skin integrity and wound care Flashcards

1
Q

epidermis

A

top layer

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2
Q

dermis

A

inner layer

collagen

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3
Q

dermal-epidermal junction

A

separates dermis and epidermis

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4
Q

patho of pressure injuries

A
pressure intensity 
- tissue ischemia
- blanching
- pressure duration 
tissue tolerance
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5
Q

risk factors for pressure ulcer development

A
  • impaired sensory
  • perception
  • impaired mobility
  • alteration in loc
  • shear
  • friction
  • moisture
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6
Q

deep tissue pressure injury (DTPI)

A
  • granulation
  • slough
  • eschar
  • exudate
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7
Q

wound classifications

A

process of wound healing

  • partial thickness wounds
  • full thickness wounds
  • primary intention
  • secondary intention
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8
Q

wound repair: partial thickness

A

inflammatory response, epithelial proliferation and migration, and reestablishment of the epidermal layers

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9
Q

wound repair: full thickness

A

hemostatsis
inflammatory
proliferative
maturation

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10
Q

complications of wound healing

A

hemorrhage
infection
dehiscence
evisceration

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11
Q

factors influencing pressure injury

A
nutrition 
tissue perfusion 
infection 
age
psychosocial impact of wounds
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12
Q

assessment of pressure ulcers

A
predictive measures
mobillity 
nutitional status
body fluids 
pain
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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
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14
Q

health promotion

A
  • prevention of pressure ulcers
  • topical skincare and incontinence management
  • positioning
  • support surfaces
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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
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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