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CNUR 103 > wound care > Flashcards

wound care Flashcards

1
Q

Stratum corneum

A

the outermost layer on skin

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2
Q

stratum lucidum

A

the second layer

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3
Q

Stratum granulosum

A

the third layer

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4
Q

Stratum spinosum

A

the 4th layer

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5
Q

Stratum germinativium

A

the inner most layer of the skin

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6
Q

when does granulation tissue form

A

during wound healing

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7
Q

what is granulation tissue

A

the new skin that grows during the healing process

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8
Q

Partial thickness wound

A

limited to epidermis

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9
Q

Full thickness wound

A

total loss of skin layer

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10
Q

4 phases of wound healing

A

homeostasis, inflammatory, proliferative, maturation

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11
Q

Homeostasis

A

-right after the injury
-clots form to seal off blood vessels
-platlets
-release growth factor and begin repair

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12
Q

inflammatory

A
  • Redness, swelling, warmth
    • Not infection
    • This is 1-4 days after
    • Neutrophils, macrophages, monocytes
    • Laborers clean up the sit (random with no specific job)
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13
Q

proliferative

A
  • Pebbled red tissue
    • 4-21 days after
    • Macrophages, pericytes, lymphocytes, angiocytes, neurocytes, fibroblasts, keratinocytes, epithelial
    • Now we have our very distinct labors (plumbers, framers) here to do their job
    • Fill defect, re-establish skin function, closure
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14
Q

Maturation

A
  • Remodelling stage
    • 21-years
    • Scar tissue
    • Deep pink
    • Fibrocytes and blasts, building tissue strength
    • Remodel or mature the skin
    • Tissue strength is only 80% of the old skin
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15
Q

healing can be delayed by

A

infection
-poor tissue
-poor nutrition
-smoking
-obesity
-medication
-chemo
-immunosuppressants
-NSAIDs

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16
Q

treatment goal for wound healing

A

maintain moisture balance (not too moist)
-Prevent infection
-protect surrounding skin
-reduce pain
-minimize odor

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17
Q

Wound round

A

the edges of the wound

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18
Q

analogy

A

the collagen is remodelled to become stronger. A scar may form. the tissue strength is only 80% of the old skin

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19
Q

primary intention

A
  • wound healing occurs when the edges of a clean surgical incision remain close together, tissue loss is minimal or absent
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20
Q

secondary intention

A

wounds that are open and have tissue loss. Granulation tissue gradually fills in the area of the wound. Skin loss is present

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21
Q

3rd intention

A

the wound is purposely left open for 3-5 days to allow edema or infection to decrease and then the wound edges are sutured or stapled shut

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22
Q

venous ulcers

A

above ankle, medial lower leg

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23
Q

Arterial ulcers

A

lower leg dorsum, foot, lateral border or foot, toe joint

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24
Q

Neuropathic ulcers

A

plantar surface, lateral border of foot

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25
Q

When doing a wound assessment note:

A

location, odor, size, undermining, tunnelling, wound base appearance, temp, peri wound

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26
Q

Laceration wound

A

a cut, jacked edge

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27
Q

Abrasion wound

A

scratch surface of skin

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28
Q

contusion

A

bruise

29
Q

hematoma

A

collection of blood

30
Q

tunneling

A

A separation of the fascial planes leading to sinus tracts
Usually involves a small % of the wound margins
Usually narrow and long, and seems to have a destination

31
Q

Undermining

A

Usually involves a greater % of the wound margins, with more shallow length than tunnelling
Usually involves subcutaneous tissues
An erosion under the edge of the wound

32
Q

hyperkeratosis

A

when a wound edge is callus like

33
Q

maceration

A

softening of tissue by fluids

34
Q

exudate terminology

A

scant, moderate, large, copious

35
Q

Colours of exudate

A

serous, sanguineous, serosanguineous, purulent

36
Q

Serous

A

light yellow to clear

37
Q

sanguineous

A

bright and fresh

38
Q

Serosanguineous

A

light red or pink

39
Q

Purulent

A

thick, yellow, green, tan, brown

40
Q

granulation tissue

A

The growth of small blood vessels and connective tissue into the wound cavity

41
Q

what does healthy granulation tissue look like

A

bright, beefy red, shiny, and granular with a velvety appearance

42
Q

A pale granulation tissue indicates

A

ischemia, infection, or a co-morbidity such as anemia

43
Q

Hyper granulation tissue

A

A building up of tissue that prevents epidermal migration or resurfacing across the wound, by proliferating above the intact margins of the skin
-excessive moisture

44
Q

Necrotic tissue

A

physical barrier to granulation, can harbour bacteria

45
Q

slough

A

Indicates less severity
Yellow to tan mucinous or stringy material
Loosely adherent to wound bed
If non-adherent will be scattered through out wound

46
Q

Eschar

A

Indicates deeper tissue damage
Black, gray, brown in color
Usually adherent or firmly adherent
May be soggy and soft or hard and leathery

47
Q

Smell of necrotic tissue

A

foul

48
Q

Smell of pseudomonas

A

sickening sweet with blue and green exudate

49
Q

wound irrigation PPE

A

-face shelf and mask and gloves

50
Q

stage 1 pressure ulcer

A

non blanching erythema with intact epidermis

51
Q

Stage 2 pressure ulcer

A

partial thickening ulcer involving epidermis and dermis

52
Q

stage 3 pressure ulcer

A

full thickness extending through dermis into subcutaneous tissue

53
Q

Stage 4 pressure ulcer

A

deep tissue destruction extending through fascia may involve muscle bone tendon

54
Q

unstageable pressure ulcer

A

depth of injury unknown to presence of necrotic tissue and eschar

55
Q

Pressure ulcer prevention

A

Encourage or assist with position changes, at least every 1–2 hours.
Avoid prolonged moisture; protect skin from urine, stool or wound drainage if present.
Utilize specialized mattresses, pads or cushions to relieve and redistribute pressure.
Maintain tissue integrity with a well balanced, protein-rich diet.

56
Q

what is the sterile border

A

1 inch

57
Q

when cleaning a wound what should be cleaned first

A

inside then outside

58
Q

what happens if drainage accumulates in the wound bed

A

wound healing is delayed

59
Q

Open drain

A

drain fluid on to a gauze pad or into a stoma bag (ex Penrose)

60
Q

Closed drains

A

The collection device is connected to a clear plastic drain with multiple perforations. Drainage collects within a closed reservoir or a suction bladder.
Drainage collects in a closed reservoir or a suction bladder

61
Q

When to change closed drain

A

when bag is half full

62
Q

How much can a JP drain hold

A

100 to 200 mL/24 hr;

63
Q

How much can a Hemovac drain hold

A

500mL/24hr (Accordion looking)

64
Q

serous

A

clear, watery. normal of healing

65
Q

serosang

A

pale, pink, water, mix of clear and red

66
Q

sang

A

Bright red, recent or active

67
Q

Purlent

A

Thick, yellow, green, foul odour infection

68
Q

Documenting drainage

A

Document emptying or re-establishing of vacuum in suction device; amount, colour, and odour of drainage; dressing change to drain site; and appearance of drain insertion site.
Document amount of drainage on intake and output (I&O) record.
Document to the health care provider a sudden change in amount of drainage, either output or absence of drainage flow.
Also report to the health care provider pungent odour of drainage or new evidence of purulence, severe pain, or dislodgment of the drainage tube.

CNUR 103 (9 decks)

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