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Nursing - Bloomberg > Wound Care > Flashcards

Wound Care Flashcards

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1
Q

Reduction of blood flow to tissue

A

Tissue ischemia

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2
Q

If tissue ischemia is relieved, vasodilation creates redness called

A

Hyperemia

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3
Q

Why wouldn’t erythematous area blanch?

A

Deep tissue damage

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4
Q

When normal red areas of light skinned patients are absent

A

Blanching

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5
Q

What are 3 related factors of developing pressure ulcers?

A
  1. Pressure intensity
  2. Pressure duration
  3. Tissue tolerance
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6
Q

Extrinsic factors of tissue tolerance are:

A

Shear, friction, and moisture

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7
Q

Systemic factors of tissue tolerance are:

A

Poor nutrition
Age
Low blood pressure

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8
Q

Risk factors for pressure ulcers

A
  1. Impaired sensory perception
  2. Impaired mobility
  3. Alteration in LOC
  4. Shear
  5. Friction
  6. Moisture
  7. Nutrition
  8. Tissue perfusion
  9. Infection
  10. Pain
  11. Age
  12. Psychosocial impact of wounds
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9
Q

Red, moist tissue composed of new blood vessels

A

Granulation tissue

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10
Q

Stingy substance attached to wound bed

A

Slough

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11
Q

Brown or black necrotic tissue

A

Eschar

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12
Q

Amount, colour, consistency and odour of wound drainage

A

Exudate

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13
Q

Response cause redness and swelling, and moderate exudate at wound edges.

A

Inflammatory response

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14
Q

Epidermal cells at wound edged quickly resurface and migrate across wound bed

A

Proliferation and migration response

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15
Q

New epithelium undergo reestablishment of epidural layers

A

Remodeling phase

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16
Q

Clear, watery plasma

A

Serous

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17
Q

Thick, yellow, green, tan or brown

A

Purulent

18
Q

Pale red watery mixture of clear and red fluid

A

Serosanguineous

19
Q

Bright red indicates active bleeding

A

Sanguineous

20
Q

What would the nurse assess from a wound?

A
  1. Redness
  2. Swelling
  3. Drainage
  4. Wound closure
  5. Temperature
  6. Pain
  7. Wound cultures
21
Q

Partial or total separation of wound layers

A

Dehiscence

22
Q

Increased amount of serosanguinous drainage may indicate

A

Dehiscence

23
Q

Protrusion of visceral organs through wound opening

A

Evisceration

24
Q

Abnormal passage between two organs or organ and outside of body

A

Fistula

25
Q

Localized collection of blood underneath tissues

A

Hematoma

26
Q

Removal of non viable, necrotic tissue

A

Debridement

27
Q

Purple or maroon localized area of discoloured intact skin or blood-filled blister. Area is painful, form, mushy, boggy, warmer or cooler.

A

Deep tissue injury

28
Q

Intact skin with nonblanchable redness, usually over bony prominence.

A

Stage 1

29
Q

Partial thickness loss of dermis presenting as shallow ulcer with red pink wound bed, without sough. May also be intact or open or ruptured serum-filled blister.

A

Stage 2

30
Q

Full thickness tissue loss. Subcutaneous fat may be visible. Slough present but does not obscure tissue depth. May include undermining and tunnelling.

A

Stage 3

31
Q

Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present, often with undermining and tunnelling.

A

Stage 4

32
Q

Full thickness tissue loss, base of ulcer covered by slough or eschar.

A

Unstageable

33
Q

Wound that is closed

A

Primary intention

34
Q

Wound edges are not approximated

A

Secondary intention

35
Q

Wound closure is delayed until risk of infection is resolved, then wound edges are approximated

A

Tertiary intention

36
Q

Ulcer caused by inadequate blood flow

A

Arterial ulcers

37
Q

Superficial and irregularly shaped wound usually with large amount of exudate caused by edema

A

Venous Ulcers

38
Q

Superficial partial-thickness wound with little bleeding

A

Abrasion

39
Q

Jagged unintentional wound sometimes with more profuse bleeding

A

Laceration

40
Q

Small circular wound with edges coming together toward center

A

Puncture

Nursing - Bloomberg (52 decks)

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