Term
| What are the functions of the skin? |
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Definition
Protection
temperature regulation
sensation
excretion
fluid and electrolyte balance
vitamin D production and absorption |
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Term
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Definition
| Involved blood vessels constrict and blood clotting begins through platelet activation and clustering. After only a brief period of constriction, these same blood vessels dilate and capillary permeability increases, allowing plasma and blood components to leak out into the area that is injured, forming a liquid |
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Term
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Definition
| the healing by which wounds from Wounds healing with well approximated edges. surgical incisions with sutured edges. |
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Term
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Definition
| Edges are not well approximated. Large open wounds such as from burns or major trauma, which requitre more tissue replacement and are often contaminated, commonly heal by this intention, take longer to heal, and have more scar tissue. |
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Term
| If a primary intention wound becomes infected it will heal by |
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Definition
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Term
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Definition
| wounds healing by delayed primary intention because the wound is left open for several days to allow edema or infection to resolve or exudate to train. Then they are closed. |
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Term
| What are the three phases of wound healing? |
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Definition
inflammatory
Proliferation
Maturation |
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Term
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Definition
| last about 4 - 6 days. White blood cells predominatly leukocytes and macrophages move to the wound. Leukocytes arrive first to ingest bacteria and cellular debris. Macrophages ingest debris and release growth factors. |
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Term
| Acute inflammation is characterized by |
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Definition
| pain heat, redness, and swelling at the site of injury. |
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Term
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Definition
| fibroblastic regenerative or connective tissue phase. Last for several weeks. New cell tissue is formed called granulation tissue |
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Term
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Definition
| The final stage in the healing begins about 3 weeks after injury, possibly continuing for months or years. Collagen is remodeled making healing stronger. |
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Term
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Definition
| dehydration, the process of drying up. Dehydrated cells die, a crust forms over the wound and delays healing. |
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Term
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Definition
| (overhydration) related to urinary and fecal incontinence can lead to impaired sking integrity. Related to moisture, changes in pH of the skin, overgrowth of bacteria and infection oft he skin, and erosion of skin from friction on moist skin. |
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Term
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Definition
| dead tissue present in the wound delays healing. Dead tissue appears as slough, moist, yellow stringy tissue, and eschar appears as dry black leathery tissue. This type of tissue MUST be removed for healing to take place. |
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Term
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Definition
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Term
| What dietary change should occur to promote wound healing? |
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Definition
| High caloric intake and increase protein. |
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Term
| What affect does corticosteroids have on the wound healing process? |
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Definition
| decreases the inflammatory process, which may delay healing. |
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Term
| What affect does radiation have on the wound healing process? |
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Definition
| Depresses bone marrow function, resulting in decreased leukocytes and an increased risk of infection. |
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Term
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Definition
| the partial or total separation of wound layers as a result of excessive stress on wounds that are not healed. |
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Term
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Definition
| is the most serious of dehiscence. The wound completely separates with protrusion of viscera (organs) through the incisional area. |
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Term
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Definition
| deficiency of blood in a particular area. Caused by insufficient blood capillaries and poor circulation to tissues. |
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Term
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Definition
| inadequate amount of oxygen available to cells. |
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Term
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Definition
| occurs when two surface rub against each other. |
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Term
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Definition
| results when one layer of skin (tissue) slides over another layer. |
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Term
| What are the psychological effects of wounds? |
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Definition
| pain, anxiety, fear, and change in body image. |
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Term
| Reactive Blanching hyperemia |
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Definition
| blanchable reddening of the skin that occurs when pressure is removed. NOT a pressure ulcer and should fade withing 60-90 minutes upon repositioning. |
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Term
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Definition
| intacke skin with nonblanchable redness of localized area usually over a bony prominence. The area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue. |
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Term
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Definition
| partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without Slough. Intact open/rupture serum-filled blister. |
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Term
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Definition
| Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed. Slough may be present but doesnt obscure the depth of tissue loss. |
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Term
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Definition
| Full thickness tissue loss with exposed bone, tendon, or muscle. Exposed bone/tendon is visible or directly palpable. Slough or escar may be present on some parts of the wound bed. can extend into muscle, tendon, fascia, joint capsule..ect. |
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Term
| What two stages of pressure ulcers are the most painful? |
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Definition
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Term
| Polly had a stage IV pressure ulcer that has been healing and is now a beefy red shallow opening with no exudate. What stage is her ulcer now at? |
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Definition
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Term
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Definition
| allow exchange of oxygen between wound and environment, self adhesive, waterproof, prevent loss of wound fluid, maintain moist cound environment, facilitate autolytic debridement. No absorption of drainage, allow visualization of wound. for wounds with minimal drainage, small and partial thickness stage I wounds. Cover dressings for gels, foams, and gause |
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Term
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Definition
| occlusive or simi-occlusive limiting exchange of o2 between wound and environment. self adhesive, provide cushioning, facilitates autolytic debridement, do not adhere to wound, reduce pain, |
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Term
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Definition
| maintain a moist wound environment, minimal absorption of drainage, facilitate autolytic debridment, do not adhere to wound, reduce pain, require a secondary dressing to secure, for partial and full thickness wounds, necrotic wounds, burns, dry wounds, wounds with minimal exudate, and infected wounds. |
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Term
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Definition
| absorb exudate, maintain a moist wound environment, facilitate autolytic debridement, requires secondary dressin, for infected and noninfected wounds, wounds with moderate to heavy exudate, partial and full thickness wounds, not for use with wounds with minimal drainage or dry eschar. Can be left for 1-3 days |
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Term
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Definition
| maintain a moist wound environment, do not adhere to wound, insulate, highly absorbent, can be left for 7 days, use around tubes and drains, not for use with wounds with dry eschar. |
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Term
| Antimicrobials (silverderm) |
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Definition
| Antibacterial action, reduce infection, prevent infection, draining, exuding, and nonhealing wounds to protect from bacterial contamination and reduce bacterial contamination, acute and chronic wounds. |
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Term
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Definition
| Absorbent, maintain a moist wound environment, do not adhere to wound, compatible with topical agents, nonadherent, conform well to the wound surgace, require secondary dressing to secure, partial or fullthickness, infected and non infected, skin grafts, donor sites, tunneling wounds, moist red and yellow wounds, wounds with minimal to heavy exudate. |
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Term
| Jackson pratt drainage tube |
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Definition
| A closed drainage system that consist of a drainage tube that may be connected to an electrical suction device or have a portable built-in reservoir. Usually sutured to the skin. |
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Term
| What is the maximum time for hot or cold therapy? |
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Definition
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Term
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Definition
| glues, no dressings needed |
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Term
| NPWT (Negative pressure wound therapy |
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Definition
| promotes wound healing and wound closure through the application of uniform negative pressure on the wound bed, reduction in bacteria in the wound, and the removal of excess wound fluid, whild providing a moist wound healing environment. |
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Term
| Thirty-siz hours after having surgery, a patient has a slightly elevated body temperature and generalized nalaise, as well as pain and redness at the surgical site. What intervention is most important to include in this patients nursing care plan? |
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Definition
| Document the findings and continue to monitor the patient |
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Term
| What term would the nurse use to document wound drainage that is thick, odorous, and green? |
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Definition
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Term
| A patient who has a large abdominal wound suddenly calls out for help because she feels as though something is falling out of her incision. Inspection reveals a gaping open wound with tissue bulging outward. In which order should the nurse perform interventions? |
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Definition
-put the patient in Fowlers
-cover the exposed tissue with steril towels moistened with NSS
-Notify the physician immediately of the situation. |
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Term
| A patient is admitted with a nonhealing surgical wound. What nursing action is MOST effective in preventing a wound infection? |
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Definition
| Performing careful hand hygiene |
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Term
| During a dressing change, inspection oif the wound reveals what appears to be a reddish-pink tissue in the wound. The nurse interprets this as most likely indicating: |
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Definition
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Term
| The nurse is performing a sterile irrigation of an open abdominal wound. What intervention should be done first?s |
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Definition
| Position the patient so the irrigation solution will flow from clean to dirty. |
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Term
| The nurse is developing a plan of care for an 86-year-old woman who has been admitted for right hip arthroplasty (hip replacement). What assessment finding indicates a high risk for pressure development? |
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Definition
| Age, patient reporting an inability to control urine, a scheduled hip arthroplasty, pt reports increased pain in rt hip when repositioning in bed or chair. |
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Term
| The nurse is explaining to a patient the anticipated effect of application of cold to an injured area. What response indicated the patient understands explanation? |
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Definition
| I should see less swelling and redness with the cold treatment |
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Term
| The nurse is providing patient teaching regarding the use of negative pressure wound therapy. Which explanation provides the most accurate information to the patient? |
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Definition
| The therapy provides a moist environment and stimulates blood flow to the wound |
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Term
| After an initial assessment, the nurse documents the presence of a reddened area that has blistered. According to recognized staging systems, as a what stage would this ulcer be classified? |
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Definition
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Term
| An older confused patient sits and slumps in her chair most of the day. She is most likely to develop a pressure ulcer because of what factor? |
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Definition
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Term
| The nurse assesses a stageIII pressure ulcer manifested as: |
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Definition
| An open lesion with full thickness tissue loss and visible subcutaneous fat |
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Term
| What action would be a priority in preventing a patient from developing a pressure ulcer? |
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Definition
| Using a mild cleansing agent when cleansing the skin |
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Term
| In which sequence should the nurse implement the interventions to clean a surgical wound with dihisced edges? |
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Definition
-explain the procedure to the patient
-Moisten sterile gauze or swab with prescribed cleansing agent
-Clean the wound in full or half circles, beginning in the center and working toward the outside
-clean to at least 1inch beyond the end of the new dressing. |
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