Fundamentals of Nursing: Chapter 48: Skin Integrity and Wound Care Flashcards


Set Details Share
created 5 years ago by mens05
618 views
Skin Integrity and Wound Care
Subjects:
nursing
show moreless
Page to share:
Embed this setcancel
COPY
code changes based on your size selection
Size:
X
Show:
1

Abrasion

Superficial with little bleeding and is considered a partial-thickness wound

2

Approximated

To come close together, as in the edges of a wound

3

Blanch Test

Pressing a finger on the affected area; it turns a lighter color and returns to a normal color.

4

Blanching

When the normal red tones of the light-skinned patient are absent

5

Blanchable Hyperemia

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

6

Collagen

A tough, fibrous protein

7

Debridement

The removal of nonviable, necrotic tissue

8

Dehiscence

Separation of the edges of a wound, revealing underlying tissues.

9

Dermal-Epidermal Junction

The membrane that separate the two skin layers

10

Dermis Layers

  • Papillae
  • Papillary Region
  • Reticular Region
11

Drainage Evacuators

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.

12

Epidermis Layers

  • Stratum Corneum
  • Stratum Lucidum
  • Stratum Granulosum
  • Stratum Spinosum
  • Melaocyte
  • Stratum Basale
13

Epithelialization

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.

14

Eschar

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.

15

Evisceration

Protrusion of visceral organs through a surgical wound.

16

Extravasation

A discharge or escape, as of blood, from a vessel into the tissues.

17

Exudate

Fluid, cells, or other substances that have been discharged from cells or blood vessels slowly through small pores or breaks in cell membranes.

18

Fibrin

A fibrous, non-globular protein involved in the clotting of blood

19

Fluctuance

Soft, boggy feeling when tissue is palpated; usually a sign of tissue infection.

20

Friction

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.

21

Granulation tissue

Red, moist tissue composed of new blood vessels, the presence of which indicates progression toward healing.

22

Hematoma

Collection of blood trapped in the tissues of the skin or an organ.

23

Hemorrhage

Bleeding from a wound site

24

Hemostasis

Termination of bleeding by mechanical or chemical means or the coagulation process of the body.

25

Hyperemia

Redness in the skin after the pressure is relieved and blood flow returns.

26

Induration

Hardening of a tissue, particularly the skin, because of edema or inflammation.

27

Laceration

Torn, jagged wound.

28

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.

29

Nonblanchable Erythema

If the erythematous area does not blanch when you apply pressure, deep tissue damage is probable.

30

Pressure Duration

Low pressure over a long period of time and high pressure over a short period of time both cause tissue damage.

31

Pressure Intensity

If pressure is applied and exceeds normal pressure and the vessel is occluded may cause damage.

32

Pressure Ulcer

Inflammation, sore, or ulcer in the skin over a bony prominence.

33

Primary Intention

Primary union of the edges of a wound, progressing to complete scar formation without granulation.

34

Puncture

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).

35

Purulent

A yellow, green, or brown color wound drainage.

36

Reactive hyperemia

The transient increase in organ blood flow that occurs following a brief period of ischemia

37

Sanguineous

Bright red; indicates active bleeding wound drainage.

38

Secondary intention

In which the wound is left open and closes naturally (Scar tissue)

39

Serosanguineous

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

40

Serous

Clear, watery plasma wound drainage

41

Shearing force

Unaligned forces pushing one part of a body in one specific direction, and another part of the body in the opposite direction.

42

Slough

Stringy substance attached to wound bed

43

Sutures

Threads or metal used to sew body tissues together

44

Tissue ischemia

Point at which tissues receive insufficient oxygen and perfusion

45

Tissue Tolerance

The ability to endure pressure depends on the integrity of the tissue and the supporting structures.

46

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.

47

Wound

A disruption of the integrity and function of tissues in the body

48

Category/Stage I

Intact Skin with nonblanchable redness in a localized area.

49

Category/Stage II

Partial thickness loss of the dermis and has a shallow, open ulcer.

50

Category/Stage III

Full thickness skin loss, subcutaneous fat may be visible, and it may include undermining and tunneling; slough may be present.

51

Category/Stage IV

Full thickness tissue loss with exposed bone, tendon, or muscle; slough or eschar may be present.

52

Unstageable/Unclassified

Full tissue loss with the depth of the ulcer obscured by slough and/or eschar in the wound bed.

53

Suspected Deep

Purple or maroon localized area of discolored intact skin or a blood filled blister caused by underlying soft tissue damage.

54

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.
55

When obtaining a wound culture to determine the presence of a wound infection, from where should the specimen be taken?

  • Cleansed wound
56

What is the correct sequence of steps when performing a wound irrigation?
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
57

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
58

Which of the following describes a hydrocolloid dressing?

  • A dressing that forms a gel that interacts with the wound surface
59

What is the removal of devitalized tissue from a wound called?

  • Debridement
60

What does the Braden Scale evaluate?

  • Risk factors that place the patient at risk for skin breakdown
61

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?

  • Unstageable
62

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.
63

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
64

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
65

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
66

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
67

Nonblanchable redness of intact skin. Discoloration, warmth, edema, or pain may also be present.

  • Category/Stage I
68

Full thickness skin loss, subcutaneous fat may be visible. May include undermining

  • Category/Stage III
69

Full thickness tissue loss, muscle and bone visible. May include undermining.

  • Category/Stage IV
70

Partial thickness skin loss or intact blister with serosanginous fluid

  • Category/Stage II