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Flashcards in wound care Deck (32)
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1

tissue integrity

the ability of the human body to regenerate and maintain normal physiologic functioning. the skin, cornea and subc tissue, and mucous membranes act as defense mechanisms for the body

2

largest organ system of body accounting for about 15% of total body wight

skin

3

skin main function

protection
providing barrier from injury, ultraviolet radiation and heat

4

skin plays a crucial role in

sensory percreption such as touch, pain, pressure, and vibration

5

skin regulates

temperature and protects the body against temperature changes
- eliminates waste and supports the underlying structures and synthesis of vitamin d

6

epidermis

outer layer of the skin composed mainly of keratinocytes and other cells, such as melanocytes, Merkel cells and lanerhans cells

7

dermis

largest portion of skin
- main function to sustain and support epidermis by providing strength and flexibility; made of connective tussye with capillaries; blood vessels; lymoth vessels; nerves; sweat and sebaceous glands; hair roots; elastic fibers; and collagen

8

subcutaneous tissue

subc fat that insulates the body, absobs shock and pads the internal organs and structures

9

risk factors for development of pressure injuries and wounds

- age
- mobility issues
- weight
- spina bifida, cerebral palsy, other chronic conditions such as liver, renal diseases, cancer and malnutrition

10

as adults skin becomes

thinner, elasticity is lost, sub c fat becomes thinner, blood supply is more sulggish and the skin becomes less hydrated. therefore, shear, friction, pressure can cause problems

11

pressure injury

- localized damage to skin, underlying tissue as a result of a pressure in combination with shear

12

pressure injuries are most often

over bony prominences but can also be a result of a pressure caused by a medical device, such as urinary catheters, oxygen tubing, endotracheal tubing, drains.
- most susceptible are held, toes, sacrum, hips, elbow, shoulders, back of head

13

stage 1

nonblanchable erythema of intact skin

14

stage 2

partial thickness skin loss with exposed dermis

15

stage 3

full thickness skin loss

16

stage 4

full thickness skin and tissue loss

17

unstageable

obscured full thickness skin and tissue loss

18

deep tissue pressure injury

persistent nonblancable deep red, maroon or purple discoloration

19

TIME ( how pressure injuries shoudl be described)

T: tissue integrity- describe how the tissue looks, the wound color, and if there is dead netcrotized tissue present

I: inflammation or infection- s/s of infection present, redness, warmth, swelling, discharge, and swelling

M: moisture- wound is dry or moist and if the wound is macerated

E: edge of wound- describe the wound edges

20

DIDNT HEAL (factors influencing wound healing)

D= diabetes
I= infection
D= drugs
N= nutritonal problems
T= tissue necrosis
H= hypoxia
E= extensive tension
A= another wound
L= low temperature

21

hemosatic/ inflammatory

damaged tissue releases cytokines which trigger a process called hemostasis; blood coagulates, and the wound starts to heal
- plasma leaks into surrounding tissue and causes swelling

22

proliferative

- new collagen fibers are formed
- nee wound bed is created
- capillaries start growing
- wound edges begin pulling closer and new granulation tissue grows

23

remodeling

stronger collagen replaces soft gelatinous collagen; however this tissue is much weaker than the orginal tissue and is susceptible to reinjury

24

primary healing or first intention

occurs in clean lacerations and surgical incisions; closed with skin ahesives or sutures

25

secondary healing or second intention

wound healing that happens when the wound is left open to heal

26

delayed primary closure

combination of primary and secondary healing, where the wound is left open for 5-10 days before it is closed with sutures

27

skin redness

usually referred to as blanchable or nonblanchable erythema
- non-blanchable erythmea is redness that does not go away when pressure is applied and is a sign that structural damage has occurred to the skin

28

methods for measuring wound size

1. tracing wound circumference
2. measuring length and width of the wound

29

acute wounds

develop as a result of injury and typically are a result of trauma

30

chronic wounds

develop over time from acute wounds that do not progress in healing