Week 12 Chapter 22 Flashcards
Common causes of skin breakdown
Dryness
Decreased mobility
General thinning of the skin
Poor nutrition and hydration
A Psw should keep skin
Clean, dry, and moistures
Skin protects the body
From microbes that cause infection
Prevent skin breakdown by
Preventing skin injury and give good skin care
A wound
Is a break in the skin or mucous membrane
Wound care involves
Preventing infection
Preventing further injury
Preventing blood loss
Preventing pain
Intentional wound
Created for treatment
Unintentional wound
Results from trauma
Open wound
A break in the skin or mucous membrane
Closed wound
Injury to tissue without breaking the skin
Clean wound
Not infected
Clean-contaminated wound
Results from sugical entry
Contaminated wound
Unintentional wound, high risk of infection
Infected wound
Wound containing a large amount of bacteria, shows signs of infection
Chronic wound
One that does not heal easily in a timely manner
Abrasion
Scrapping away or rubbing of the skin
Contusion
Blow to the body (bruise)
Incision
Clean, intentionally cut into the skin
Laceration
Torn, jagged edges
Penetrating wound
Skin and underlying tissue pierced
Puncture wound
Open wound caused by sharp object
Partial-thickness wound
The dermis and epidermis of skin is broken
Full thickness wound
The dermis, epidermis and subcutaneous tissue are penetrated; muscle and bone may be involved
Skin tear
A break or rip in the skin
Painful
Report
Preventing skin tears
Use turning sheet
Gently transfer or position of client
Pressure ulcer
Is an injury caused by unrelieved pressure to the skin and or underlying tissue
Causes of pressure ulcers
Pressure, shearing, and friction
Signs of pressure ulcers
Pale or grey skin, warmed an reddened area
Complaints of pain, burning, itching, or tingling
Stage 1 of pressure ulcer
The skin is intact
Coloured
Stage 2 of pressure ulcer
Partial thickness of skin loss
Stage 3 of pressure ulcer
Full thickness of skin loss
May be drainage
Stage 4 of pressure ulcer
Full thickness of tissue loss
Muscle, tendon, bone exposure
Stage 5 of pressure ulcer
Pressure ulcer cannot be staged due to necrosis
Blackened tissue
Protective devices used to prevent and treat pressure ulcers
Special beds
Bad cradles
Pillows
Some diseases that affect blood flow to and from the legs and feet
Edema
Gangrene
Circulatory ulcers (vascular ulcers)
Are open sores on the lower legs or feet
Venous ulcers
Are open sores on lower legs or feet caused by poor blood flow through the veins
Arterial ulcers
Are open wounds on the lower legs or feet caused by poor arterial blood flow
Appearance of arterial ulcer
May feel cool
Appears grey or blue or shiny
Painful during rest
First phase of wound healing
Inflammatory phase
3 days
Second phase of wound healing
Proliferation phase
3 to 21 days
Third phase of wound healing
Maturation phase
21 to 1-2 years
Hemorrhage
Excessive loss of blood in short period of time
Hematoma
Collection of blood under the skin
Shock results from
When there is not enough blood supply to organs and tissues
Wound drainage- serous
Clear and watery
Wound drainage - sanguineous
Bloody drainage
Wound drainage- serosanguineous
Thin water drainage that is blood tinged
Wound drainage - purulent
Thick drainage that is green, yellow, or brown
Clients with infected and draining wounds will require more of which two nutrients
Protein and vitamin C
Common causes of skin breakdown and pressure ignuries
Pressure, friction, shearing
Risk factors for developing of arterial ulcers
Aging
Smoking
Diabetes
High blood pressure
How long should you wait to perform procedures after pain medication are given
30 minutes
Gangrene
Is a condition in which tissue dies and then decays
Primary intention
Used on closed wounds
Secondary intention
Is used in contaminated and infected wounds
Tertiary intention
Involves leaving a wound open for a time before closing it
Evisceration
Is the separation of the wound
Tape cannot
Encircle the entire body part, impair circulation
