Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

NRSG 201 > Lab 9 skin and wound integrity > Flashcards

Lab 9 skin and wound integrity Flashcards

1
Q

if the braden scale is less than 18 how often should you reassess the client

A

Every two days or PRN

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

what is an intentional wound

A

a planned wound that is a result of therapy ie surgical incision

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

what is an unintentional wound

A

one that is a result of injury

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

whats the definition of a partial thickness skin tear

A

when there is separation between the epidermis and dermis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

what is the definition of a full thickness skin tear

A

separation of the dermis/epidermis from the underlying structure

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

what are the four ways a wound can be described

A

Clean
clean contaminated
contaminated
infected

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

what is a clean wound

A

Primarily closed wounds with minimal inflammation where resp GI and GU tracts have not been entered

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

what is a clean contaminated wound

A

surgical wounds where there is no sign of infection but the resp GI and GU tracts have been entered under a controlled environment

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

what is a contaminated wound

A

-includes open fresh wounds caused by surgery or accident
-break in sterile technique or exposed to gross spillage
-non purulent inflammation is visible

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

what is the definition of an infected wound

A

-old traumatic wound with retained dead tissue
-has existing clinical infection
-internal body cavities have been perforated (ie GI tract)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

what are the three types of wound repair

A

-Primary intention
-secondary intention
-tertiary intention

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

What is primary intention wound healing

A

when the tissue surfaces have been approximated and there is little to no tissue loss (ie incision)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

What is secondary intention

A

when the wound edges can not be approximated and there is longer healing time

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

what is tertiary intention

A

wounds that are left open for 3-5 days and than closed

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

what are the 4 phases of partial thickness wound repair

A

-hemostasis
-inflammatory response
-epithelial proliferation and migration
-re establishment of the epithelial layers

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

what are the 4 phases of full thickness wound repair

A

-Hemostasis
-Inflammatory phase
-proliferative phase
-remodelling/ maturation phase

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

what 3 things happen during the homeostasis phase of wound healing

A

-vasoconstriction occurs to stop the bleeding
-platelets aggregate to from clot/scab
-wound edges start to pull in

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

how soon does hemostasis occur after injury

A

begins immediately after injury

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

how soon does the inflammatory phase start after injury

A

begins immediately after injury once bleeding is controlled

20
Q

how long does the inflammatory phase last

A

3-4 days after injury

21
Q

what happens during the inflammatory phase

A

WBC and macrophages engulf debris and bacteria and secrete angiogenesis factors that stimulate the formation of granulation tissue

22
Q

when does proliferation phase start and how long does it last

A

starts on day 3 or 4 and lasts for about 24 days

23
Q

what happens during the proliferative phase

A

fibroblasts begin to synthesize collagen and proteoglycan and capillaries grow across the wound which results in granulation tissue

24
Q

when does proliferative phase start

A

starts on day 3-4 after injury

25
Q

how long does the proliferation phase last

A

lasts 21-24 days

26
Q

when does the remodeling phase begin

A

begins once the wound is closed

27
Q

how long does the remodeling phase last

A

can last for up to 2 years

28
Q

what happens during the remodeling phase

A

fibroblasts continue to synthesize collagen and the collagen arranges itself in a more organized structure

29
Q

What is induration

A

Redness/hardness spreading to surrounding tissue as part of the inflammatory response

30
Q

What is Ecchymosis

A

bleeding into the subcutaneous tissue (bruising)

31
Q

what are the 4 types of drainage that a wound can have

A

serous
sanguineous
Serosanguineous
purulent

32
Q

What does sanguineous drainage look like

A

Bright red as it is a result of fresh blood

33
Q

when is a hemorrhage of a surgical wound most likely to occur

A

48 hours after surgery

33
Q

What does serosanguineous drainage look like

A

thin watery fluid that is slightly red as its a mix of blood and serous fluid

33
Q

how are retention sutures different from normal sutures

A

that also attach underlying tissues of fat and muscle as well as skin and as a result are much larger

33
Q

What is an indication that a wound may dehiscence or evisceration

A

if there is an increased flow of serosanguinous drainage into the wound dressing

33
Q

when is wound dehiscence or evisceration most likely to occur

A

4-5 days after operation

33
Q

what should a nurse do if dehiscence or evisceration occurs

A

apply saline soaked sterile dressing
place client in bed with knees bent
call surgeon

33
Q

what is wound contamination on the wound infection continum

A

-Wound contains low levels of non proliferating microbes
-Wound healing is not impeded

33
Q

What is a wound colonization

A

wound does have proliferating microbes but there is no host reaction yet

33
Q

what is the main difference between sterile glove technique and no tough clean glove technique

A

in sterile glove only the sterile glove will ever touch the wound whereas in no touch clean glove only sterile instruments are used to tough the wound

33
Q

how long are surgical dressing usually left on for after surgery

A

usually left on for the first 48 hours

34
Q

True or false
A sterile field becomes contaminated if it comes into contact with moisture from above or below the sterile surface

A

True

34
Q

how often would you change a dressing on a superficial wound such as a skin tear and why

A

usually every 5-7 days because you want to decrease the risk of tearing the skin again

34
Q

after a bottle of saline is opened how long is it considered sterile for

A

it is considered sterile for 24 hours

NRSG 201 (12 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions