Chapter 26 Prepu

Front 1

Proliferation stage

Back 1

A beefy red wound that bleeds easily. Has granulated tissue

Front 2

Initial phase

Back 2

Hemostasis, involving activation of platelets.

Front 3

Inflammatory phase

Back 3

White blood cells and macrophages enter the wound to remove debris

Front 4

Maturation phase

Back 4

Collagen remodeling and scar formation. Final stage of full thickness wound healing.

Front 5

Sutures

Back 5

Knotted ties that hold an incision together.

Front 6

Staples

Back 6

Wide metal clips that form a bridge to hold two wound margins together

Front 7

Bandage

Back 7

Strip or roll of cloth wrapped around a body part

Front 8

Open drains

Back 8

Tubes that provide pathways for drainage toward the dressing

Front 9

Shearing force

Back 9

When one layer of tissue slides over another layer. Clients who are pulled instead of lifted when being moved are at risk

Front 10

Superficial first degree burn

Back 10

Burn that is pinkish or red with no blistering

Front 11

Partial thickness second degree burn

Back 11

Burn that is moderate to deep that may be pink, red, pale ivory, or light yellow brown. Moist with blisters.

Front 12

Full thickness third degree

Back 12

Burn varies from brow or black to cherry red or pearly white. Bullae may be present, can appear dry and leathery

Front 13

Laceration

Back 13

Wound with ragged edges with torn tissue. Torn and irregular edges.

Front 14

Abrasion

Back 14

Wound involving skin friction. Surface layers have been scraped away.

Front 15

Contusion

Back 15

Closed wound with bleeding in underlying tissues

Front 16

Puncture

Back 16

Wound involving penetration of the skin and underlying tissue

Front 17

Evisceration

Back 17

Protusion of viscera through an abdominal wound opening. Can follow dehiscence if the opening extends deeply enough to allow the abominal fascia to separate and internal organs to protrude.

Front 18

Transparent film

Back 18

Used to secure an IV to allow visualization of the IV site. Self adhesive and protects against contamination

Front 19

Subcutaneous tissue

Back 19

Stores fat for energy

Front 20

Epidermis

Back 20

Outer layer that protects the body with a waterproof layer of cells

Front 21

Dermis

Back 21

Contains the nerves, hair follicles, blood vessels, and glands

Front 22

Muscle layer

Back 22

Moves the skeleton

Front 23

Corticosteroids

Back 23

Decrease inflammatory process. Delay wound healing

Front 24

Secondary intention

Back 24

Occurs in wounds with edges that do note readily approximate. Wound gradually fills with granulation tissue.

Front 25

Primary intention

Back 25

Wounds with minimal tissue loss, such as clean surgical incisions and shallow sutured wounds, heal this way. Edges are approximated and risk of infection is lower.

Front 26

Tertiary intention

Back 26

Occurs when there is a delay between injury and wound closure.

Front 27

Apply saline moistened dressing

Back 27

What to do when organs protrude from a surgical wound

Front 28

Every 2 hours

Back 28

How often to change positions and provide incontient care

Front 29

Penrose drain

Back 29

Open drainage system that lacks a collection device.

Front 30

Ulceration

Back 30

Shallow crater in which skin or mucous membrane is missing

Front 31

Heat therapy

Back 31

Dilates peripheral blood vessels, helping to dissipate heat from the body and increase blood flow to the area. Reduces venous congestion. Accelerates the inflammatory process.

Front 32

Transparent

Back 32

Dressing to use for IV

Front 33

Serosanguineous

Back 33

Pale pink-yellow, thin and contains plasma and red cells.

Front 34

Serous

Back 34

Pale yellow and watery, like blister fluid

Front 35

Sanguineous

Back 35

Bloody drainage

Front 36

Purulent

Back 36

White cells and microorganisms and occurs when an infection is present. Thick and opaque pale yellow to green or tan (pus)

Front 37

Work outward (clean to dirty)

Back 37

How to clean a postoperative wound

Front 38

Sharp debridement

Back 38

Removes necrotic tissue from healthy area of the wound with scissors, forceps ect.

Front 39

Enzymatic debridement

Back 39

Involves the use of topically appliced chemical substances that break down and liquefy wound debris

Front 40

Autolyic debridement

Back 40

Self-dissolution debridement. Painless natural physiologic process that allows the body's enzymes to soften, liquefy and release devitalized tissue.

Front 41

Mechanical debridement

Back 41

Involves physical removal of debris from a deep wound

Front 42

Remodeling period

Back 42

When a surgical wound contracts and scarring shrinks

Front 43

Skin appendage

Back 43

Hair, sebaceous glands, eccrine sweat glands

Front 44

Avsulsion

Back 44

Large areas of skin and underlying tissue have been stripped away

Front 45

Incision

Back 45

Clean separation of skin and tissues with smooth even edges

Front 46

Closed drains

Back 46

More effecient drain that pulls fluid by creating a vacuum or nefatige pressure

Front 47

Distally to proximally

Back 47

Way to apply bandage wrap

Front 48

Gauze

Back 48

Ideal for fresh wounds likely to bleed or wounds that exude drainage because of its highly absorbent nature.

Front 49

Hydrocolloid

Back 49

Dressing used on a client with a superficial burn wound. Self adhesive, opaque, air and water occlusive coverings that keep wounds moist.

Front 50

Transparent

Back 50

Dressing that allows the nurse to assess a wound without removing the dressing; good for IV

Front 51

Bandage

Back 51

Strip or roll of cloth wrapped around a body part to help support the area around the wound

Front 52

Figure of eight turn

Back 52

Wrap used to keep a dressing around joints in place.

Front 53

Circular turn

Back 53

Dressing wrap used primarily to anchor a bandage. Start a spiral turn, a figure 8, and a recurrent bandage.

Front 54

Spiral turn

Back 54

Useful wrap for wrist, fingers and trunk

Front 55

Recurrent bandage

Back 55

Used for fingers, head, and residual limbs after amputation

Front 56

Jackson pratt drain

Back 56

Small bulblike collection chamber kept under negative pressure

Front 57

Hemovac

Back 57

Round collection chamber with a spring inside that must be kept under negative pressure

Front 58

Applying medicated gel with an applicator

Back 58

Allows for better control over the application, thus minimizing any additional trauma to the wound

Front 59

First intention

Back 59

Wound healing with wound edges close together. Minimal scarring. Simple reparative process.

Front 60

Second intention

Back 60

Complex reparative process in which the margins of the wound are not in direct contact

Front 61

Third intention

Back 61

Takes place when the wound edges are intentionally left widely separated and later brought together for closure

Front 62

Proliferation phase

Back 62

Reproduction and migration of pink epidermal cells across the surface of the wound in a process called epithelialization

Front 63

Partial thickness wound

Back 63

Wound where a portion or all ofbthe dermis is intact

Front 64

Full thickness

Back 64

Wound characterized by severing of the dermis, sweat glands and hair follicles

Front 65

Positioning devices

Back 65

Pillows, foam wedges or pressure reducing boots proved helpful to keep body weight off bony prominences

Front 66

Sebaceous glands

Back 66

Glands that lubricate the skin producing sebum

Front 67

Eccrine glands

Back 67

Glands that help transport sweat to the outer skin surface

Front 68

Apocrine glands

Back 68

Glands that produce sweat that contribute to body odor

Front 69

Melanocytes

Back 69

Produce melanin

Front 70

Hemostatis

Back 70

Initial phase after an injury. Stimulates cells to come to the wound to begin other phases of wound healing

Front 71

Pressure injury

Back 71

Indication of the use of negative pressure wound therapy

Front 72

Elastic bandages

Back 72

Provide light support to an area or to secure dressings

Front 73

New gauze for each downward stroke of cleansing agent

Back 73

What action to use during wound care

Front 74

Mechanical and surgical debridement

Back 74

Involves physical removal of necrotic tissue

Front 75

Biosurgical debridement

Back 75

Utilizes fly larvae to clear the wound of necrotic tissue because of the enzyme they release (type of mechanical debridement)

Front 76

Autolytic debridement

Back 76

Involves using the client's own body to break down the necrotic tissue

Front 77

Enzymatic debridement

Back 77

Involves the use of synthetic enzymes that breakveown necrotic tissue when applied to the wound bed

Front 78

Skin functions

Back 78

Protection. Temperature regulation. Psychosocial. Sensation. Vitamin D production. Immunological. Absorption. Elimination.

Front 79

Position client to put the least strain on the operated area

Back 79

What to do first if wound disruption is suspected

Front 80

Recurrent turn

Back 80

Dressing technique used to wrap amputated stump or head

Front 81

Spica turn

Back 81

Dressing wrap used for a portion of the trunk or chest

Front 82

Spica turn

Back 82

Dressing wrap used for arms and legs

Front 83

Alginate

Back 83

Dressing used in infected or noninfected wounds with moderate to heavy drainage

Front 84

Hydrogels

Back 84

Dressing used with dry wounds or wounds with minimal damage

Front 85

Hydrocolloids

Back 85

Used with light to moderate drainage in wounds with necrosis or slough

Front 86

Transparent

Back 86

Dressing used with wounds having minimal drainage, small size and partial thickness

Front 87

Clean technique

Back 87

Can be used on a closed wound

Front 88

Alginate dressing

Back 88

Contains alginic acid from brown seaweed. Absorb exudate, maintain a moist wound environment, and facilitate autolytic debridement