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N11 - Nursing Foundations > Skin Integrity and Wound Care > Flashcards

Skin Integrity and Wound Care Flashcards

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1
Q

presence of normal skin and skin later uninterrupted by wounds

A

intact skin

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2
Q

what are the factors that affect skin integrity?

A

genetics and integrity, age, underlying health, activity, illnesses, medications

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3
Q

occurs during therapy, examples are operations or venipuncture

A

intentional trauma

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4
Q

accidental; examples are fracture

A

unintentional wounds

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5
Q

tissues are traumatized without a break in the skin

A

closed wounds

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6
Q

skin or mucous membrane surface is broken

A

open wounds

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7
Q

uninfected wounds in which there is minimal inflammation and the respiratory, gastrointestinal, genital, and urinary tracts are not entered; primarily closed wounds.

A

clean wounds

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8
Q

surgical wounds in which the respiratory, gastrointestinal, genital, or urinary tract has been entered; show no evidence of infection

A

clean-contaminated wounds

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9
Q

include open, fresh, accidental wounds and surgical wounds involving a major break in sterile technique or a large amount of spillage from the gastrointestinal tract; show evidence of inflammation

A

contaminated wounds

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10
Q

include wounds containing dead tissue and wounds with evidence of a clinical infection

A

Dirty or infected wounds

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11
Q

confined to the skin (dermis and epidermis), and can be healed by regeneration

A

Partial thickness

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12
Q

involving the dermis, epidermis, subcutaneous tissue, and possibly muscle and bone, and require connective tissue repair

A

Full thickness

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13
Q

caused by a sharp instrument

A

incision

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14
Q

blow from a blunt instrument

A

contusion

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15
Q

surface scrape, either unintentional or intentional

A

abrasion

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16
Q

penetration of the skin and often the underlying tissues by a sharp instrument, either intentional or unintentional

A

puncture

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17
Q

tissues torn apart often from accidents

A

laceration

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18
Q

penetration of the skin and the underlying tissues, usually unintentional

A

penetrating wound

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19
Q

injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of force alone or in combination with movement; previously called decubitus ulcers, pressure sores, or bedsores; due to localized ischemia

A

Pressure ulcers

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20
Q

bright red flush that occurs when pressure is relieved from the skin; usually lasts one half to three quarters as long as the duration of impeded blood flow; If the redness disappears in that time, no tissue damage is anticipated. If, however, the redness does not disappear, then tissue damage has occurred

A

reactive hyperemia

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21
Q

friction and shearing, immobility, inadequate nutrition, fecal and urinary incontinence, decrease mental status, diminished sensation, excessive body heat, advanced age, chronic medical conditions, poor lifting and transferring techniques, incorrect positioning, hard support surfaces, and incorrect application of pressure-relieving devices are risk factors for what?

A

pressure ulcers

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22
Q

a force acting parallel to the skin surface; can abrade the skin, that is, remove the superficial layers, making it more prone to breakdown

A

Friction

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23
Q

a combination of friction and pressure; occurs commonly when a client assumes a sitting position in bed

A

Shearing force

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24
Q

a reduction in the amount and control of movement a person has

A

Immobility

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25
Q

What three conditions reduce the amount of padding between the skin and the bones, thus increasing the risk of pressure ulcer?

A

Prolonged inadequate nutrition causes weight loss, muscle atrophy, and the loss of subcutaneous tissue

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26
Q

abnormally low protein content in the blood

A

hypoproteinemia

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27
Q

presence of excess interstitial fluid; increases the distance between the capillaries and the cells, thereby slowing the diffusion of oxygen to the tissue cells and of metabolites away from the cells

A

edema

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28
Q

tissue softened by prolonged wetting or soaking

A

maceration

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29
Q

area of loss of the superficial layers of the skin; also known as denuded area

A

excoriation

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30
Q

TRUE OR FALSE: moisture from the incontinence makes the epidermis more easily eroded and susceptible to injury, digestive enzymes in feces, urea in urine, and gastric tube drainage also contribute; accumulation of secretions or excretions is irritating to the skin, harbors microorganisms, and makes an individual prone to skin breakdown and infection

A

TRUE

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31
Q

WHAT STAGE OF PRESSURE ULCER IS THIS: nonblanchable erythema signaling potential ulceration

A

stage I of pressure ulcer

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32
Q

WHAT STAGE OF PRESSURE ULCER IS THIS: partial-thickness skin loss involving the epidermis and possibly the dermis

A

stage II of pressure ulcer

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33
Q

WHAT STAGE OF PRESSURE ULCER IS THIS: full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia; presents clinically as a deep crater with or without undermining of adjacent tissue

A

stage III of pressure ulcer

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34
Q

WHAT STAGE OF PRESSURE ULCER IS THIS: full-thickness skin loss with tissue necrosis or damage to muscle, bone, or supporting structures

A

stage IV of pressure ulcer

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35
Q

WHAT STAGE OF PRESSURE ULCER IS THIS: full-thickness skin or tissue loss—depth unknown: actual depth of the ulcer is completely obscured by slough and/or eschar in the wound bed

A

unstageable/unclassified

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36
Q

WHAT STAGE OF PRESSURE ULCER IS THIS: depth unknown; purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear; eep tissue injury may be difficult to detect in individuals with dark skin tones

A

suspected deep tissue injury

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37
Q

what are the two risk assessment tools for pressure ulcers?

A

Braden Scale for Predicting Pressure Sore Risk, and Norton’s Pressure Area Risk Assessment Scoring System

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38
Q

what pressure ulcer risk assessment tool consists of six subscales: sensory perception, moisture, activity, mobility, nutrition, and friction and shear, and where a total of 23 points is possible and an adult who scores below 18 points is considered at risk?

A

Braden Scale for Predicting Pressure Sore Risk

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39
Q

what pressure ulcer risk assessment tool includes the categories of general physical condition, mental state, activity, mobility, and incontinence; category of medications is added by some users, resulting in a possible score of 24, and where scores of 15 or 16 should be viewed as indicators, not predictors, of risk?

A

Norton’s Pressure Area Risk Assessment Scoring System

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40
Q

begins immediately after injury and lasts 3 to 6 days, and involves 2 major processes: hemostasis and phagocytosis

A

inflammatory phase

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41
Q

cessation of bleeding; results from vasoconstriction of the larger blood vessels in the affected area, retraction (drawing back) of injured blood vessels, the deposition of fibrin (connective tissue), and the formation of blood clots in the area

A

hemostasis

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42
Q

may form on the surface of the wound, consists of clots and dead and dying tissue, and serves to aid hemostasis and inhibit contamination of the wound by microorganisms

A

scab

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43
Q

located below the scab, migrates into the wound from the edges, and serve as a barrier between the body and the environment, preventing the entry of microorganisms

A

epithelial cells

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44
Q

what does vascular and cellular responses do?

A

intend to remove any foreign substances and dead and dying tissues

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45
Q

_______ migrate into the interstitial space, and are replaced about 24 hours after injury by ________

A

leukocytes; macrophages

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46
Q

process in which macrophages engulf microorganisms and cellular debris

A

phagocytosis

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47
Q

secreted by macrophages, which stimulates the formation of epithelial buds at the end of injured blood vessels

A

angiogenesis factor

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48
Q

sustains the healing process and the wound during its life; this response is essential to healing

A

microcirculatory network

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49
Q

second phase in healing, extends from day 3 or 4 to about day 21 postinjury; fibroblasts (connective tissue cells), which migrate into the wound starting about 24 hours after injury, begin to synthesize collagen

A

proliferative phase

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50
Q

_______ grow across the wound, increasing the blood supply, and fibroblasts move from the bloodstream into the wound, depositing fibrin

A

capillaries

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51
Q

begins on about day 21 and can extend 1 or 2 years after the injury; fibroblasts continue to synthesize collagen; the wound is remodeled and contracted, and scar becomes stronger but the repaired area is never as strong as the original tissue

A

Maturation phase

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52
Q

assigns scores to the ulcer length, width, amount of exudate, and tissue type; the change in the total score over time can be used as an indication of healing

A

Pressure Ulcer Scale for Healing (PUSH) tool

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53
Q

_________ is when microorganisms are in the wound surface, and compete with new cells for oxygen and nutrition, and produce by products that can interfere with a healthy surface condition

A

colonization

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54
Q

what are the factors that affect wound healing?

A

age, nutritional status, lifestyle, and medications

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55
Q

growing only in the presence of oxygen; generally found on the surface of the wound

A

aerobic (organisms)

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56
Q

growing only in the absence of oxygen; found in deep wounds, tunnels, and cavities

A

anaerobic (organisms)

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57
Q

______ means closed

A

approximated

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58
Q

strip of cloth used to wrap some part of the body

A

bandage

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59
Q

type of bandage designed for a specific body part

A

binder

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60
Q

whitish protein substance that adds tensile strength to the wound; as the amount of collagen increases, so does the strength of the wound

A

collagen

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61
Q

reduces the swelling and keeps blood moving more efficiently in the injured area

A

compress

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62
Q

removal of the necrotic material

A

debridement

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63
Q

partial or total rupturing of a sutured wound; usually involves an abdominal wound in which the layers below the skin also separate

A

dehiscence

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64
Q

wound that does not close by epithelialization, and area becomes covered with dried plasma proteins and dead cells

A

eschar

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65
Q

protrusion of the internal viscera through an incision

A

evisceration

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66
Q

area of loss of the superficial layers of the skin; also known as denuded area

A

excoriation

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67
Q

material, such as fluid and cells, that has escaped from blood vessels during the inflammatory process and is deposited in tissue or on tissue surfaces

A

exudate

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68
Q

tissue that has translucent red color, is fragile and bleeds easily, that results from development of a capillary network

A

granulation tissue

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69
Q

a localized collection of blood underneath the skin that may appear as a red- dish blue swelling (bruise)

A

hematoma

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70
Q

massive bleeding; a dislodged clot, a slipped stitch, or erosion of a blood vessel may cause severe bleeding

A

hemorrhage

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71
Q

a deficiency in the blood supply to the tissue

A

ischemia

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72
Q

a hypertrophic scar, that results from abnormal amount of collagen

A

keloid

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73
Q

internal direct pressure that places gauze material directly on the lacerated blood vessels in an attempt to control bleeding

A

packing

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74
Q

tissue surfaces have been approximated (closed) and there is minimal or no tissue loss; formation of minimal granulation tissue and scarring; it is also called primary union or first intention healing

A

primary intention healing

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75
Q

thicker than serous exudate because of the presence of pus; vary in color depending on causative organism

A

purulent exudate

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76
Q

consists of leukocytes, liquefied dead tissue debris, and dead and living bacteria

A

pus

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77
Q

quality of living tissue; also known as healing

A

regeneration

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78
Q

large amounts of red blood cells, indicating damage to capillaries that is severe enough to allow the escape of red blood cells from plasma

A

sanguineous exudate

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79
Q

consisting of both clear and blood-tinged drainage, is commonly seen in surgical incisions

A

seroanguineous exudate

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80
Q

consisting of pus and blood, is often seen in a new wound that is infected

A

purosanguineous discharge

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81
Q

wound that is extensive and involves considerable tissue loss, and in which the edges cannot or should not be approximated; repair time is longer, scarring is greater, susceptibility to infection is greater

A

secondary intention healing

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82
Q

blood-tinged drainage

A

serosanguineous

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83
Q

consists chiefly of serum (the clear portion of the blood) derived from blood and the serous membranes of the body, such as the peritoneum; looks watery and has few cells; an example is the fluid in a blister

A

serous exudate

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84
Q

used to soak a client’s perineal or rectal area

A

sitz bath

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85
Q

process of pus formation

A

suppuration

86
Q

wounds that are left open for 3 to 5 days to allow edema or infection to resolve or exudate to drain and are then closed with sutures, staples, or adhesive skin closures heal; also called delayed primary intention

A

tertiary intention

87
Q

reduces blood flow to the affected area and thus reduces the supply of oxygen and metabolites, decreases the removal of wastes, and produces skin pallor and coolness

A

vasoconstriction

88
Q

extra blood floods to the area to compensate for the preceding period of impeded blood flow

A

vasodilation

89
Q

TRUE OR FALSE: Removing barriers to assessment is very important—Antiembolic stockings, braces, or devices must be removed to assess the skin condition underneath

A

TRUE

90
Q

TRUE OR FALSE: Assessing skinfolds such as under the breasts, in areas that are frequently moist such as the perineum, and in areas that receive extensive pressure are not necessary

A

FALSE—Particular attention is paid to skin condition in those areas since they are most likely to break down

91
Q

usually seen shortly after an injury

A

Untreated wounds

92
Q

usually assessed to determine the progress of healing

A

Treated wounds or sutured wounds

93
Q

only stains the dressing

A

Minimal drainage

94
Q

saturates the dressing without leakage

A

Moderate drainage

95
Q

overflows the dressing prior to scheduled change

A

Heavy drainage

96
Q

when the wound reaches under the skin surface, and can result in a sinus tract or tunnel

A

undermining

97
Q

To measure wound _______ is to place a second swab parallel to the first and measure the distance from the edge of the wound to the tip of the exposed swab

A

depth

98
Q

ASSESSING WOUND: should the nurse should assess location and extent of tissue damage, inspect wound for bleeding, control severe bleeding, and assess associated injuries?

A

YES

99
Q

ASSESSING WOUND: if wound is contaminated, the nurse shouldn’t determine when the client last had a tetanus toxoid injection. Is this correct?

A

NO

100
Q

ASSESSING WOUND: should the nurse prevent infection by cleaning or flushing with normal saline and covering wound with a clean dressing if possible, control swelling and If bleeding is severe or if internal bleeding is suspected, and assess the client for signs of shock?

A

YES

101
Q

TRUE OR FALSE: the easiest and most accurate method of documenting wound size and shape is with disposable wound-measuring guides

A

TRUE

102
Q

For irregularly shaped wounds, the nurse can use two layers of _________

A

transparent film

103
Q

To measure an area located on a curved portion of the body, the nurse must use a __________

A

flexible measure

104
Q

LAB VALUES: decreased ___________ can delay healing and increase the possibility of infection

A

leukocyte count

105
Q

LAB VALUES: ___________ below the normal range indicates poor oxygen delivery to the tissues

A

hemoglobin level

106
Q

LAB VALUES: ___________ can result in excessive blood loss and prolonged clot absorption

A

prolonged coagulation times

107
Q

LAB VALUES: __________ can lead to intravascular clotting, and result in a deficient blood supply to the wound area

A

Hypercoagulability

108
Q

LAB VALUES: ____________ provides an indication of the body’s nutritional reserves for rebuilding cells

A

Serum protein analysis

109
Q

LAB VALUES: ___________ is an important indicator of nutritional status (below 3.5 g/dL indicates poor nutrition)

A

Albumin

110
Q

LAB VALUES: ___________ can either confirm or rule out the presence of infection

A

Wound cultures

111
Q

LAB VALUES: __________ are helpful in the selection of appropriate antibiotic therapy

A

Sensitivity studies

112
Q

WHAT DIAGNOSIS: vulnerable to localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure, or pressure in combination with shear

A

Risk for Pressure Ulcer

113
Q

WHAT DIAGNOSIS: vulnerable to alteration in epidermis and/or dermis which may compromise health.

A

Risk for Impaired Skin Integrity

114
Q

WHAT DIAGNOSIS: altered epidermis and/or dermis

A

Impaired Skin Integrity

115
Q

WHAT DIAGNOSIS: damage to mucous membrane, cornea, integumentary system, muscular fascia, muscle, tendon, bone, 
cartilage, joint capsule, and/or ligament

A

Impaired Tissue Integrity

116
Q

WHAT DIAGNOSIS: if the skin impairment is severe, the client is immunosuppressed, or the wound is caused by trauma

A

Risk for Infection

117
Q

WHAT DIAGNOSIS: related to nerve involvement within the tissue impairment or as a consequence of procedures used to treat the wound

A

Acute Pain

118
Q

what are the two major goals for clients at Risk for Impaired Skin Integrity?

A

to maintain skin integrity and to avoid potential associated risks

119
Q

what are the two major goals for clients with Impaired Skin Integrity?

A

demonstrate progressive wound healing and regain intact skin within a specified time frame

120
Q

TRUE OF FALSE: Increasingly, wound care is provided in the home rather than in health care facilities.

A

TRUE

121
Q

what are the nursing interventions for maintaining skin integrity and wound care?

A

supporting wound healing, preventing pressure ulcers, treating pressure ulcers, dressing and cleaning wounds, supporting and immobilizing wounds, and applying heat and cold

122
Q
  1. SUPPORTING WOUND HEALING: The dressing and frequency of change should support _______ wound bed conditions. Wound beds that are too _______ or disturbed too often fail to heal
A

moist; dry

123
Q

SUPPORTING WOUND HEALING: Clients should be assisted to take in at least ________ mL of fluids a day unless conditions contraindicate this amount

A

2,500

124
Q

SUPPORTING WOUND HEALING: sufficient protein, vitamins _, _, __, __, and zinc are important

A

C, A, B1, B5

125
Q
  1. SUPPORTING WOUND HEALING: what are the two main aspects to controlling wound infection?
A

preventing microorganisms from entering the wound, and preventing the transmission of bloodborne pathogens to or from the client to others

126
Q

SUPPORTING WOUND HEALING: what is the position that keep pressure off the wound?

A

off-loading

127
Q

SUPPORTING WOUND HEALING: client should be assisted to be as ________ as possible because activity enhances circulation

A

mobile

128
Q

PREVENTING PRESSURE ULCERS, TRUE OR FALSE: identifying clients at risk, and reliably implementing prevention strategies for all clients who are identified as being at risk, should be done.

A

TRUE

129
Q

PREVENTING PRESSURE ULCERS: _________ intake of calories, protein, vitamins, and iron is believed to be a risk factor for pressure ulcer development

A

inadequate

130
Q
  1. PREVENTING PRESSURE ULCERS: what are the three pertinent lab work that should be monitored?
A

lymphocyte count, protein (especially albumin), and hemoglobin

131
Q

PREVENTING PRESSURE ULCERS, TRUE OR FALSE: When bathing the client, the nurse should minimize the force and friction applied to the skin, using mild cleansing agents that minimize irritation and dryness and that do not disrupt the skin’s “natural barriers.”

A

TRUE

132
Q

PREVENTING PRESSURE ULCERS: avoid using ____ water, which increases skin dryness and irritation.

A

hot

133
Q
  1. PREVENTING PRESSURE ULCERS: Nurses can minimize dryness by avoiding exposure to ________ and _____ humidity
A

cold; low

134
Q
  1. PREVENTING PRESSURE ULCERS, TRUE OR FALSE: Dry skin is best treated with moisturizing lotions applied while the skin is moist after bathing
A

TRUE

135
Q

PREVENTING PRESSURE ULCERS, TRUE OR FALSE: client’s skin should be kept in contact with urine, feces, sweat, and incomplete drying after a bath is alright

A

FALSE—client’s skin should be clean and dry and free of irritation and maceration

136
Q

PREVENTING PRESSURE ULCERS, TRUE OR FALSE: Providing the client with a smooth, firm, and wrinkle-free foundation on which to sit or lie helps prevent skin trauma

A

TRUE

137
Q

PREVENTING PRESSURE ULCERS: shearing force can be reduced by elevating the head of the bed to no more than ___, if this position is not contraindicated by the client’s condition

A

30°

138
Q

PREVENTING PRESSURE ULCERS: __________ and _________ are never used as friction or moisture prevention

A

Baby powder; cornstarch

139
Q

PREVENTING PRESSURE ULCERS, TRUE OR FALSE: Frequent shifts in position, even if only slight, effectively change pressure points. The client should shift weight 10° to 15° every 15 to 30 minutes and, whenever possible, exercise or ambulate to stimulate blood circulation

A

TRUE

140
Q

PREVENTING PRESSURE ULCERS, TRUE OR FALSE: it’s alright for nurses to not use a lifting device, such as a trapeze, in moving patient

A

FALSE—nurses should use a lifting device rather than dragging the client across or up in bed

141
Q

PREVENTING PRESSURE ULCERS: Any at-risk client confined to bed—even when a special support mattress is used—should be repositioned at least every ___________, depending on the client’s need,

A

2 hours

142
Q

PREVENTING PRESSURE ULCERS: massage over bony prominences is ideal, and promotes healing

A

FALSE—it should be avoided

143
Q

PREVENTING PRESSURE ULCERS, TRUE OR FALSE: pressure on bony prominences can be relieved through a combination of turning, positioning, and use of pressure-relieving surfaces

A

TRUE

144
Q

PREVENTING PRESSURE ULCERS: _____________ provide continuous passive motion or oscillation therapy, which is intended to counteract the effects of a client’s immobility

A

Kinetic beds

145
Q

PREVENTING PRESSURE ULCERS: _______________ should not be used since they limit blood flow and can cause tissue damage to the areas in direct contact with the device

A

Doughnut-type devices

146
Q
  1. PREVENTING PRESSURE ULCERS: _____________ Polyvinyl, silicone, or Silastic pads filled with a gelatinous substance similar to fat
A

Gel flotation pads

147
Q

PREVENTING PRESSURE ULCERS: ____________ Supports positioning and offloads bone on bone contact.

A

Pillows and wedges

148
Q

PREVENTING PRESSURE ULCERS: _________ Can raise or “float” a body part off the surface; prevent shearing and limit pressure on heel area

A

Heel protectors

149
Q

PREVENTING PRESSURE ULCERS: __________ Polyurethane foam mattress distributes weight over bony areas evenly. Foam molds to the body

A

Memory foam mattress/chair pad

150
Q
  1. PREVENTING PRESSURE ULCERS: ____________ Composed of a number of cells in which the pressure alternately increases and decreases; uses a pump
A

Alternating pressure mattress

151
Q

PREVENTING PRESSURE ULCERS: __________ Support surface filled with water. Water temperature can be controlled.

A

Water bed

152
Q

PREVENTING PRESSURE ULCERS: ___________ Consists of many air-filled cushions divided into four or five sections

A

Static low-air-loss (LAL) bed

153
Q

PREVENTING PRESSURE ULCERS: ____________ Like the static LAL, but in addition gently pulsates or rotates from side to side, thus stimulating capillary blood flow and facilitating movement of pulmonary secretions.

A

Active or second-generation LAL bed

154
Q

PREVENTING PRESSURE ULCERS: ___________ Forced temperature-controlled air is circulated around millions of tiny silicone-coated beads, producing a fluid-like movement.

A

Air-fluidized (AF) bed

155
Q

based on the color of an open wound—red, yellow, or black (RYB)—rather than the depth or size of a wound

A

RYB color code

156
Q

the goal of wound care are to: protect (cover)

A

red

157
Q

the goal of wound care are to: cleanse

A

yellow

158
Q

the goal of wound care are to: debride

A

black

159
Q

Wounds that are _________ are usually in the ________________ of tissue repair need to be protected to avoid disturbance to regenerating tissue.

A

red; late regeneration phase

160
Q

_______ wounds are characterized primarily by liquid to semiliquid “slough” that is often accompanied by purulent drainage or previous infection. The nurse cleanses these wounds to remove nonviable tissue

A

Yellow

161
Q

________ wounds are covered with thick necrotic tissue, or eschar, and require debridement

A

Black

162
Q

a scalpel or scissors is used to separate and remove dead tissue

A

sharp debridement

163
Q

accomplished through scrubbing force or damp-to- damp dressings

A

Mechanical debridement

164
Q

more selective than sharp or mechanical techniques; Collagenase enzyme agents such as papainurea are currently most recommended for this use

A

Chemical debridement

165
Q

dressings such as hydrocolloid and clear absorbent acrylic dressings trap the wound drainage against the eschar. The body’s own enzymes in the drainage break down the necrotic tissue

A

autolytic debridement

166
Q

When the eschar is removed, the wound is treated as ______, then _______

A

yellow; red

167
Q

When more than one color is present, the nurse treats the most serious color first, that is, ______, then _______, then ________.

A

black; yellow; red

168
Q

TYPES OF DRESSING: Adhesive plastic, semipermeable, nonabsorbent dressings allow exchange of oxygen between the atmosphere and wound bed. They are impermeable to bacteria and water.

A

transparent film

169
Q

TYPES OF DRESSING: Woven or nonwoven cotton or synthetic materials are impregnated with petrolatum, saline, zinc-saline, antimicrobials, or other agents.

A

Impregnated nonadherent

170
Q

TYPES OF DRESSING: Waterproof adhesive wafers, pastes, or powders,

A

hydrocolloids

171
Q

TYPES OF DRESSING: has an inner adhesive layer that has particles that absorb exudates and form a hydrated gel over the wound; and an outer film that provides an occlusive seal.

A

wafers (hydrocolloids)

172
Q

TYPES OF DRESSING: Transparent absorbent wafer designed to be worn 5–7 days. The acrylic layer absorbs exudates and evaporates the excess off the transparent membrane

A

clear absorbent acrylic

173
Q

TYPES OF DRESSING: Glycerin or water-based nonadhesive jelly-like sheets, granules, or gels are oxygen permeable, unless covered by a plastic film

A

hydrogels

174
Q

TYPES OF DRESSING: Nonadherent hydrocolloid dressings

A

polyurethane foams

175
Q

TYPES OF DRESSING: Nonadherent dressings of powder, beads or granules, ropes, sheets, or paste conform to the wound surface and absorb up to 20 times their weight in exudate

A

alginates (exudate absorbers)

176
Q

TYPES OF DRESSING: Gels, pastes, powders, granules, sheets, sponges derived from animal sources, often cow or pig

A

collagen

177
Q

____________ dressings are often applied to wounds including ulcerated or burned skin areas

A

Transparent

178
Q

_____________ dressings are frequently used over pressure ulcers

A

Hydrocolloid

179
Q

___________ involves the removal of debris, and other microorganisms

A

Wound cleaning

180
Q

____________ is the washing or flushing out of an area; Sterile technique is required for a wound

A

irrigation (lavage)

181
Q

______________ which refers to the use of suction equipment to apply negative pressure to a variety of wound types

A

vacuum-assisted closure (VAC), wound VAC, vacuum sealing, and topical negative pressure

182
Q

________ light and porous and readily molds to the body; used to retain dressings on wounds and to bandage the fingers, hands, toes, and feet; supports dressings and at the same time permits air to circulate; can be impregnated with petroleum jelly or other medications for application to wounds.

A

Gauze

183
Q

_____________ applied to provide pressure to an area.

A

Elasticized bandages

184
Q

__________ used to anchor bandages and to terminate them; usually are not applied directly over a wound because of the discomfort the bandage would cause

A

Circular turns

185
Q

___________ used to bandage parts of the body that are fairly uniform in circumference

A

Spiral turns

186
Q

____________ used to bandage cylindrical parts of the body that are not uniform in circumference

A

Spiral reverse

187
Q

____________ used to cover distal parts of the body

A

Recurrent turns

188
Q

___________ permit some movement after application.

A

Figure-eight turns

189
Q

arm sling and straight abdominal are types of what?

A

binder

190
Q

HEAT OR COLD: has been a long-standing remedy for aches and pains, and people often equate heat with comfort and relief

A

heat

191
Q

HEAT OR COLD: causes vasodilation and increases blood flow to the affected area, bringing oxygen, nutrients, antibodies, and leukocytes

A
192
Q

HEAT OR COLD: promotes soft tissue healing and increases suppuration

A

heat

193
Q

HEAT OR COLD: disadvantage is that it increases capillary permeability which may result in edema or an increase in preexisting edema

A

heat

194
Q

HEAT OR COLD: often used for clients with musculoskeletal problems

A

heat

195
Q
  1. HEAT OR COLD: lowers the temperature of the skin and underlying tissues and causes vasoconstriction
A

cold

196
Q

HEAT OR COLD: reduces the supply of oxygen and metabolites, decreases the removal of wastes, and produces skin pallor and coolness

A

cold

197
Q

HEAT OR COLD: disadvantage is prolonged exposure results in impaired circulation, cell deprivation, and subsequent damage to the tissues from lack of oxygen and nourishment

A

cold

198
Q

HEAT OR COLD: most often used for sports injuries to limit postinjury swelling and bleeding

A

cold

199
Q

_________________ adapt to temperature changes. Clients may be tempted to change the temperature of a thermal application because of the change in thermal sensation following adaptation

A

Temperature (thermal) receptors

200
Q

________________ occurs at the time the maximum therapeutic effect of the hot or cold application is achieved and the opposite effect begins

A

rebound phenomenon

201
Q

heat produces maximum vasodilation in ______ minutes

A

20 to 30

202
Q

cold applications, maximum vasoconstriction occurs when the involved skin reaches a temperature of ________

A

15°C (60°F)

203
Q

________ is applied locally by means of a hot water bottle, aquathermia pad, disposable heat pack, or electric pad

A

Dry heat

204
Q

_________ can be provided by compress, hot pack, soak, or sitz bath

A

Moist heat

205
Q

_________ is generally applied locally by means of a cold pack, ice bag, ice glove, or ice collar

A

Dry cold

206
Q

_________ can be provided by compress or a cooling sponge bath

A

Moist cold

207
Q

___________ (also referred to as a K-pad) is constructed with tubes containing water

A

Aquathermia pad

208
Q

__________ provide a constant, even heat, are lightweight, and can be molded to a body part

A

Electric pads

209
Q

_________ is a moist gauze dressing applied to a wound or injury, and can either be hot or cold

A

compress

210
Q

_______ refers to immersing a body part in a solution or to wrapping a part in gauze dressings and then saturating the dressing with a solution

A

soak

211
Q

___________ is to reduce a client’s fever by promoting heat loss through conduction and vaporization

A

cooling sponge bath

N11 - Nursing Foundations (10 decks)

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