Pressure Ulcers, Wounds, and Wound Management - ATI - Chapter 55 Flashcards Preview

461 - Foundations Exam 2 > Pressure Ulcers, Wounds, and Wound Management - ATI - Chapter 55 > Flashcards

Flashcards in Pressure Ulcers, Wounds, and Wound Management - ATI - Chapter 55 Deck (169)
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1

Wounds are a result of injury to the ____.

skin.

2

Although there are many different methods and degrees of injury, the ______ of healing are essentially the same for most wounds.

basic phases

3

A pressure ulcer (formerly called a _______) is a specific type of tissue injury from unrelieved pressure or friction over bony prominences that results in ischemia and damage to the underlying tissue.

decubitus ulcer

4

The stages of wound healing

Inflammatory Stage
Proliferative Stage
Maturation or remodeling Stage

5

Inflammatory stage begins with the injury and lasts _____ days.

3-6 days

6

Controlling bleeding with vasoconstriction and retraction of blood vessels, and with ______ in the inflammatory stage.

clot formation

7

During the ______ stage oxygen, white blood cells, and nutrients are delivered to the area via the blood supply.

inflammatory stage

8

____ occurs along with fibrin formation during the inflammatory stage.

hemostasis

9

____ engulf microorgansims and cellular debris (phagocytosis) during the inflammatory stage.

macrophages

10

The ____ stage lasts the next 3 to 24 days in the wound healing process.

proliferative

11

During the proliferative stage lost tissue is replaced with ______ or ______ tissue or collagen.

connective or granulated

12

During the proliferative stage the wound's edges are ____.

contracting

13

Resurfacing of new _______ occurs during the proliferative stage.

epithelial cells

14

____ stage occurs after day 21 and involves the strengthening of the collagen scar and the restoration of a more normal appearance.

maturation or remodeling stage

15

It can take more than a year to complete, depending on the extent of the original wound during the _____ stage.

maturation or remodeling stage

16

The types of the healing processes

primary intention
secondary intention
tertiary intention

17

Little or no tissue loss
Edges approximated, as with a surgical incision
Heals rapidly
Low risk of infection
No or minimal scarring

i.e. closed surgical incision with staples or sutures or liquid glue to seal laceration.

primary intention

18

Loss of tissue
Wound edges widely separated, unapproximated (pressure ulcers, open burn areas)
Longer healing time
Increase for risk of infection
Scarring
Heals by granulation

i.e. pressure ulcer left open to heal

secondary intention

19

Widely separated
Deep
Spontaneous opening of a previously closed wound
Closure of wound occurs when free of infection
Risk of infection
Extensive drainage and tissue debris
Closed later
Long healing time

i.e. Abdominal wound initially left open until infection is resolved and then closed.

Tertiary intention

20

Factors affecting wound healing

Age
Overall Wellness
Decreased leukocyte count
Some medications
malnourished clients
tissue perfusion
low Hgb levels
obesity
chronic diseases
smoking
wound stress

21

Increased ___ delays healing.

age

22

A wound in a young, healthy client will heal faster than a wound in an older adult who has a chronic illness due to the _______ risk factor that affects wound healing.

overall wellness

23

_____ delays wound healing because the immune system function is to fight infection by destroying invading pathogens.

decreased leukocyte count

24

Age effects wound healing because of the following (8)

loss of skin turgor
skin fragility
decrease in peripheral circulation and oxygenation
slower tissue regeneration
decrease in absorption of nutrients
decrease in collagen
impaired immune system function
dehydration due to decreased thirst sensation

25

_____ interfere with the body's ability to respond to and prevent infection.

some medication

26

what medications interfere with the body's ability to respond to and prevent infection.

anti-inflammatory
antineoplastic

27

_______ do not get the nutrition they need which provides energy and elements for wound healing.

malnourished clients

28

______ provides circulation that delivers nutrients for tissue repair and infection control can effect wound healing.

tissue perfusion

29

_____ effect wound healing because Hgb is essential for oxygen delivery to healing tissues.

low Hgb levels

30

______ can effect wound healing because fatty tissue lacks blood supply.

obesity