Fundamentals of Nursing: Chapter 48: Skin Integrity and Wound Care Flashcards
Superficial with little bleeding and is considered a partial-thickness wound
To come close together, as in the edges of a wound
Pressing a finger on the affected area; it turns a lighter color and returns to a normal color.
When the normal red tones of the light-skinned patient are absent
Redness of the skin caused by dilation of the superficial capillaries. When pressure is applied to the skin, the area blanches, or turns a lighter color
A tough, fibrous protein
The removal of nonviable, necrotic tissue
Separation of the edges of a wound, revealing underlying tissues.
The membrane that separate the two skin layers
- Papillary Region
- Reticular Region
Convenient portable units that connect to tubular drains lying within a wound bed and exert a safe, constant, low-pressure vacuum to remove and collect drainage.
- Stratum Corneum
- Stratum Lucidum
- Stratum Granulosum
- Stratum Spinosum
- Stratum Basale
The formation of granulation tissue into an open wound allows the reepithelialization phase to take place, as epithelial cells migrate across the new tissue to form a barrier between the wound and the environment.
Thick layer of dead, dry tissue that covers a pressure ulcer or thermal burn. It may be allowed to be sloughed off naturally, or it may need to be surgically removed.
Protrusion of visceral organs through a surgical wound.
A discharge or escape, as of blood, from a vessel into the tissues.
Fluid, cells, or other substances that have been discharged from cells or blood vessels slowly through small pores or breaks in cell membranes.
A fibrous, non-globular protein involved in the clotting of blood
Soft, boggy feeling when tissue is palpated; usually a sign of tissue infection.
The force of two surfaces moving across one another such as the mechanical force exerted when skin is dragged across a coarse surface such as bed linens.
Red, moist tissue composed of new blood vessels, the presence of which indicates progression toward healing.
Collection of blood trapped in the tissues of the skin or an organ.
Bleeding from a wound site
Termination of bleeding by mechanical or chemical means or the coagulation process of the body.
Redness in the skin after the pressure is relieved and blood flow returns.
Hardening of a tissue, particularly the skin, because of edema or inflammation.
Torn, jagged wound.
Negative Pressure Wound Therapy
A therapeutic technique using a vacuum dressing to promote healing in acute or chronic wounds and enhance healing of second and third degree burns.
If the erythematous area does not blanch when you apply pressure, deep tissue damage is probable.
Low pressure over a long period of time and high pressure over a short period of time both cause tissue damage.
If pressure is applied and exceeds normal pressure and the vessel is occluded may cause damage.
Inflammation, sore, or ulcer in the skin over a bony prominence.
Primary union of the edges of a wound, progressing to complete scar formation without granulation.
Wounds bleed in relation to the depth, size, and location of the wound (e.g., a nail puncture does not cause as much bleeding as a knife wound).
A yellow, green, or brown color wound drainage.
The transient increase in organ blood flow that occurs following a brief period of ischemia
Bright red; indicates active bleeding wound drainage.
In which the wound is left open and closes naturally (Scar tissue)
Pale, pink, watery; mixture of clear and red fluid wound drainage.
Clear, watery plasma wound drainage
Unaligned forces pushing one part of a body in one specific direction, and another part of the body in the opposite direction.
Stringy substance attached to wound bed
Threads or metal used to sew body tissues together
Point at which tissues receive insufficient oxygen and perfusion
The ability to endure pressure depends on the integrity of the tissue and the supporting structures.
Vacuum-assisted closure (V.A.C.)
A device that helps in wound closure by applying localized negative pressure to draw the edges of a wound together.
A disruption of the integrity and function of tissues in the body
Intact Skin with nonblanchable redness in a localized area.
Partial thickness loss of the dermis and has a shallow, open ulcer.
Full thickness skin loss, subcutaneous fat may be visible, and it may include undermining and tunneling; slough may be present.
Full thickness tissue loss with exposed bone, tendon, or muscle; slough or eschar may be present.
Full tissue loss with the depth of the ulcer obscured by slough and/or eschar in the wound bed.
Purple or maroon localized area of discolored intact skin or a blood filled blister caused by underlying soft tissue damage.
When repositioning an immobile patient, the nurse notices redness over the hip bone. What is indicated when a reddened area blanches on fingertip touch?
- Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode.
When obtaining a wound culture to determine the presence of a wound infection, from where should the specimen be taken?
- Cleansed wound
What is the correct sequence of steps when performing a wound
1. Use slow continuous pressure to irrigate wound.
2. Attach angio catheter to syringe
3. Fill syringe with irrigation fluid
4. Place water proof bag near bed
5. Position angio catheter over wound
- 4, 3, 2, 5, 1
For a patient who has a muscle sprain, localized hemorrhage, or hematoma, which wound care product helps prevent edema formation, control bleeding, and anesthetize the body part?
- Ice bag
Which of the following describes a hydrocolloid dressing?
- A dressing that forms a gel that interacts with the wound surface
What is the removal of devitalized tissue from a wound called?
What does the Braden Scale evaluate?
- Risk factors that place the patient at risk for skin breakdown
On assessing your patient’s sacral pressure ulcer, you note that the tissue over the sacrum is dark, hard, and adherent to the wound edge. What is the correct category/stage for this patient’s pressure ulcer?
After surgery the patient with a closed abdominal wound reports a sudden “pop” after coughing. When the nurse examines the surgical wound site, the sutures are open, and pieces of small bowel are noted at the bottom of the now-opened wound. Which are the priority nursing interventions? (Select all that apply.)
- Notify the surgeon
- Cover the area with sterile, saline-soaked towels and immediately.
Which skin care measures are used to manage a patient who is experiencing fecal and/or urinary incontinence? (Select all that apply.)
- Frequent position changes.
- Using an incontinence cleaner
- Applying a moisture barrier ointment
Which of the following is an indication for a binder to be placed around a surgical patient with a new abdominal wound? (Select all that apply.)
- Provides support to abdominal tissues when coughing or walking
- Reduction of stress on the abdominal incision
When is an application of a warm compress to an ankle muscle sprain indicated? (Select all that apply.)
- To relieve edema
- To improve blood flow to an injured part
Which of the following are measures to reduce tissue damage from shear? (Select all that apply.)
- Use a transfer device, e.g. transfer board
- Have head of bed flat when re positioning patients
- Raise head of bed 30 degrees when patient positioned supine
Nonblanchable redness of intact skin. Discoloration, warmth, edema, or pain may also be present.
- Category/Stage I
Full thickness skin loss, subcutaneous fat may be visible. May include undermining
- Category/Stage III
Full thickness tissue loss, muscle and bone visible. May include undermining.
- Category/Stage IV
Partial thickness skin loss or intact blister with serosanginous fluid
- Category/Stage II