skin integrity and wound care Flashcards
1
Q
epidermis
A
top layer
2
Q
dermis
A
inner layer
collagen
3
Q
dermal-epidermal junction
A
separates dermis and epidermis
4
Q
patho of pressure injuries
A
pressure intensity - tissue ischemia - blanching - pressure duration tissue tolerance
5
Q
risk factors for pressure ulcer development
A
- impaired sensory
- perception
- impaired mobility
- alteration in loc
- shear
- friction
- moisture
6
Q
deep tissue pressure injury (DTPI)
A
- granulation
- slough
- eschar
- exudate
7
Q
wound classifications
A
process of wound healing
- partial thickness wounds
- full thickness wounds
- primary intention
- secondary intention
8
Q
wound repair: partial thickness
A
inflammatory response, epithelial proliferation and migration, and reestablishment of the epidermal layers
9
Q
wound repair: full thickness
A
hemostatsis
inflammatory
proliferative
maturation
10
Q
complications of wound healing
A
hemorrhage
infection
dehiscence
evisceration
11
Q
factors influencing pressure injury
A
nutrition tissue perfusion infection age psychosocial impact of wounds
12
Q
assessment of pressure ulcers
A
predictive measures mobillity nutitional status body fluids pain
13
Q
assessment of wounds
A
emergency setting stable setting wound apperance character of wound drainage drains wound closure palpation of wound wound cultures psychosocial
14
Q
health promotion
A
- prevention of pressure ulcers
- topical skincare and incontinence management
- positioning
- support surfaces
15
Q
heat and cold therapy
A
- choice of moist or dry
- warm, moist compresses
- warm soaks
- sitz baths
- commerical hot and cold packs
- cold, moist and dry compresses
- cold soaks
- ice bags or collar
16
Q
safety guidelines for nursing skills
A
- follow proper aseptic technique
- routinely assess for risk of pressure injuries
- inspect skin daily
- use approaches to minimize friction and shear
- modify the frequency of wound assessment based on wound condition
- chronic diseases, especially vascular disease and diabetes, increase a pt. risk for pressure injury development and impede healing of wounds
