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Nurs 270 > Wound Care Key Points > Flashcards

Wound Care Key Points Flashcards

1
Q

Sublethal injury

A

Alters function without causing cell death

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2
Q

Lethal injury

A

An irreversible process that causes cell deaths

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3
Q

What is common in cublethal injuries

A

Cell adaptations
-part of many normal physiological processes

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4
Q

Hypertrophy

A

Increase in the size of cells
-resulting in increased tissue mass without cell division

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5
Q

Hyperplasia

A

Increase in number of cells
-resulting from increased cellular division
-reversible when stimulus is removed

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6
Q

Atrophy

A

Decrease in size of tissue or organ
-caused by decrease number of cells or reduction in the size of individual cells

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7
Q

Metaplasia

A

Transformation of one cell type into another
-in response to a change in physiological condition or an external irritant

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8
Q

Dysplasia

A

Abnormal differentiation of dividing cells that results in changes in their size, shape, appearance

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9
Q

Anaplasia

A

Cell differentiation to a more immature or embryonic form

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10
Q

Examples of individual cell death in normal situations

A

Skin, gut epithelium and embryogenesis

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11
Q

Apoptosis

A

Programmed cell death
-human health dependant on this process

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12
Q

When is cell death not a normal event

A

In developed tissues such as brain, liver, necrosis

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13
Q

Inflammatory response

A

Sequential reaction to cell injury
-neutralizes and dilutes inflammatory agent
-removes necrotic materials
-creates healing environment

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14
Q

The inflammatory response can be divided into

A

Vascular, cellular, formation and healing
-responses

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15
Q

Vascular response

A

Results in vasodilation causing hyperaemia which raises filtration pressure
-increased blood flow in the area

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16
Q

Cellular response

A

Neutrophils and monocytes move to the inner surface of the capillaries and then through capillary wall to site of injury

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17
Q

Exudate

A

Consists of fluid, leukocytes that move from the circulation to the site of injury

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18
Q

Nature and quantity of exudate depend on

A

Type and severity of the injury and tissues involved

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19
Q

Healing includes two major components

A

Regeneration and repair

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20
Q

Regeneration

A

Replacement of lost cells and tissues with cells of the same type

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21
Q

Repair

A

More common type of healing, results in scar formation

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22
Q

Primary intention

A

Healing takes place when wound margins are neatly approximated as in surgical incision or a paper cut

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23
Q

Secondary intention

A

Healing occurs in wounds from trauma, ulceration and infection
-large amounts of exudate and wide irregular wound margins

24
Q

Tertiary intention

A

Healing occurs with delayed suturing of a wound in which two layers of granulation tissue are sutured together

25
Q

Three basic types of inflammation

A

Acute, subacute, chronic

26
Q

Acute inflammation

A

Healing occurs in 2 to 3 weeks and usually leaves no residual damage

27
Q

Subacute inflammation

A

Features of the acute process but lasts longer

28
Q

Chronic inflammation

A

Lasts for weeks, months, or even years

29
Q

Wounds can be classified by

A

-cause (surgical/non surgical or acute/chronic)
-level of contamination
-depth of tissue affected (superficial, partial thickness, full thickness)
-color of wound (red, yellow, black)

30
Q

Complications of wound healing may include

A

Adhesions, contractures, dehiscence, evisceration, excess granulation tissue, fistula formation, infection, hemorrhage, formation of hypertrophic scars and keloids

31
Q

Best management of inflammation is prevention of

A

Infection, trauma, surgery, and contact with potentially harmful agents

32
Q

Three purposes of wound management

A
  1. Cleaning a wound to remove any dirt and debris from wound bed
  2. Treating infection to prepare the wound for healing
  3. Protecting a clean wound from trauma so that it can heal normally
33
Q

Pressure injury

A

Localized injury to skin or underlying tissue
-over bony prominence as result of pressure or pressure in combination with shear friction or both

34
Q

Shearing force

A

Pressure exerted on skin when it adheres to the bed and underlying skin layers slide in the direction of body movement

35
Q

What three things contribute to pressure injuries

A

-shearing force
-friction
-excessive moisture

36
Q

Care of a patient with pressure injuries revolves around the

A

Whole person
-nutrition, pain management, control of other medical conditions, pressure relief

37
Q

Chances of wound infection are greater when

A

-wound contains dead or necrotic tissue
-foreign bodies lie on or near wound
-blood supply and tissue defences are reduced

38
Q

TIME framework

A

T- tissue management
I- inflammation/infection
M- moisture
E- edge of wounds perimeter

39
Q

Dry gauze

A

Abrasions and non draining postoperative incisions
-rapid moisture evaporation

40
Q

Pressure bandages

A

Control excessive, sudden, unanticipated bleeding
-stops blood flow and promotes clotting

41
Q

Transparetns film dressings

A

Clear, adherent, nonabsorptive, impermeable to fluids and bacteria
-prophylaxis on high risk intact skin, superficial wounds, with minimal exudate and Escher covered wounds

42
Q

Hydrocolloid dressings

A

Formed of elastomeric, adhesive, gelling agents
-absorb drainage and hydrate and debride wounds

43
Q

Hydrogel dressings

A

Hydrate wounds
-polyurethane foam dressings are capable of holding wound exudate away from wound bed
-alienate dressings promote autolysis, granulation, epithelization

44
Q

Bandages are secondary dressings which provide

A

Protection, pressure, immobilization and anchorage of underlying dressings or splints

45
Q

Effective dressing control..

A

Wound moisture and drainage, protect the wound, debride dead tissue, and reduce the spread of infection

46
Q

Key components of a physiological wound environment are

A

Adequate moisture, pH balance, temperature control, low bacterial burden

47
Q

Dressing type used for autolytic debride ent of non infected wounds

A

Hydrocolloid dressing

48
Q

Dressing type that is useful to keep dressings intact and occlusive

A

Transparent film dressing

49
Q

Gauze dressing should be non woven if touching the wound bed (t/f)

A

True

50
Q

Used for moderate to heavy exudate wounds are adhesive or non adhesive and come in regular and lite versions

A

Foam dressing s

51
Q

The four phases of wound healing are hemostasis, inflammation, proliferation and maturation (t/f)

A

True

52
Q

Chronic wounds often stall in the inflammatory or proliferation phase of healing (t/f)

A

True

53
Q

Inflammation and infection are influenced by

A

Prescience of non viable tissue, high bacterial loads, and impaired leukocytes

54
Q

Tissue management involves removing non viable tissue from the wound (t/f)

A

True

55
Q

You have just removed a Hydrocolloid dressing from a venous ulcer, the exudate shows this wound is infected (t/f)

A

FALSE

Nurs 270 (24 decks)

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