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Fundamentals of Nursing Lab > Wound Assessment > Flashcards

Wound Assessment Flashcards

1
Q

Epidermis layer characteristics :

A
  • outermost layer
  • composed of epithelial cells which play a unique role in wound healing
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2
Q

Dermis layer characteristics :

A
  • it is known as the factory of the skin
  • it is a very vascular layer
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3
Q

What is the dermis layer composed of?

A
  1. nerve endings
  2. lymphatic tissue
  3. connective tissue
  4. hair follicles
  5. sweat glands
  6. sebaceous glands
  7. collagen proteins
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4
Q

Hypodermis / subcutaneous layer characteristics :

A
  • the thickest layer
  • protective layer
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5
Q

What is the hypodermis composed of?

A
  1. adipose tissue
  2. connective tissue
  3. blood vessels
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6
Q

What is the function of connective tissue?

A

It supports, protects & gives structure to other tissues & organs in the body
It helps repair damaged tissues

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7
Q

What is the REEDA scale?

A

It is a scale used to assess wound healing & symptoms of inflammation.
R = Redness
E = Edema
E = Eccmocysis
D = Drainage
A = Approximation

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8
Q

What are the types of wounds?

A
  • clean
  • clean/contaminated
  • contaminated
  • infected
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9
Q

What is a clean wound?

A
  • an uninfected wound
  • minimal inflammation
  • GTI tracts, genitals & urinary tract not entered
  • Primarily closed wound
  • made under aseptic conditions
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10
Q

What is a clean/contaminated wound?

A
  • a surgical wound
  • GTI tract, genital & urinary tract has been entered
  • no evidence of infection
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11
Q

What is a contaminated wound?

A
  • a wound exposed to a high level of microorganisms or foreign material that increases the risk of infection
  • breaches in aseptic technique
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12
Q

What is an infected wound?

A
  • dirty or infected wound
  • evidence of clinical infection
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13
Q

What are the factors that affect wound healing?

A
  • age
  • circulation & oxygenation
  • nutritional status
  • wound condition
  • smoking
  • some medications
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14
Q

In wound assessment, what are the clinical appearances of the wound & what do they represent?

A

Black - necrotic
Green - infected
Yellow - sloughing
Red - granulating
Pink - epitheliating

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15
Q

In wound assessment, what do we measure in terms of dimension?

A
  • circumference
  • depth
  • width
  • length
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16
Q

What are Exudates?

A

It is material such as fluid & cells which has escaped from blood vessels during the inflammatory process & is deposited in tissue or on tissue surfaces

17
Q

What determines the nature & amount of exudates?

A
  • the type of tissue involved
  • the intensity & duration of the inflammation
  • the presence of microorganisms
18
Q

What are the indications for cleaning a wound?

A
  • presence of infection
  • Excessive exudates
  • presence of foreign bodies or debris
  • a need to reduce contamination or dead tissue prior to suturing
19
Q

Why should we perform gentle cleansing?

A
  • because new epithelial cells are very fragile & easily removed with vigorous cleaning
  • gentle cleaning should only remove debris & foreign bodies
  • we should keep surrounding skin clean & dry
20
Q

What solutions can we use to clean/irrigate wounds?

A
  1. isotonic saline
  2. wound cleansers
  3. diluted antimicrobial solutions
  4. normal saline
21
Q

How much solution should we use when cleaning/irrigating?

A

3x the volume of wound

22
Q

How do you manage pain when dressing a wound?

A
  • you assess for pain 30 minutes prior to dressing & manage the pain if present
  • Monitor for pain during the procedure
  • reassess pain after the procedure
  • document
23
Q

What equipment during wound dressing should be sterile?

A
  1. gloves
  2. scissors or forceps
  3. the appropriate dressing material
  4. sterile saline solution
  5. cotton-tipped swabs
  6. culture tubes in cases of infection suspicion
  7. irrigation equipment
24
Q

What equipment during wound dressing should be unsterile or is just clean?

A
  1. gloves (when undressing)
  2. plastic bag
  3. tape
  4. bed pads
  5. gown
25
Q

What solution should NEVER be used within the wound, only topically?

A

Topical antiseptics

26
Q

What is the most ideal environment for wound healing?

A

Moist environment

27
Q

What is the ideal dressing?

A

The dressing that can keep the wound bed moist while keeping the periwound tissue dry
1. maintain moist environment
2. absorb exudate
3. debride necrotic tissue
4. allow gaseous interchange
5. interact with wound to promote healing
6. protects
7. non-allergenic
8. hydrates dry tissue
9. conforms to depth & contour
10. Provides active bacterial control
11. provides odor control
12. stays in place well via its own adhesive

Fundamentals of Nursing Lab (8 decks)

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