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Fundamentals > Wound Care > Flashcards

Wound Care Flashcards

1
Q

Functions of skin

A 
Protects
Controls body temp
Functions as excretory organ
Functions as sensory organ
Provides identity
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2
Q

Functional components of the skin

A

Epidermis
Dermis
Subcutaneous tissue

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3
Q

Epidermis

A

Tough leathery outer skin
Keritinocytes, melanocytes, Merkel cells, Langerhan’s cells
Functions:protection, regulates body fluid, production of vitamin D

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4
Q

Dermis

A

Highly vascular
Superficial lymphatics
Fibroblasts, macrophages, WBC, mast cells
Functions: nutrition, thermoregulation, sensation

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5
Q

Subcutaneous tissue

A

Supports the skin

Adipose tissue and fascia

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6
Q

Partial thickness wounds

A

Loss of epidermis

Can lose part of dermis

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7
Q

Full thickness wounds

A

Loss of epidermis and dermis

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8
Q

Sequence for tissue healing

A

Inflammatory phase
Proliferation
Maturation/remodeling

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9
Q

Signs and symptoms of inflammation

A

Redness
Swelling
Heat
Pain

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10
Q

Proliferation

A

When cells needed for repair and regeneration reach the injury site

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11
Q

4 crucial events during proliferative phase

A

Angiogenesis
Granulation tissue formation
Wound contraction
Epithelialization

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12
Q

Maturation/remodeling

A

The granulation tissue laid down must be strengthened/reorganized
Collagen synthesis continues
Fibers reorient along lines of stress
Internal influence
External influence
Continues up to 2 years
Scar tissue is at most 80% of original tissue strength

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13
Q

3 processes of wound closure

A

Primary intention
Secondary intention
Tertiary intention

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14
Q

Primary intention

A 
Wounds without tissue loss
Edges approximated
Low risk for infection
Heals quicly
Dry dressing or no dressing
Surgical incision
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15
Q

Secondary intention

A 
Wounds with tissue loss 
Edges not approximated
High risk for infection
Heals slowly
Wet to dry dressing
Pressure ulcer, burn
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16
Q

Tertiary intention

A 
Wounds in which closure is purposefully delayed
Moderate infection risk
Moderate scar
Heals quickly once closed
Moist dressing when dry, dry when closed
Contaminated wound, traumatic injury
17
Q

Signs and symptoms of infection

A 
Temperature
Flu symptoms
Tachycardia
WBC, C-reactive protein test
Purulent drainage
Edema/erythema
Malodorous wound drainage
Induration
18
Q

Factors affecting wound healing

A

Local: circulation, sensation, mechanical stress
Systemic: age, drugs, lifestyle, diseases

19
Q

At-risk clients

A 
Immobility
COPD, PVD, cardiac disease
Immune deficiencies, infection
Poor nutrition/hydration
Diabetes/obesity
Meds
Age
Severity of wound
20
Q

Assessment

A

Inspection, palpation, olfaction

21
Q

Subjective data

A

Pain, pruritus, body image

22
Q

Objective data

A

ABCDE

23
Q

Expected findings

A 
Clean pink/red edges
Moderate to no edema
Temp same as other tissue
Minimal drainage
Pain decreasing consistently
24
Q

Complications

A 
Bleeding
Dehiscence
Fistula formation
Infection
Excessive pain
Loss of mobility or function
Anxiety
Body image disturbance
25
Q

Dehiscence

A

Separation of epidermis and dermis

26
Q

Fistula formation

A

Opening between organ and outside or two organs

27
Q

Types of wound drainage

A

Sanguineous: bleeding
Serosanguineous: thing watery
Serous: clweawr, thin, watery
Purulent: thick, opaque, tan/yellow/green/brown

28
Q

Host interventions

A

Hand washing
Improve nutrition: Vitamins A and V, protein, zinc, iron, calories (>4000/day extra), fluids (2 L/day)
Mobility
Rest

29
Q

Mode of transmission interventions

A 
Handwashing
Clean environment
PPE
Barrier techniques
Cover portals
30
Q

Agent interventions

A 
Handwashing
Isolation precautions
Proper disposal of contaminated items
Antibiotics
Culture and sensitivity of wound

Fundamentals (11 decks)

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