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TERM 3 N2160 SKILLS 3 > WEEK 11 WOUND CARE > Flashcards

WEEK 11 WOUND CARE Flashcards

1
Q

What is the term for a wound that is a straight line and closed with sutures or staples?

A

Surgical incision

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2
Q

What is the term for a wound that is superficial, affecting only the epidermal layer?

A

Abrasion

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3
Q

What is the term for a wound that was created by penetrating the skin with a sharp object?

A

Puncture

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4
Q

What is the term for a wound that is torn or cut open, has jagged edges, and likely contaminated by foreign material?

A

Laceration

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5
Q

What is the term for a wound that is a localized open sore?

A

Ulcer

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6
Q

What is the difference between friction and shear?

A

Friction: A force acting parallel to the skin’s surface (e.g. sheets sliding against skin)

Shear: Combination of pressure and friction (e.g. sliding down in bed)

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7
Q

What is the definition of a stage I pressure injury?

A

Damage to epidermis only (Intact area of non-blanching erythema)

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8
Q

What is the definition of a stage II pressure injury?

A

Damage extends into but no deeper than the dermis (Appears like a blister)

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9
Q

What is the definition of a stage III pressure injury?

A

Damage extends into, but no deeper than the subcutaneous layer (Area appears like a crater, may have undermining/tunneling)

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10
Q

What is the definition of a stage IV pressure injury?

A

Damage to full thickness of skin and subcutaneous layers
(Muscle, bone, tendon visible, may have undermining/tunneling)

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11
Q

What are the 6 categories assessed with the braden scale?

A
  1. Sensory perception
  2. Moisture
  3. Activity
  4. Mobility
  5. Nutrition
  6. Friction/shear
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12
Q

A braden scale score of LOWER than 18 indicates what?

A

High risk for pressure injury

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13
Q

What is approximation, and what kind of wounds can be approximated?

A

Bringing wound edges together

Lacerations and incisions can be approximated

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14
Q

What is the difference between healing by primary intention and healing by secondary intention?

A

Primary: edges are approximated, minimal tissue loss, minimal scarring

Secondary: cannot be approximated, considerable tissue loss, greater risk of scarring/infection

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15
Q

What are the 3 stages of wound healing, and how long do they last?

A
  1. Inflammation (3-6 days)
  2. Proliferation (Days 3-21)
  3. Remodelling/maturation (1-2 years)
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16
Q

What may palpation of a hard lump under the skin of a wound indicate?

A

Hemorrhage/bleeding

17
Q

Why are the chest and abdomen more at risk of dehiscence?

A

Areas under high pressure

18
Q

What are 5 words used to describe amount of drainage, and what do they mean?

A
  1. Absent: no drainage
  2. Scant: <5%
  3. Minimal: 5-25%
  4. Moderate: 25-75%

5: Copious: >75%

19
Q

What are 6 areas to assess in a circular wound?

A
  1. Location
  2. Drainage
  3. Size
  4. Type/stage
  5. Wound bed
  6. Surrounding skin
20
Q

What is the term for a buildup of dead cells in a wound bed, usually tan in colour?

A

Slough

21
Q

What is a term for hardened necrotic tissue in a wound bed, usually black or brown in colour?

A

Eschar

22
Q

What is the term for softened wound edges due to moiture, usually white in colour?

A

Maceration

23
Q

Why should a wound be palpated during assessment?

A

Assess for induration

24
Q

What is the term for a procedure to remove dead cells such as slough or eschar?

A

Debridement

25
Q

What are 7 things to be assessed in a surgical incision?

A
  1. Location
  2. Drainage
  3. Length
  4. Approximation
  5. Number of sutures/staples
  6. Condition of surrounding skin
  7. Complications
26
Q

What are 2 things to ask a patient before performing a dressing change?

A
  1. Need to go to the bathroom
  2. Need pain management
27
Q

What is important to remember when obtaining a wound culture?

A

Do not swab drainage. Rotate the swab and apply pressure to elicit fluid.

28
Q

What are 3 things that could indicate complications are occuring?

A
  1. Unexpected changes in drainage type
  2. Fluctuations in pain
  3. Sudden discharge of drainage
29
Q

What does the abbreviation LOTA mean?

A

Left open to air

30
Q
A

TERM 3 N2160 SKILLS 3 (11 decks)

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