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Terms > Wounds > Flashcards

Wounds Flashcards

1
Q

Wound

A

Injury that’s results in a disruption in the normal continuity

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2
Q

INCISIONS

A

Cutting or sharp instrument; wound edges in close approximation and aligned

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3
Q

Contusion

A

Blunt instrument, overlying skin remains intact, with injury to underlying soft tissue; possible resultant bruising and/or hematoma

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4
Q

Abrasion

A

Friction; rubbing or scraping epidermal layers of skin; top layer of skin abraded

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5
Q

Laceration

A

Tearing of skin and tissue with blunt or irregular instrument; tissue not aligned, often with loose flaps of skin and tissue

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6
Q

Puncture

A

Blunt or sharp instrument puncturing the skin; intentional (such as venipuncture) or accidental

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7
Q

Penetrating

A

Foreign object entering the skin or mucous membrane and lodging in underlying tissue; fragments possibly scattering throughout tissues

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8
Q

Avulsion

A

Tearing a structure from normal anatomic position; possible damage to blood vessels, nerves, and other structures

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9
Q

Chemical

A

Toxic agents such as drugs, acids, alcohols, metals, and substances released from cellular necrosis

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10
Q

Thermal

A

High or low temperatures; cellular necrosis as a possible result

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11
Q

Irradiation

A

UV light or radiation exposure

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12
Q

Pressure ulcers

A

Compromised circulation secondary to pressure or pressure combined with friction

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13
Q

Venous ulcers

A

Injury and poor venous return, resulting from underlying conditions, such as incompetent valves or obstruction

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14
Q

Arterial ulcers

A

Injury and underlying ischemia, resulting from underlying conditions, such as atherosclerosis or thrombosis

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15
Q

Diabetic ulcers

A

Injury and underlying diabetic neuropathy, peripheral arterial disease, diabetic foot structure

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16
Q

Desiccation

A

Localized wound dehydration

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17
Q

Maceration

A

Localized wound over-hydration or excess moisture

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18
Q

Necrosis

A

is death of tissue in the wound.

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19
Q

Evisceration

A

is complete separation of the wound, with protrusion of viscera through the incisional area.

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20
Q

Bandages and binders are

A

used to secure dressings, apply pressure, and support the wound.

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21
Q

A roller bandage is

A

a continuous strip of material wound on itself to form a cylinder or roll and is applied using a circular turn, spiral turn, or figure-of-eight turn. It is effective for use around joints, such as the knee, elbow, ankle, and wrist

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22
Q

Stage III wounds

A

have full-thickness tissue loss. Subcutaneous tissue may be visible but no bone, tendons, or muscle should be seen.

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23
Q

Stage I involves

A

intact skin with nonblanchable redness.

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24
Q

Stage II involves

A

a partial tissue loss such as a blister.

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25
Q

Stage IV involves

A

full-thickness tissue loss with exposed bone, tendon, or muscles

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26
Q

Undermining is

A

the term for a hollow area between the outer wound and the wound bed. It resembles a cave.

27
Q

Eschar is a

A

leathery covering that is dead tissue and is usually removed by debridement.

28
Q

Tunneling is

A

a cavity or channel formed from a wound.

29
Q

Dehiscence

A

is the opening of a previously closed surgical wound.

30
Q 
Risk of pressure ulcers albumin level  
Hemoglobin A1C
Glucose 
Body weight 
Total lymphocyte count
A 
Albumin of less than 3.2 mg/dL .  
Hemoglobin A1C levels greater than 8%  due to prolonged high glucose levels. 
Glucose levels greater than 120 mg/dL 
Body weight decrease 5%-10%
TLC <1,800/mm3
31
Q

Primary intention

A

Wounds healed by primary intention are well approximated (skin edges tightly together).
Intentional wounds
minimal tissue loss,
such as those made by a surgical incision with sutured approximated edges, usually heal by primary intention.

32
Q

Secondary intention

A

Wounds healed by secondary intention have edges that are not well approximated.
Large, open wounds, such as from burns or major trauma, require more tissue replacement
often contaminated,
take longer to heal
form more scar tissue.

If a wound that is healing by primary intention becomes infected, it will heal by secondary intention.

33
Q

Tertiary or delay primary closure

A 
are those wounds left open for several days to allow 
edema or
infection to resolve or 
fluid to drain, 
and then are closed
34
Q

OpSite

A

The nurse would place an OpSite over a central venous access device insertion site. An OpSite helps to secure the device and is appropriate for a site with little drainage. The nurse would use appropriate aseptic techniques when changing a dressing.

35
Q

Sof-wik

A

The nurse would place a Sof-Wick around a drain insertion site.
The Sof-Wick absorbs drainage and protects the wound from contamination or injury.

36
Q

Tefla

A

purpose of a Telfa is to not adhere to the wound, and allows drainage to pass through to a secondary dressing.

37
Q

When applying a negative pressure dressing,

A

a piece of foam is cut to the shape of the wound and placed in the wound bed.
Irrigation requires sterile, not clean, technique
and the pressure setting of the V.A.C. Therapy Unit is specified by the physician rather than increased until drainage is visible.
Suction is always provided by the V.A.C. Therapy Unit, not by attaching the tubing to wall suction.

38
Q

Biosurgical debridement
Autolytic debridement
Enzymatic debridement
Mechanical debridement

A

Biosurgical debridementuses fly larvae to clear the wound of necrotic tissue. This is accomplished through an enzyme the larvae releases.
Autolytic debridement involves using the client?s own body to break down the necrotic tissue.
Enzymatic debridement involves the use of synthetic enzymes that break down necrotic tissue when applied to the wound bed.
Mechanical debridement involves physically removing the necrotic tissue, such as surgical debridement.

39
Q

Penrose drain

A

Provides sinus tract

Ex. After incision and drainage of abscess, in abdominal surgery

40
Q

T-tube

A

For bike drainage

Ex. After gallbladder surgery

41
Q

Jackson-Pratt

A

Decreases dead space by collecting drainage

Ex. After breast removal abdominal surgery

42
Q

Drainage for after breast removal abdominal surgery

A

Jackson-Pratt

Decreases dead space by collecting drainage

43
Q

Hemovac

A

Decreases dead space by collecting drainage

Ex. After abdominal surgery orthopedic surgery

44
Q

Gauze, iodoform gauze, NuGauze

A

Allow healing from base of wound

Ex. Infected wounds after removal of hemorrhoid

45
Q

Normal albumin level

A

3.5-5 mg/dL

<3.2 risk

46
Q

Normal total lymphocytes count

A

1000-4000/mm3

<1800@risk

47
Q

Normal hemoglobin A1C

A

<6%

Greater then 8 % @risk

48
Q

Normal Glucose

A

70-120 mg/dL

Greater then 120 @risk

49
Q

Skin assessment for pressure ulcers includes inspection of

A

Location of any lesion or ulcer
Identification of the stage
Size of the ulcer: length, width, depth; presence of undermining, a hollow between the skin surface and the wound bed, resulting from death of the underlying tissue
Color and type of wound tissue
Presence of any abnormal pathways in the wound, such as a sinus tract (a cavity or channel underneath the wound that has the potential for infection) or tunneling (a passageway or opening that may be visible at skin level, but with most of the tunnel under the surface of the skin).

Visible necrotic tissue; necrotic tissue that is in the process of separating from viable portions of the body is referred to as slough.

Presence of an exudate or drainage (amount and type)
Presence of odor
Presence or absence of granulation tissue
Visible evidence of epithelialization
Periwound skin condition

50
Q

Preventing pressure ulcers

A

Assess the skin of patients at risk on a daily basis. Pay particular attention to bony prominences.
Cleanse the skin routinely and whenever any soiling occurs. Use a mild cleansing agent, minimal friction, and avoid hot water.
Maintain higher humidity in the environment and use skin moisturizers for dry skin.
Avoid massage over bony prominences.
Protect the skin from moisture associated with episodes of incontinence or exposure to wound drainage.
Minimize skin injury from friction and shearing forces by using proper positioning, turning, and transferring techniques. Use lubricants, protective films, dressings, and padding to diminish the effects of friction on the skin.
Use appropriate support surfaces (tissue load management surfaces).
Investigate reasons for inadequate dietary intake of protein and calories. Administer nutritional supplements or more aggressive nutritional intervention as needed.
Continue efforts to improve mobility and activity. If this is unrealistic, attempt to maintain current level of activity, mobility, and range of motion.
Document measures used to prevent pressure ulcers and the results of these interventions

51
Q

General purpose of dressing

A 
Provide physical, psychological, and aesthetic comfort
Prevent, eliminate, or control infection
Absorb drainage
Maintain a moist wound environment
Protect the wound from further injury
Protect the skin surrounding the wound
Remove necrotic tissue, if appropriate
52
Q 
Dressing : Purpose Transparent films, such as:
 Bioclusive
 DermaView
 Mefilm
 Polyskin
 Uniflex
 OpSite
 Tegaderm
A

Allow exchange of oxygen between wound and environment
Are self-adhesive
Protect against contamination; waterproof
Prevent loss of wound fluid
Maintain a moist wound environment
Facilitate autolytic débridement
No absorption of drainage
Allow visualization of wound
May remain in place for 24 to 72 hours, resulting in less interference with healing

53
Q 
Dressing : USE Transparent films, such as:
 Bioclusive
 DermaView
 Mefilm
 Polyskin
 Uniflex
 OpSite
 Tegaderm
A

Wounds with minimal drainage
Wounds that are small; partial-thickness
Stage I pressure ulcers
Cover dressings for gels, foams, and gauze
Secure intravenous catheters, nasal cannulas, chest tube dressing, central venous access devices

54
Q 
PURPOSE 
The Hydrocolloid dressings, such as:
 DuoDerm
 Comfeel
 PrimaCol
 Ultec
 Exuderm
A

Are occlusive or semi-occlusive, limiting exchange of oxygen between wound and environment
Minimal to moderate absorption of drainage
Maintain a moist wound environment
Are self-adhesive
Provide cushioning
Facilitate autolytic débridement
Protect against contamination
May be left in place for 3 to 7 days, resulting in less interference with healing

55
Q 
USE The Hydrocolloid dressings, such as:
 DuoDerm
 Comfeel
 PrimaCol
 Ultec
 Exuderm
A

Partial- and full-thickness wounds
Wounds with light to moderate drainage
Wounds with necrosis or slough
Not for use with wounds that are infected

56
Q

Ischemia

A

Blanching of skin over an area under pressure results from ischemia. When pressure is relieved, reactive hyperemia follows and the skin is red and feels warm. Reactive hyperemia is not a stage I pressure ulcer.

57
Q

CBT

A

Cognitive behavior therapy (CBT) requires a therapist to work through any maladaptive sleep beliefs. CBT can be very successful is used with other complementary therapies. CBT can include progressive muscle relaxation measures, stimulus control, and sleep restriction therapy. Sedatives and hypnotics would not be used in conjunction with CBT. Pharmacological approaches do not have to be attempted prior to CBT initiation. A client undergoing CBT is not asked to stay in bed during normal sleep hours if the client is not able to sleep.

58
Q

Red wounds are in what stage and intervention needed

A

Proliferation stage
Gentle cleansing and change of dressing
Need protection

59
Q

Which color wounds need cleansing and irrigating

A

Yellow

60
Q

occlusive or semiocclusive dressings that limit exchange of oxygen between wound and environment, provide minimal to moderate absorption of drainage, maintain a moist wound environment, and may be left in place for 3 to 7 days, resulting in less interference with healing.

A

Hydrocolloids

61
Q

maintain a moist wound environment and are best for partial or full-thickness wounds.

A

Hydrogel

62
Q

absorb exudate and maintain a moist wound environment. They are best for wounds with heavy exudate.

A

Alginates

63
Q

allow exchange of oxygen between wound and environment. They are best for small, partial-thickness wounds with minimal drainage

A

Transfer films

Terms (2 decks)

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