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204 Exam 2 > Skin, Integrity, Wound Care > Flashcards

Skin, Integrity, Wound Care Flashcards

1
Q

Intact skin with non-blanchable redness
“at risk” people
Discoloration of skin, warmth, edema, hardness, or p!

A

Stage 1 ulcer

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2
Q

i. surgical complication in which a wound rupture along a surgical incision

A

Dehiscence

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3
Q

Hydrogel, what stage to use?

A

2, 4

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4
Q

Full-thickness tissue loss with visible fat
Slough may be present
Bone/tendon is not directly palpable

A

Stage 3 ulcer

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5
Q

Hydrocolloid, what stage to use?

A

1, 2, 3

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6
Q

i. Not closed—fills with scar tissue
ii. Pressure ulcer, burns
iii. Longer healing time—more chance for infection

A

secondary intention

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7
Q

Combine physically distinct components into a single product to provide multiple functions such as a bacterial barrier

A

Composite

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8
Q

Intervention of wound care 5 things

A

a. Post and implement a turning schedule.
b. Obtain and place over the patient’s mattress a low-air-loss overlay.
c. Clean wound and periwound skin; dry periwound skin.
d. Apply a hydrocolloid dressing to the wound
e. Determine in collaboration with dietitian an appropriate diet.

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9
Q

Partial-thickness skin loss involving epidermis, dermis or both
Shallow, open ulcer with red-pink would bed WITHOUT slough
Could be open/ruptured serum-filled or serosanguineous-filled blister

A

Stage 2 ulcer

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10
Q

i. When surgical incision opens & the abdominal organs then protrude or come out of the incision
ii. EMERGENCY

A

Evisceration

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11
Q

bright red; indicates active bleeding

Deep wounds

A

Sanguineous

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12
Q

Factors influencing heat and cold tolerance (5)

A
  1. Exposure time
  2. Exposed skin
  3. Temperature
  4. Age
  5. Perception of sensory stimuli
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13
Q

Complications of wound healing (5)

A 
Hemorrhage
Infection (2nd most common)
Dehiscence
Evisceration
Cultures
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14
Q

First aid for Wounds

A 
Hemostasis (control bleeding)
Bandage
Cleaning
Protection
Dressing
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15
Q

Full-thickness tissue loss with exposed bone, muscle, or tendon

A

Stage 4 ulcer

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16
Q

Purposes of dressings (6)

A
  1. Protects from microorganisms
  2. Aids in hemostasis
  3. Promotes healing by absorbing drainage or debriding a wound
  4. Supports wound site
  5. Promotes thermal insulation
  6. Provides a moist environment
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17
Q

Two surfaces moving against each other
Happens on skin
“Sheet burn”

A

Friction

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18
Q

Appropriate support surface for stage 1 or 2 ulcer

A

foam
avoid HOB elevation
limit sitting to 3x per day of 60 min or less

19
Q

Basic Skin cleaning (3)

A
  1. Clean from least contaminated to the surrounding skin
  2. Use gentle friction
  3. When irrigating, allow the solution to flow from the least to most contaminated area (circular rotations)
20
Q

Risk factors for pressure ulcer development (6 things)

A 
Impaired sensory perception
impaired mobility
Alteration in LOC
Shear
Friction
Moisture
21
Q

Effects of cold application

A

Vasoconstriction
Local anesthesia
Reduced cell metabolism & muscle tension
Increased BV

22
Q

REEDA

A 
Redness
Edema
Ecchymosis
Discharge
Approximation (are edges closed)
23
Q

Wound irrigation, what is done?

A

a. Sterile technique
b. 35 mL syringe with 19-gauge soft Angiocatheter
c. Delivers safe pressure—doesn’t damage good healing tissue
d. Hold syringe 2.5 cm (1 in) about upper end of wound

24
Q

Factors influencing pressure ulcer formation and wound healing (5)

A 
Nutrition
Tissue perfusion
Infection
Age
Psychosocial impact of wounds
25
Q

Happens beneath the skin

Sliding movement of skin while the underlying muscle & bone are stationary

A

Shear

26
Q

Stage III ulcer treatment

A

Clean with:
Prescribed dressing
Surgical intervention
Proteolytic enzymes

Nutritional supplements
Analgesic
Antimicrobials (topical or systemic)

27
Q

Keeps wound slightly moist, releasing water

A

hydrogel

28
Q

i. Edges are approximated

ii. A surgical wound, that is closed (approximated)

A

primary intention

29
Q

3 pressure related factors

A
  1. Pressure Intensity
  2. Tissue tolerance
  3. Pressure duration
30
Q

pale, pink, watery; mixture of clear & red fluid

Most often seen

A

Serosanguineous

31
Q

thick, yellow, green, tan, or brown

A

Purulent

32
Q

Stage IV ulcer treatment

A

non adherent dressing change ever 12 hrs

33
Q

Stage II ulcer treatment (4 things)

A

Maintain most healing environment
Natural healing while preventing scar tissue
Provide nutritional supplements
Analgesics

34
Q

Black, brown, tan or necrotic tissue

A

eschar

35
Q

Clear, watery plasma

A

Serous drainage

36
Q

Appropriate support surface for stage 3, 4, unstageable ulcer

A 
Avoid prolonged HOB elevation
low-air loss
alternating pressure
air fluidized surface
consider a wheelchair
37
Q

Gauze, what stage to use?

A

3, 4 & unstageable

38
Q

Transparent film, what stage to use?

A

1

39
Q

Usually absorbent, waterproof, adheres to surrounding skin

A

Hydrocolloid

40
Q

Effects of heat application
Vaso-
Reduced
Increased

A

Vasodilation
Reduced BV, muscle tension
Increased tissue metabolism & capillary permeability

41
Q

Pressure Intensity

A

Tissue ischemia

blanching

42
Q

COCA

A
  1. Color
  2. Odor
  3. Consistency
  4. Amount
43
Q

Acute care–wound management (5)

A
  1. Debridement: the removal of damaged tissue or foreign objects from a wound
  2. Education
  3. Nutritional status
  4. Protein status
  5. Hemoglobin: oxygen needed for wound healing

204 Exam 2 (9 decks)

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