wound care Flashcards

1
Q

tissue integrity

A

the ability of the human body to regenerate and maintain normal physiologic functioning. the skin, cornea and subc tissue, and mucous membranes act as defense mechanisms for the body

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2
Q

largest organ system of body accounting for about 15% of total body wight

A

skin

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3
Q

skin main function

A

protection

providing barrier from injury, ultraviolet radiation and heat

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4
Q

skin plays a crucial role in

A

sensory percreption such as touch, pain, pressure, and vibration

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5
Q

skin regulates

A

temperature and protects the body against temperature changes
- eliminates waste and supports the underlying structures and synthesis of vitamin d

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6
Q

epidermis

A

outer layer of the skin composed mainly of keratinocytes and other cells, such as melanocytes, Merkel cells and lanerhans cells

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7
Q

dermis

A

largest portion of skin
- main function to sustain and support epidermis by providing strength and flexibility; made of connective tussye with capillaries; blood vessels; lymoth vessels; nerves; sweat and sebaceous glands; hair roots; elastic fibers; and collagen

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8
Q

subcutaneous tissue

A

subc fat that insulates the body, absobs shock and pads the internal organs and structures

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9
Q

risk factors for development of pressure injuries and wounds

A
  • age
  • mobility issues
  • weight
  • spina bifida, cerebral palsy, other chronic conditions such as liver, renal diseases, cancer and malnutrition
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10
Q

as adults skin becomes

A

thinner, elasticity is lost, sub c fat becomes thinner, blood supply is more sulggish and the skin becomes less hydrated. therefore, shear, friction, pressure can cause problems

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11
Q

pressure injury

A
  • localized damage to skin, underlying tissue as a result of a pressure in combination with shear
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12
Q

pressure injuries are most often

A

over bony prominences but can also be a result of a pressure caused by a medical device, such as urinary catheters, oxygen tubing, endotracheal tubing, drains.
- most susceptible are held, toes, sacrum, hips, elbow, shoulders, back of head

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13
Q

stage 1

A

nonblanchable erythema of intact skin

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14
Q

stage 2

A

partial thickness skin loss with exposed dermis

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15
Q

stage 3

A

full thickness skin loss

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16
Q

stage 4

A

full thickness skin and tissue loss

17
Q

unstageable

A

obscured full thickness skin and tissue loss

18
Q

deep tissue pressure injury

A

persistent nonblancable deep red, maroon or purple discoloration

19
Q

TIME ( how pressure injuries shoudl be described)

A

T: tissue integrity- describe how the tissue looks, the wound color, and if there is dead netcrotized tissue present

I: inflammation or infection- s/s of infection present, redness, warmth, swelling, discharge, and swelling

M: moisture- wound is dry or moist and if the wound is macerated

E: edge of wound- describe the wound edges

20
Q

DIDNT HEAL (factors influencing wound healing)

A
D= diabetes
I= infection 
D= drugs 
N= nutritonal problems
T= tissue necrosis
H= hypoxia
E= extensive tension 
A= another wound
L= low temperature
21
Q

hemosatic/ inflammatory

A

damaged tissue releases cytokines which trigger a process called hemostasis; blood coagulates, and the wound starts to heal
- plasma leaks into surrounding tissue and causes swelling

22
Q

proliferative

A
  • new collagen fibers are formed
  • nee wound bed is created
  • capillaries start growing
  • wound edges begin pulling closer and new granulation tissue grows
23
Q

remodeling

A

stronger collagen replaces soft gelatinous collagen; however this tissue is much weaker than the orginal tissue and is susceptible to reinjury

24
Q

primary healing or first intention

A

occurs in clean lacerations and surgical incisions; closed with skin ahesives or sutures

25
Q

secondary healing or second intention

A

wound healing that happens when the wound is left open to heal

26
Q

delayed primary closure

A

combination of primary and secondary healing, where the wound is left open for 5-10 days before it is closed with sutures

27
Q

skin redness

A

usually referred to as blanchable or nonblanchable erythema
- non-blanchable erythmea is redness that does not go away when pressure is applied and is a sign that structural damage has occurred to the skin

28
Q

methods for measuring wound size

A
  1. tracing wound circumference

2. measuring length and width of the wound

29
Q

acute wounds

A

develop as a result of injury and typically are a result of trauma

30
Q

chronic wounds

A

develop over time from acute wounds that do not progress in healing

31
Q

surgical debridement

A
  • accumulated debris and dead tissue are removed with a scalpel or scissors
  • debridement decreases the number of bacteria in the wound and stimulates the rebuilding of the wound bed by contraction and epithelialization
32
Q

major complications of wounds are

A
infections 
dehiscences- wound comes apart
evisceration- even further process
hematomas/seromas
fistulas- different layers connect in the wrong spot