Skin/Wound Flashcards
1
Q
Pressure injury:
A
localized damage to skin around bony prominences from a long term pressure on the area.
2
Q
Purulent drainage:
A
white blood cells, liquified dead tissue debris, and dead and live bacteria
3
Q
Sanguineous drainage:
A
containing or mixed with blood
4
Q
Scar:
A
connective tissue that fills wound area, leaving a mark
5
Q
Serosanguineous drainage:
A
mixture of serum and red blood cells
6
Q
Serous drainage:
A
clear, serous portion of blood and from serous membrane
7
Q
Shear:
A
force created when layers of tissue move on one another
8
Q
Subcutaneous tissue:
A
underlying layer of skin that attaches to tissue in body
9
Q
Wound:
A
injury or disruption in normal body tissue of skin
10
Q
Eschar:
A
necrotic leathery scab, dry and thick; remove for healing to occur
11
Q
Evisceration:
A
protrusion of viscera through incision
12
Q
Exudate:
A
fluid that accumulates in wound
13
Q
Fistula:
A
abnormal passage from internal organ to skin or to another organ
14
Q
Friction:
A
when two surfaces rub together
15
Q
Granulation Tissue:
A
new tissue that is pink/red that contain fibroblasts and help heal open wounds
16
Q
Hematoma:
A
localized mass of clotted blood
17
Q
Ischemia:
A
lack of blood in a particular area
18
Q
Maceration:
A
overhydration
19
Q
Necrosis:
A
death of cell and tissue
20
Q
Negative Pressure wound therapy (NPWT):
A
help with wound healing with negative pressure
21
Q
Abscess:
A
collection of infected fluid that needs to be drained
22
Q
Bandage:
A
gauze or material to cover wound
23
Q
Biofilm:
A
thick group of microorganisms
24
Q
Debridement:
A
cleaning wounds of foreign matter and dead tissue
25
Dehiscence:
separation of layers of surgical wound; partial, superficial or complete
26
Dermis:
layer skin below epidermis
27
Desiccation:
dehydration
28
Dressing:
protective covering for wounds
29
Epidermis:
outer most layer of skin; superficial
30
Epithelialization:
stage of wound healing; epithelial cells form at surface of wound.
31
Erythema:
redness of the skin
32
Layers of Skin
Epidermis- outer most later
Dermis: middle layer
Subcutaneous tissue- inner most layer
33
Functions of Skin
Has functions of: protection, temp regulation, psychosocial, sensation, vitamin D production, immunologic, absorption, and elimination
34
Intentional vs. unintentional wounds
Intentional- Therapy or treatments may result in an intentional wound (clean edges)
Unintentional- accidental, uncontrollable, longer healing time
35
Open vs. closed wounds
Open- Skin surface is broken; tissue is damaged and increase of infection risk
Closed- skin surface is intact and hemorrhage is a risk and soft tissue is damage
36
Acute vs. chronic wounds
Acute- usually heal in days-weeks; infection risk is low
| Chronic- healing is impeded, and takes much longer
37
Phases of Wound Healing
Hemostasis
Inflammatory phase
Proliferation phase
Maturation phase
38
Hemostasis phase
Immediately after initial injury
| Blood vessels constrict and blood clotting begins; increased perfusion
39
Inflammatory Phase
Lasts 2-3 days
| White blood cells move to wound
40
Proliferation Phase
Known as regenerative phase
Collagen synthesis
Granulation tissue
41
Maturation Phase
Known as remodeling
Scar is formed
Final step in wound healing
42
Factors that affect wound healing
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Local factors:
Pressure
Desiccation
Maceration
Trauma
Edema
Infection
Excessive bleeding
Necrosis
Biofilm
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Systemic Factors:
Age
circulation and oxygenation
Nutritional status
Wound etiology
Medications and health status
Immunosuppression
Adherence to treatment plan
```
43
Wound Complications
Infection
Hemorrhage
Dehiscence & evisceration
Fistula formation
44
First intention healing
the healing that occurs when a clean laceration or a surgical incision is closed primarily with sutures, Steri-Strips, or skin adhesive.
45
Second intention healing
a wound will be left open (rather than being stitched together) and left to heal by itself, filling in and closing up naturally.
46
How would you describe a drain for a knee replacement? What is the need? and Why?
“The drain allows removal of blood and drainage from the surgical wound, which enables healing and protects the skin around the wound.”
47
How long should you leave a heating pad on a patient for?
20-30 minutes and reassess
48
What is the primary goal for debridement of a wound?
removing dead or infected tissue to promote wound healing
49
Where is the trochanter area?
Upper thighs and buttocks
50
What type of wound leaves the skin blue and purple?
contusion
51
Stage 1 Pressure Ulcer
Stage 1:
| Pressure injury: no blanchable erythema of intact skin
52
Stage 2 Pressure Ulcer
Stage 2:
| Pressure Injury: partial- thickness skin loss with exposed dermis
53
Stage 3 Pressure Ulcer
Stage 3:
| Pressure Injury: full- thickness skin loss
54
Stage 4 Pressure Ulcer
Stage 4:
| Pressure Injury: full- thickness skin and tissue loss
55
What scale is used to assess risk of pressure ulcers for a patient?
Braden Scale
56
The nurse observes the presence of intestinal contents protruding from the client's surgical wound after colon resection. What action will the nurse take?
Apply saline solution–moistened gauze over the protruding area.
57
A client recovering from abdominal surgery sneezes and then screams, “My insides are hanging out!” What is the initial nursing intervention?
applying sterile dressings with normal saline over the protruding organs and tissue
58
A client sitting in a chair who slides down is at risk for what?
Shearing forces to develop a pressure injury
59
If you are removing staples and you see the incision separating as you take them out, what should you do?
Stop removing staples and inform the surgeon
60
What diet is good for healing wounds?
High protein, vitamin A and vitamin C
61
What dressing would promote autolytic debridement of the wound?
Hydrocolloid
62
How long is incisional pain normal?
2-3 days
63
What is the proper way to clean a gunshot wound?
Clean the wound from the top to the bottom and from the center to outside.
64
What would you use to assess the depth of tunneling in a wound?
a sterile, flexible applicator moistened with saline
65
What is the most important question to ask to determine patients risk for a pressure ulcer?
“Do you experience incontinence?”
66
What is an instruction to teach patients when moving after the removal of staples?
To splint the area when engaging in activity
67
A client reports acute pain while negative pressure wound therapy is in place. What should the nurse do first?
Assess the client’s wound and vital signs.
68
If a client states it feels like my incision just gave way, what may this mean for the nurse to assess?
Dehiscence of the wound
69
The nurse and client are looking at the client’s heel pressure injury. The client asks, “Why does my heel look black?” What is the nurse’s appropriate response?
“That is necrotic tissue, which must be removed to promote healing.”
70
which medication will delay the healing of the operative wound?
corticosteroids
71
Which dressing supply will the nurse gather to take in the client’s room to insert an IV
transparent
72
What would you document for a pt wound?
Document the color, odor, amount, and type of wound drainage.
73
During a dressing change of the surgical site, the nurse observed a pale pink drainage on the dressing. Which drainage type should the nurse document?
serosanguineous
74
The nurse is caring for a client with a sacral wound. Upon assessment, the wound is noted to have slough and a bad odor, and it extends into the muscle. How will the nurse categorize this pressure injury?
Stage 4
