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Fundamentals > Skin Integrity and Wound Care > Flashcards

Skin Integrity and Wound Care Flashcards

1
Q

approximated

A

define edges that are in close proximity

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2
Q

blanching

A

turns white when pressed

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3
Q

debridement

A

cleaning

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4
Q

dehiscence

A

pulling a wound apart and seeing viscera

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5
Q

eschar

A

black crusty tissue that cover a wound

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6
Q

evisceration

A

viscera comes out of the body

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7
Q

exudate

A

drainage/fluid

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8
Q

fistula

A

tunnel or hole that connects two organs

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9
Q

induration

A

the change in depth with pitting

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10
Q

ischemia

A

lack of oxygen

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11
Q

laceration

A

cut/scrape not clean, usually tears

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12
Q

maceration

A

when skin softens from presence of moisture

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13
Q

non-blachable erythema (redness)

A

area of redness that doesnt turn white when pressed

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14
Q

slough

A

stingy yellow stuff around wound

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15
Q

VAC

A

vacuum assisted closure

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16
Q

What does the development of a pressure ulcer depend on?

A

pressure intensity

pressure duration

tissue tolerance

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17
Q

What are some risk factors to develop pressure ulcers?

A

impaired sensory perception

impaired mobility

altered LOC

shear

friction

moisture

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18
Q

Describe a stage 1 pressure ulcer

A

intact skin with non-blanchable ertythema

darker skin may not have visible blanching but a different color skin

skin is still intact

may be discomfort with swelling and congestion

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19
Q

stage II pressure ulcer?

A

partial thickness skin loss, may involve epidermis or dermis

ulcer is superficial

abraision, blister or shallow crater

edema may be present

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20
Q

stage III pressure ulcer?

A

full thickness tissue loss

sub Q fat may be visible

may extend to fascia

no exposure of bone, tendon, or muscle

may include underminning or tunneling

drainage or infection common

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21
Q

Stage IV ulcer?

A

full thickness tissue loss

exposed bone, tendon or muscle is common

often includes undermining or tunneling

eschar or slough may be visible in parts of wound

22
Q

unstageable pressure ulcer?

A

cant visualize base of the wound

depth is obscured by slough of eschar

23
Q

What are some examples of a suspected deep-tissue injury with an unknown depth?

A

purple or maroon area blood-filled caused by damage of soft tissue from pressure or shear

may be boggy or mushy when compared to surrounding skin

24
Q

Is deep-tissue injury harder to detect in patients with darker skin tones?

A

YES

need to know baseline skin tone

good lighting

evaluate color specific changes in skin tone

25
Q

mongolian spot?

A

a blue spot that is a congenital birth mark

26
Q

describe eschar

A

black or brown necrotic tissue

27
Q

Acute wound?

A

heals faster and easier

28
Q

Chronic wound?

A

fails to proceed to reparative stage.

29
Q

tertiary intention?

A

wound that needs cleaned and left open until it is clean enough to be closed surgically

excessive drainage and debris

high risk of infection

30
Q

secondary intention?

A

wounds with tissue loss

edges are wide

formation of granulation tissue, wound contraction and epithelialization

longer healing time, increased risk of infection

scarring occurs

31
Q

What are the different stages of wound healing?

A

inflammatory (first 3 days) control bleeding form clots nutrients to wound site

proliferative (3 day-3 wks) growth of granulation tissue contraction of wound edges resurfacing new epithelial cells

maturation (remodeling (3wks - 6 months)) strengthening of collagen and restoration of normal appearance

32
Q

What are some risk factors of infection

A

Age

impaired circulation or oxygenation

wound condition/nature

immunocompromised

malnutrition

chronic disease

inadequate wound care

33
Q

What are some risk factors for dehiscence and evisceration?

A

chronic disease

advanced age

obesity

invasive abdominal cancer

vomiting

dehydration/malnutrition

abdominal surgery

ineffective suturing

34
Q

What are the subscales of the braden scale

A

sensory perception

moisture

activity

mobility

nutrition

friction and shear

35
Q

Do we massage reddened areas?

A

NO

36
Q

What is an abrasion?

A

superficial wound with minimal bleeding (partial-thickness)

37
Q

What is a puncture wound?

A

something that has puntures the skin (like a nail)

38
Q

What is woven gauze used for?

A

absorbing exudate

dry

moist to dry change

39
Q

What is non-adherent (tefla) dressing for?

A

doesnt adhere to wound bed

40
Q

transparent dressing?

A

“second skin”

for small wounds

41
Q

Hydrocolloid dressing?

A

maintains granulation in wound bed

on for up to 5 days

swells in presence of exudate

42
Q

Hydrogel dressing?

A

provides moist wound bed

reduces pain in wound

debrides wound by softening necrotic tissue

doesnt adhere to wound base

43
Q

When do you usually remove sutures and staples?

A

around 7 days

staples close outer skin (less tissue trauma)

44
Q

why do we use binders?

A

create pressure over a body part

immobilize a body part

support a wound

reduce edema

securing splint

securing dressing

45
Q

What is hard about abdominal binders?

A

they are hard to keep in place, most patients are obese and have egg shaped stomachs

46
Q

Should binders feel snug?

A

yes, but still should allow circulation

check distal areas for circulatory impairment

47
Q

do binders promote venous return?

A

YES

48
Q

does drainage affect healing?

A

yes

49
Q

How do drains work?

A

through negative pressure

50
Q

Do we take binders off every 2 hours?

A

yes, have patient take deep breath while you keep pressure on wound to keep from dehiscence

Fundamentals (7 decks)

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