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Flashcards in 310 EXAM 3 Deck (59):
1

Factors Affecting Wound Healing

-Age
-Circulation & oxygenation
-Nutritional status
-Wound condition (need protein)
-Health status

2

Psychological Effects of Wounds

Changes in body image -----> face wounds

3

Six Functions of Skin

Protection

Body temperature regulation

Sensation

Excretion

Water, fluid/electrolyte balance

Vit. D

4

sebaceous cysts

adolescents

5

loose collagen

adult

6

wound put there in purpose

intentional

7

wound not supposed to be there

unintentional

8

classifications of wounds

intentional/unintentional

open/closed

acute/chronic

9

very thin & obese people

dehydration

10

causes of skin alterations

excessive precipitation

jaundice

skin disease

very thin & obese people

11

Factors that Affect Wound Healing

pressure

desiccation

maceration

trauma

edema

infection

necrosis

12

dry

desiccation

13

maceration

wet

14

tissue death

necrosis

15

yellow green slimy

slough

16

black

eschar

17

no odor. will let fall off.

dry gangrene

18

has odor

Wet gangrene

19

wound drainage

purulent

20

clean every 12 hours

infected wounds

21

non infected wound

clean every other day

22

brown. what type of wound?

venous ulcer

23

hard non pitting

brawny

24

what do you do if you see bright red blood in wound vac?

turn it off

25

red

protect

26

yellow

cleanse

27

black

debride

28

partial thickness

top 2 layers gone

29

full thickness

down to the bone

30

clear, watery

serous

31

red, bloody

sanguineous

32

light pink to blood tinged

serosanguineous

33

thick, musty foul odor. dark yellow or green. WBCs die and causes pus.

purulent

34

increased drainage in days ____ means it will split.

4-5

35

S/Sx of infection

redness
fever
pain
swelling
drainage

36

check wound and dressing frequently.

saturated dressing

hemorrhage

37

saturated dressing?

apply additional dressings to act as sponges.

assess vital signs

contact attending MD

38

Edges of skin separate when staples or sutures are removed. keep wound moist. Cover it. Call button. don’t leave room. sterile saline. moisture gauze.

Dehiscence

39

Protrusion of viscera through incisional area

Evisceration

40

An opening from one organ to another.


Tear in vagina during a traumatic delivery leaving a hole between the rectum and the vagina.

Fistula Formation

41

Usually most severe the first 2 or 3 days and progressively diminishes

pain

42

if pain persists

check for other signs of infection.

43

Scared it will burst open if you stand up straight.
Is the wound offensive to the people having to change the dressing.

anxiety and fear

44

REEDA

redness
edema
ecchymosis
drainage
approximation of wound edges

45

Inspection for sight and smell

Palpation for appearance, drainage, and pain

Sutures, drains or tube, manifestation of complications

wound assesment

46

presence of infection

-swollen
-skin deep red color
-hot
-drainage increased
-foul odor
-wound edges separated

47

open systems

penrose drain

48

closed systems

jackson-pratt drain

hemovac drain

49

Perform dressing change:

in accordance with doctor’s orders & in accordance with agency policy.

50

before wound culture?

clean it

51

usually irrigate wound when?

when cleaning or changing a dressing

52

Persistent redness, blue or purple hues
Treatment
Relieve pressure

stage I

53

Abrasion, blister, or shallow crater
Treatmemt
Occulsive dressing that promotes healing

stage II

54

Deep crater
Treatment
Wet to dry dressings, debridement

Stage III

55

Full thickness skin loss with damage to muscle and bone
Treatment
May require skin grafts

Stage IV

56


Plan for Pressure Ulcers

Assess
Clean
Lotion
Position
Move
Feed
ROM

57

Dilates
Helps blood get to tissues
Reduces muscle tension
Helps relieve pain

heat

58

Constricts
Reduces: inflammation, edema, muscle spasms
Promotes comfort

cold

59

After 30 minutes of heat or cold…..

A rebound affect occursThe opposite reaction occurs