factor for developing a pressure injury?
Having later stage dementia
You observe a reddened area on Mr N left hip area. What should your next action be?
Reposition in a right lateral position
You are changing a clients heel dressing and when you attempt to remove the old dressing, the dressing sticks to the wound. What would be the best action to take?
Refer to the clients care plan. Soak the dressing with the prescribed wound cleanser and then slowly attempt to remove the old dressing.
You are asked to perform a dressing change on Mr G pressure injury. How do you find out the dressing procure for Mr G?
Check the care plan
The procedure for Mr G wound directs you to cleanse it with gauze and soaked in normal saline. What step would you follow when cleansing his wound?
Start at the top of the centre of the wound and wipe down. Change your gauze with each wipe, and continue the process moving from the centre to the area surrounding the breakdown.
What are the characteristics of a stage 1 pressure injury?
Intact reddened area on the skin
A skin tear can be caused by:
Removing a dressing adhesive in a quick and upwards motion
Which of the following purposes is not a function of a wound dressing?
To prevent drainage
