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Flashcards in skin integrity and wound care Deck (16)
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1

epidermis

top layer

2

dermis

inner layer
collagen

3

dermal-epidermal junction

separates dermis and epidermis

4

patho of pressure injuries

pressure intensity
- tissue ischemia
- blanching
- pressure duration
tissue tolerance

5

risk factors for pressure ulcer development

- impaired sensory
- perception
- impaired mobility
- alteration in loc
- shear
- friction
- moisture

6

deep tissue pressure injury (DTPI)

- granulation
- slough
- eschar
- exudate

7

wound classifications

process of wound healing
- partial thickness wounds
- full thickness wounds
- primary intention
- secondary intention

8

wound repair: partial thickness

inflammatory response, epithelial proliferation and migration, and reestablishment of the epidermal layers

9

wound repair: full thickness

hemostatsis
inflammatory
proliferative
maturation

10

complications of wound healing

hemorrhage
infection
dehiscence
evisceration

11

factors influencing pressure injury

nutrition
tissue perfusion
infection
age
psychosocial impact of wounds

12

assessment of pressure ulcers

predictive measures
mobillity
nutitional status
body fluids
pain

13

assessment of wounds

emergency setting
stable setting
wound apperance
character of wound drainage
drains
wound closure
palpation of wound
wound cultures
psychosocial

14

health promotion

- prevention of pressure ulcers
- topical skincare and incontinence management
- positioning
- support surfaces

15

heat and cold therapy

- choice of moist or dry
- warm, moist compresses
- warm soaks
- sitz baths
- commerical hot and cold packs
- cold, moist and dry compresses
- cold soaks
- ice bags or collar

16

safety guidelines for nursing skills

- follow proper aseptic technique
- routinely assess for risk of pressure injuries
- inspect skin daily
- use approaches to minimize friction and shear
- modify the frequency of wound assessment based on wound condition
- chronic diseases, especially vascular disease and diabetes, increase a pt. risk for pressure injury development and impede healing of wounds