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Amy's Nursing 50B > Wound Care > Flashcards

Flashcards in Wound Care Deck (46):
0

What is the largest organ in the body?

The skin

1

What are four ways to maintain healthy skin?

SKIN: Support surfaces, Keep moving, Incontinence control, Nutrition

2

How often should you reposition bed bound patients?

Every 2 hours

3

What degree should you position the HOB if a patient is at risk for pressure ulcers?

Less than 30 degrees

4

What are the top three reasons that foleys leak?

1. constipation
2. dehydration
3. uti

5

What are three interventions to prevent dermatitis?

Cleanse (routine daily cleansing for everyone), moisturize (cleanse and moisturize after each major incontinent episode), protect (apply moisture barrier for significant incontinence)

6

What kinds of wounds are stageable?

Pressure ulcers

7

Which stage of pressure ulcers are reportable to State DHS?

Stages III & IV

8

Which assessment tool is used to evaluate a person's risk for skin breakdown?

Braden scale

9

What does a low number indicate on the Braden scale?

A high risk

10

What does a high number indicate on the Braden scale?

A low risk

11

Define pressure ulcer.

Localized area of tissue breakdown resulting from compression of soft tissue between a bony prominence and an external surface

12

Which bony prominences have the highest incidence of pressure ulcers?

Sacrum and heels

13

Define stage I pressure ulcer.

Non-blanchable erythema of intact skin (may include discoloration, warmth/coolness, edema, change in tissue consistency)

14

Define stage II pressure ulcer.

Partial thickness loss of dermis

15

Define stage III pressure ulcer.

Full thickness skin loss (with or without undermining, eschar/slough may be present, subcut fat may be visible)

16

Define stage IV pressure ulcer.

Full thickness skin loss (with visible or palpable muscle/bone/tendon, may include undermining/sinus tracts)

17

Define unstageable pressure ulcer.

Ulcer bed is covered with eschar or slough so that the full extent of the injury cannot be assessed

18

Define suspected deep tissue injury.

Purple or maroon area of intact skin, or blood filled blister due to damage of underlying tissue. May evolve into ulcer.

19

What are the four cardinal signs of inflammation?

Rubor (redness), tumor (swelling), calor (heat), dolor (pain)

20

Define proliferation.

To grow by rapid production of new cells (first stage of wound healing)

21

Which nursing measures can optimize wound healing preoperatively?

Nutrition, reduce steroids, eliminate aspirin, patient education to reduce anxiety

22

Which nursing measures can optimize wound healing postoperatively?

Pain control, warmth, hydration, oxygenation, support binders

23

Define acute wound.

Wounds with sudden onset including superficial, penetrating, perforating, laceration, abrasion, contusion, skin tear, surgical wound

24

Define chronic wound.

Any acute wound that fails to heal or pressure, venous, arterial, diabetic and neuropathic wounds

25

Define undermining.

Tissue destruction to underlying intact skin along wound edges

26

Define tunneling.

A measurable tract extending from the wound bed

27

Define serous wound exudate.

Clear, watery plasma

28

Define sanguineous wound exudate.

Bright red; indicates active bleeding

29

Define serosanguineous wound exudate.

Pale pink, watery drainage; mixture of clear and red fluid

30

Define purulent wound exudate.

Thick, yellow, green or brown drainage.

31

What might a foul smelling wound indicate?

Infection (or expected in the presence of eschar or slough)

32

What would a red-colored wound indicate?

Usually granulation tissue

33

What would a yellow-colored wound indicate?

Slough (soft-necrotic tissue)

34

What would a black-colored wound indicate?

Eschar (firm/hard necrotic tissue)

35

What is the most basic principle of wound healing?

Keep the wound warm, dark, moist and protected

36

What is the best way to prevent pressure ulcers on the heels?

Float heels

37

How is a wound measured?

Length x width x depth

38

How do you care for a dehisced wound?

Keep it open and pack lightly (must heal from the inside out to prevent an abscess from forming)

39

Which area of the body never gets debrided if it is intact and not infected?

Heels (too thin of tissue, debriding would reveal bone easily)

40

What is wound healing by primary intention?

Wound approximating; healing occurs by epithelialization; wound approximates quickly and with minimal scar formation (ex: staples, sutures)

41

What is wound healing by secondary intention?

Wound not approximating;heals by granulation, wound contraction and epithelialization (ex: pressure ulcers)

42

What is wound healing by tertiary intention?

Closure of wound is delayed to resolve risk of infection, then wound is approximated

43

Why would a wound be debrided?

To rid the wound of source of infection, enable visualization of wound bed, or provide a clean base necessary for healing

44

Normal Values: prealbumin

15-36 mg/dL

45

Normal values: albumin

3.5-5 g/dL