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Nursing > Wounds1 > Flashcards

Wounds1 Flashcards

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1
Q

What are the 3 layers of skin?

A

Epidermis
Dermis
Subcutaneous layer

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2
Q

According to NPIAP what is classified as a pressure injury ?

A

Localized damage to the skin and underlying soft tissue usually under a body prominence or related to a medical or other device

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3
Q

What are some risk factors for getting a pressure injury ?

A

Advanced age
Anemia
Contractors
Diabetes
Loc alteration
Impaired mobility
Obesity
Incontinence

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4
Q

What are some prevention interventions for pressure injuries?

A

Reposition patient
Clean skin properly after incontinence
Pressure reducing mattress
Flat heels off bed
Use lifting devices to prevent dragging

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5
Q

What are the 4 main type of classifications for pressure injuries?

A

Unstageable
Deep tissue pressure injury
Medical device related pressure injury
Mucosal membrane pressure injury

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6
Q

Deep tissue injury (DTi)

A

Happens from deep within
- look like a hematoma

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7
Q

What are the stages of pressure injuries?

A

1-4

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8
Q

Stage 1 pressure injuries

A

Intact skin with localized area of non blanchable erythema

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9
Q

Stage 2 pressure injury

A

Partial thickness loss of skin with exposed dermis
- wound bed visible / pink or red / moist

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10
Q

Stage 3 pressure injuries

A

Full thickness loss of skin
- adipose visible in ulcer and granulation tissue and episode ( rolled wound edge)

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11
Q

Stage 4 pressure injury

A

Full thickness tissue loss with exposed bone , muscle, or tendon

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12
Q

Epibole is

A

The rolling of skin inwards towards moisture

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13
Q

What is stable escar

A

It protects itself making the wound not broken open

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14
Q

What does a “healed stage 4 mean”?

A

A pressure injury was a stage four but it healed however it is more likely to break open again

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15
Q

Surgical acute wound

A

Skin graft donor

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16
Q

Surgical chronic wound

A

Infected incision

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17
Q

Nonsurgical acute wound

A

Burn/ skin tear

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18
Q

Non surgical chronic wound would be

A

Pressure injury
Lower leg ulcer

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19
Q

Primary intention in wound healing

A

Surgical - maintained by suchers / staples/ stitches

20
Q

Secondary intention

A

Burn
Pressure ulcers
Severe laceration

21
Q

Wound repair for a partial thickness

A

Inflammatory response, epithelial proliferation and migration , reestablishment of epidermal layers

22
Q

Wound repair for a Full thickness pressure injury requires

A

Inflammatory response
Proliferation phase
Remodeling (svar)

23
Q

3 phases part of wound repair

A

Inflammation
Proliferation/ granulation
Remodeling/ maturation

24
Q

What are some complications that can happen during wound healing

A

Hemorrhage shock
Infection
Evisceration
Fistula formation
Adhesions

25
Q

Dehiscence

A

Skin layers start to separate due to pressure
- happen 1week -1 1/2 week

26
Q

Evisceration

A

Bowel goes out of wound

27
Q

Fistula formation

A

Communication b/w two things that should not be happening

  • colon & bladder become one
28
Q

Wound vac purpose

A

Clean out a wound

29
Q

What affects wound healing ?

Think: didn’t heal

A

D iabetes
I nfection
D rugs
N utrition
T issue necrosis
H ypoxia
E xcessive tension
A new wound
Low temp

30
Q

Biofilm is

A

A slimy / shinny covering over a wound
- needs to be wiped off

31
Q

What nutrients are important for wound healing?

A

Increase of calories
Protein
VitMin c
Vitamin a
Zinc

32
Q

Serous drainage

A

Clear/ watery plasma

33
Q

Purulent drainage

A

Thick yellow / green pus

34
Q

Serosanguineous drainage

A

Pale pink watery mixture to clear and red fluid

35
Q

Sanguineous drainage

A

Bright red : actively bleeding

36
Q

Types of ways to close wounds

A

Staples
Stitches
Seri strips

37
Q

What do you include in your assessment of a wound ?

A

Size : lxwxd
Anatomical markings
Tissue involvement - stage / thickness level
Wound bed characteristics
Is there undermining . Tunneling?
Condition of surrounding skin

38
Q

Gluteal cleft

A

The butcrack

39
Q

When doing measurements of a wound you should

A

Use it as a clock
12-6 is length
3-9 width

40
Q

Is a wound a sterile or clean technique

A

Clean - do not touch or try not to touch as much as possible

41
Q

Time framework is focusing on

A

Tissue management
Inflammation/ infection present?
Moisture imbalance
Edge

42
Q

Wound management includes

A

Moist wound environment
Prevent / manage infection
Ensure wound bed in clean/ intact
Proper nutritional intake
Pain managed
Education

43
Q

Types of wound debridement

A

Sharp - surgical
Mechanical - irrigation/ wet to dry dressings
Chemical - medical maggots

44
Q

How do you clean a wound? Where to start?

A

Clean least to most contaminated
- wound to outside

45
Q

Types of dressings

A

Gauze
Wet to dry
Telefax
Transparent
Hydrocolloid
Hydrogel

46
Q

Hen does a patients wound usually get evaluated?

A

About 2 weeks

47
Q

What is candidiasis

A

Fungal / yeast infection
- usually found under skin folds

Nursing (5 decks)

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