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Fundamentals > Skin/Wound > Flashcards

Skin/Wound Flashcards

1
Q

Pressure injury:

A

localized damage to skin around bony prominences from a long term pressure on the area.

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2
Q

Purulent drainage:

A

white blood cells, liquified dead tissue debris, and dead and live bacteria

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3
Q

Sanguineous drainage:

A

containing or mixed with blood

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4
Q

Scar:

A

connective tissue that fills wound area, leaving a mark

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5
Q

Serosanguineous drainage:

A

mixture of serum and red blood cells

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6
Q

Serous drainage:

A

clear, serous portion of blood and from serous membrane

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7
Q

Shear:

A

force created when layers of tissue move on one another

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8
Q

Subcutaneous tissue:

A

underlying layer of skin that attaches to tissue in body

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9
Q

Wound:

A

injury or disruption in normal body tissue of skin

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10
Q

Eschar:

A

necrotic leathery scab, dry and thick; remove for healing to occur

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11
Q

Evisceration:

A

protrusion of viscera through incision

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12
Q

Exudate:

A

fluid that accumulates in wound

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13
Q

Fistula:

A

abnormal passage from internal organ to skin or to another organ

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14
Q

Friction:

A

when two surfaces rub together

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15
Q

Granulation Tissue:

A

new tissue that is pink/red that contain fibroblasts and help heal open wounds

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16
Q

Hematoma:

A

localized mass of clotted blood

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17
Q

Ischemia:

A

lack of blood in a particular area

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18
Q

Maceration:

A

overhydration

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19
Q

Necrosis:

A

death of cell and tissue

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20
Q

Negative Pressure wound therapy (NPWT):

A

help with wound healing with negative pressure

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21
Q

Abscess:

A

collection of infected fluid that needs to be drained

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22
Q

Bandage:

A

gauze or material to cover wound

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23
Q

Biofilm:

A

thick group of microorganisms

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24
Q

Debridement:

A

cleaning wounds of foreign matter and dead tissue

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25
Q

Dehiscence:

A

separation of layers of surgical wound; partial, superficial or complete

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26
Q

Dermis:

A

layer skin below epidermis

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27
Q

Desiccation:

A

dehydration

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28
Q

Dressing:

A

protective covering for wounds

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29
Q

Epidermis:

A

outer most layer of skin; superficial

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30
Q

Epithelialization:

A

stage of wound healing; epithelial cells form at surface of wound.

31
Q

Erythema:

A

redness of the skin

32
Q

Layers of Skin

A

Epidermis- outer most later
Dermis: middle layer
Subcutaneous tissue- inner most layer

33
Q

Functions of Skin

A

Has functions of: protection, temp regulation, psychosocial, sensation, vitamin D production, immunologic, absorption, and elimination

34
Q

Intentional vs. unintentional wounds

A

Intentional- Therapy or treatments may result in an intentional wound (clean edges)
Unintentional- accidental, uncontrollable, longer healing time

35
Q

Open vs. closed wounds

A

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
Q

Acute vs. chronic wounds

A

Acute- usually heal in days-weeks; infection risk is low

Chronic- healing is impeded, and takes much longer

37
Q

Phases of Wound Healing

A

Hemostasis

Inflammatory phase

Proliferation phase

Maturation phase

38
Q

Hemostasis phase

A

Immediately after initial injury

Blood vessels constrict and blood clotting begins; increased perfusion

39
Q

Inflammatory Phase

A

Lasts 2-3 days

White blood cells move to wound

40
Q

Proliferation Phase

A

Known as regenerative phase
Collagen synthesis
Granulation tissue

41
Q

Maturation Phase

A

Known as remodeling
Scar is formed
Final step in wound healing

42
Q

Factors that affect wound healing

A 
Local factors: 
Pressure
Desiccation
Maceration
Trauma
Edema
Infection
Excessive bleeding
Necrosis
Biofilm
Systemic Factors:
Age
circulation and oxygenation
Nutritional status
Wound etiology
Medications and health status
Immunosuppression
Adherence to treatment plan
43
Q

Wound Complications

A

Infection
Hemorrhage
Dehiscence & evisceration
Fistula formation

44
Q

First intention healing

A

the healing that occurs when a clean laceration or a surgical incision is closed primarily with sutures, Steri-Strips, or skin adhesive.

45
Q

Second intention healing

A

a wound will be left open (rather than being stitched together) and left to heal by itself, filling in and closing up naturally.

46
Q

How would you describe a drain for a knee replacement? What is the need? and Why?

A

“The drain allows removal of blood and drainage from the surgical wound, which enables healing and protects the skin around the wound.”

47
Q

How long should you leave a heating pad on a patient for?

A

20-30 minutes and reassess

48
Q

What is the primary goal for debridement of a wound?

A

removing dead or infected tissue to promote wound healing

49
Q

Where is the trochanter area?

A

Upper thighs and buttocks

50
Q

What type of wound leaves the skin blue and purple?

A

contusion

51
Q

Stage 1 Pressure Ulcer

A

Stage 1:

Pressure injury: no blanchable erythema of intact skin

52
Q

Stage 2 Pressure Ulcer

A

Stage 2:

Pressure Injury: partial- thickness skin loss with exposed dermis

53
Q

Stage 3 Pressure Ulcer

A

Stage 3:

Pressure Injury: full- thickness skin loss

54
Q

Stage 4 Pressure Ulcer

A

Stage 4:

Pressure Injury: full- thickness skin and tissue loss

55
Q

What scale is used to assess risk of pressure ulcers for a patient?

A

Braden Scale

56
Q

The nurse observes the presence of intestinal contents protruding from the client’s surgical wound after colon resection. What action will the nurse take?

A

Apply saline solution–moistened gauze over the protruding area.

57
Q

A client recovering from abdominal surgery sneezes and then screams, “My insides are hanging out!” What is the initial nursing intervention?

A

applying sterile dressings with normal saline over the protruding organs and tissue

58
Q

A client sitting in a chair who slides down is at risk for what?

A

Shearing forces to develop a pressure injury

59
Q

If you are removing staples and you see the incision separating as you take them out, what should you do?

A

Stop removing staples and inform the surgeon

60
Q

What diet is good for healing wounds?

A

High protein, vitamin A and vitamin C

61
Q

What dressing would promote autolytic debridement of the wound?

A

Hydrocolloid

62
Q

How long is incisional pain normal?

A

2-3 days

63
Q

What is the proper way to clean a gunshot wound?

A

Clean the wound from the top to the bottom and from the center to outside.

64
Q

What would you use to assess the depth of tunneling in a wound?

A

a sterile, flexible applicator moistened with saline

65
Q

What is the most important question to ask to determine patients risk for a pressure ulcer?

A

“Do you experience incontinence?”

66
Q

What is an instruction to teach patients when moving after the removal of staples?

A

To splint the area when engaging in activity

67
Q

A client reports acute pain while negative pressure wound therapy is in place. What should the nurse do first?

A

Assess the client’s wound and vital signs.

68
Q

If a client states it feels like my incision just gave way, what may this mean for the nurse to assess?

A

Dehiscence of the wound

69
Q

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?

A

“That is necrotic tissue, which must be removed to promote healing.”

70
Q

which medication will delay the healing of the operative wound?

A

corticosteroids

71
Q

Which dressing supply will the nurse gather to take in the client’s room to insert an IV

A

transparent

72
Q

What would you document for a pt wound?

A

Document the color, odor, amount, and type of wound drainage.

73
Q

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?

A

serosanguineous

74
Q

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?

A

Stage 4

Fundamentals (6 decks)

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