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Patient-Centered Care > Tissue Integrity > Flashcards

Tissue Integrity Flashcards

1
Q

What are the 3 phases of wound healing?

A
  1. Inflammatory
  2. Granulation
  3. Maturation
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2
Q

How long does the inflammatory phase last?

A

3-5 days

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3
Q

How long is the granulation phase?

A

5-21 days

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4
Q

What occurs during the maturation phase?

A

scar formation and contraction occurs

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5
Q

What is a primary intention wound healing?

A

clean-cut wound
risk for infection is low
minimal scar formation

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6
Q

What is secondary intention wound healing?

A

pressure wound, burns
wound left open and filled with scar tissue

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7
Q

What is tertiary intention wound healing?

A

infected wound after sutures
wound was closed and is open again

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8
Q

What is shearing?

A

the force created when layers of tissue move on each other
(always occurs with friction)

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9
Q

What are some dietary interventions?

A

protein
vitamin A
vitamin C
iron

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10
Q

What acronym promotes reducing the risk of melanoma?

A

SMART

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11
Q

What does SMART stand for?

A

Spend time in the shade between 11-3pm
Make sure you never burn
Aim to cover up
Remember to take extra care with children
Then use SPF of 15 or higher

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12
Q

How long does SPF 15 protect skin for?

A

150min

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13
Q

Sunscreen use?

A
  • apply 30min before exposure
  • reapply every 2 hours
  • not recommended for babies under 6 months old
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14
Q

What does the ABCDEs of melanoma detection stand for?

A

Asymmetry
Borders
Color
Diameter (larger than a pencil eraser 7mm)
Evolving

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15
Q

When providing irrigation of a wound what solution do you use?

A

normal saline

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16
Q

At what stages of pressure injuries do hospitals not receive reimbursement?

A

3 and 4

17
Q

What scale is used to asses for risk factors for skin breakdown?

A

Braden scale

18
Q

What is included in the Braden scale?

A

sensory perception
moisture
activity
mobility
nutrion
friction and shear

19
Q

What score on the Braden scale indicates a higher risk?

A

the lower the score

20
Q

What areas are more at risk for skin breakdown?

A

head
shoulder
sacrum
buttock
heel

21
Q

When trying to alleviate pressure over boney prominences, do not elevate HOB more than…

A

10-20 degrees
Exceptions: COPD, CHF (elevate knees first)

22
Q

What should be used in skin folds?

A

water insoluble creams
- don’t use powder

23
Q

When should nutritional status be completed?

A

within 24 hours of admission

24
Q

How much protein can a patient lose with an open, weeping pressure ulcer?

A

50g per day

25
Q

What what level should hemoglobin be maintained to promote wound healing?

A

12g per 100mL

26
Q

What is an example of autolytic debridement?

A

dressings

27
Q

What is nevi?

A

a mole

28
Q

What is pruiritis?

A

itching

Patient-Centered Care (10 decks)

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