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fundamentals of nursing > ch 33 skin integrity & wound care > Flashcards

ch 33 skin integrity & wound care Flashcards

(77 cards)

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1
Q

abscess

A

collection of infected fluid that has not been drained

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2
Q

biofilm

A

a thick grouping of microorganisms

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3
Q

debridement

A

cleaning away devitalized tissue & foreign matter from a wound

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4
Q

dehiscence

A

separation of the layers of a surgical wound; may be partial, superficial, or a complete disruption of the surgical wound

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5
Q

dermis

A

layer of the skin below the epidermis

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6
Q

desiccation

A

dehydration; the process of being rendered free from moisture

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7
Q

epidermis

A

superficial layer of the skin

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8
Q

epithelialization

A

stage of wound healing in which epithelial cells form across the surface of a wound; tissue color ranges from the color of “ground glass” to pink

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9
Q

erythema

A

redness of the skin

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10
Q

eschar

A

thick, leathery scab or dry crust that is necrotic and must be removed for adequate healing to occur

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11
Q

evisceration

A

protrusion of viscera (organs) through an incision

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12
Q

exudate

A

fluid that accumulates in wound; may contain serum, cellular debris, bacteria, & wbc

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13
Q

fistula

A

an abnorm passage from an internal organ to the skin or from one internal organ to another

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14
Q

friction

A

occurs when 2 surfaces rub against each other; the resulting injury resembles an abrasion & can also damage superficial blood vessels directly under the skin

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15
Q

granulation tissue

A

new tissue that is pink/red in color & composed of fibroblasts & small blood vessels that fill an open wound when it starts to heal

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16
Q

hematoma

A

localized mass of usually clotted blood

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17
Q

ischemia

A

deficiency of blood in a particular area

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18
Q

maceration

A

softening through liquid; overhydration

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19
Q

negative pressure wound therapy

A

NPWT

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20
Q

pressure injury

A

1) localized damage to the skin & underlying tissue that usually occurs over a bony prominence or is related to the use of a (medical or other) device
2) any lesion caused by unrelieved pressure that results in damage to underlying tissue; formerly known as pressure ulcer

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21
Q

purulent drainage

A

comprised of wbc, liquefied dead tissue debris, & both dead & live bacteria

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22
Q

sanguineous drainage

A

the initial discharge produced after an injury or an open wound where the skin is broken

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23
Q

scar

A

connective tissue that fills a wound area

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24
Q

serosanguineous drainage

A

mixture of serum & rbc

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25
serous drainage
composed of clear, serous portion of the blood & from serous membranes
26
shear
when tissue layers move over the top of each other, causing blood vessels to stretch and break as they pass through the subcutaneous tissue
27
subcutaneous tissue
underlying layer that anchors the skin layers to the underlying tissue of the body
28
vasoconstriction
the narrowing (constriction) of blood vessels by small muscles in their walls
29
vasodilation
the dilatation of blood vessels, which decreases blood pressure
30
what are the functions of the skin
protection body temp reg psychosocial sensation vit d produc immunologic absorption elimination
31
resistance to injury is affected by...
age, amt of underlying tissues; & illness
32
children less than 2 yo
-thinner & weaker skin -easily injured & subj to infection, increased risk for dehydration
33
older adults
-circulation & collegen formation impaired -decreased elasticity -increased risk of tissue damaged from pressure
34
_____ _____ during illness causes dehydration & predisposes skin to breakdown
fluid loss
35
_____ causes increased risk for excoriation & open wounds
jaundice
36
intentional wounds
e.g. surgical incisions
37
unintentional
traumatic
38
neuropathic/vascular
occur when a patient with the poor neurological function of the peripheral nervous system has pressure points that cause ulceration through the epidermal and dermal tissue layers
39
pressure-related wounds
40
classification of wounds
-open vs closed -acute vs chronic -partial thickness, full thickness, or complex
41
contusion
bruise
42
abrasion
superficial injury
43
laceration
e.g. a cut caused by glass (no skin is missing)
44
puncture
a type of cut that is made when a sharp object, like a nail, goes through the skin and into the tissue underneath (e.g . bite)
45
penetrating
occurs when a foreign object pierces the skin and enters/remains in the body creating a wound
46
avulsion
a forcible tearing off of skin or another part of the body, such as an ear or a finger
47
irradiation
impact of energetic particles or photons
48
venous ulcer
leg ulcers caused by problems with blood flow (circulation) in your leg veins
49
arterial ulcer
a painful, deep sore or wound in the skin of the lower leg or foot due to lack of blood flow to the area
50
diabetic ulcer
open sore or wound that occurs in approx 15% of pts with diabetes, and is commonly located on the bottom of the foot
51
wound healing principles
-careful hand hygiene -systemic process -adequate blood supply -wound is clean -extent of damage and state of health -proper nutrition
52
hemostasis (wound healing stage)
-immediate after injury -blood vessels constrict and clotting begins -exudate is formed, causes swelling & pain -increased perfusion, causes heat & redness -platelets stimulate other cells to migrate to injury
53
inflammatory phase
-lasts 2-3 days -wbcs move to the wound, ingest debris, release growth factors to attract fibroblasts -exudate cont to form and accumulate -generalized body response to the injury
54
proliferation phase
-lasts for several weeks -new tissue is built by fibroblasts to fill the wound space -capillaries grow across the wound space -thin layer of epithelial cells forms across the wound -granulation tissue forms a foundation for scar tissue
55
maturation phase
-final stage (3 weeks after injury months-years) -collagen is remodeled -new collagen is deposited, compressing the blood vessels, which creates scar tissue -scars do not sweat, grow hair, or tan
56
local factors affecting wound healing
-pressure -desiccation (the removal of moisture from something) -maceration (the process of skin softening and breaking down due to prolonged contact with moisture that is usually not present on the skin) -trauma -edema -infection -excessive bleeding -necrosis -presence of biofilm -primary vs secondary intention
57
systemic factors affecting wound healing
-age -circulation & oxygen -nutritional status -wound etiology -health status -immunosuppression -medication use -adherence to treatment plan -didn't heal acronym
58
wound complication
-infection -hemorrhage (the release of blood from a broken blood vessel, either inside or outside the body) -dehiscence -evisceration -fistula formation (abscess)
59
mechanisms in pressure injury development
-external pressure -friction or shearing forces -microclimate
60
stages of pressure injuries
stage 1: nonblanchable erythema of intact skin stage 2: partial-thickness skin loss w exposed dermis stage 3: full-thickness skin loss, not involving underlying fascia stage 4: full-thickness skin & tissue loss unstageable: obscured full-thickness skin & tissue loss, eschar deep tissue pressure injury: persistent non-blanchable deep red, maroon, or purple discoloration
61
preventing pressure injuries
-assess daily -cleanse -protect (from excess moisture) -minimize friction/shearing forces -positioning, turning -support surfaces -nutritional supplements -improve mobility & activity
62
serous
clear, thin, & watery fluid
63
serosanguineous
thin & watery w light red or pink hue
64
sanguineous
bright red, fresh blood (may be hemorragic)
65
purulent
thick, opaque & odorous build-up from infection
66
wound dressing for maintaining moisture
tegaderm transparent film
67
wound dressing for absorbing moisture
-hydrocolloid dressing -alginate dressing -foam dressing (mepilex)
68
wound dressing for adding moisture
hydrogels
69
types of wound dressings for securement
-roller bandages (kerlex, ACE wrap); should be spiral or figure-8 wrapped to avoid compression -binders (abdominal, chest)
70
pressure injury drsg changes are usually a _________ procedure
sterile
71
remove old dressing
-assess the wound, measure -note the drainage, type of tissue to wound bed, etc...
72
cleanse the wound
-new gauze for each wipe -clean to dirty - center of wound to the outside w each wipe -irrigation w normal saline (NS), if ordered -dry in same manner w gauze
73
open systems wound drains
penrose drain (a soft, flexible rubber tube that drains fluid away from a wound)
74
close systems wound drains
-jackson-pratt drain (closed-suction medical device that is commonly used as a post-operative drain for collecting bodily fluids from surgical sites) -hemovac drain (drainage tube, larger and can hold more fluid than jp drains) -negative pressure wound therapy (wound vac)
75
applying heat
-dilates perpipheral blood vessels -increases tissue metabolism -reduces blood viscosity & increases capillary permeability -reduces muscle tension -helps relieve pain
76
applying cold
-constricts peripheral blood vessels -reduces muscle spasms -promotes comfort
77
safety of application of hot or cold treatments
-15-20 min at a time -never apply excess pressure -never place the body on top of material, rather place the material on top of the body area

fundamentals of nursing (14 decks)

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