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37 Cards in this Set

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abrasion
a superficial wound with little bleeding and is considered a partial-thickness wound. May appear weepy.
Approximated
the skin edges are closed as in a surgical insicision (no tissue is lost)
Blanching
turns light in color. A normal characterists for lightly pigmented skin.
Debridement
the removal of nonviable necrotic tissue.
Mechanical Debridement
1. use of wet-to-dry saline gauze dressings
2. high pressure irrigation
3. whirlpool
Autolytic debridement
uses synthetic dressings over a wound that allow the necrotic tissue (eschar) to be digested by the body's enzymes. ex.transparent film dressings.
chemical debridement
employ the use of topical enzymes to breakdown the necrotic tissue. ex: sterile maggots and Dakin's solution.
surgical debridement
surgical removal of necrotic tissue. used when client has cellulitis or sepsis.
Dehiscence
the partial or total separation of wound layers.
Dermis
the inner layer of the skin it proveds support to the epidermis and protection to the muscles, contains connective tissue and collagen.
epidermis
the top layer of the skin
erythema
red discoloration of the skin, may indicate circulatory changes
eschar
necrotic tissue, usually black or brown in color.
edema
swelling
evisceration
a protrusion of viseral organs through a wound opening.
exudate
describes the amount, color, odor, and consistency of wound drainage.
granulation tissue
red moist tissue
slough
stringy sbstance attached to wound bed that must be removed before wound can heal.
friction
the mechanical force that is created when skin is dragged across a coarse surface.
Shearing force
example: The head of the bed is elevated and the sliding of the skeleton starts, but the skin is fixed becuase of friction with the bed.
Hematoma
a localized collection of blood underneath the tissues.
homeostasis
equilibrium
ischemia
an inadequate blood supply to an organ or part of the body. resulting from collapsed capillaries= vessel occluding
Necrosis
dead cells
purulent
consistingof, containing, or discharging of pus.
pressure ulcer
impaired skin integrity related to unrelieved, prolonged pressure.
Norten Scale
It scores 5 risk factors for pressure ulcers. total score ranges from 5 to 20.
Braden Scale
most commonly used. Composed of 6 sudscales: sensory perc., moisture, mobility, nutrition, friction and shear. A lower score indicates a higher risk.
Sanguinous
Bright red wound drainage; indicates active bleeding.
Serosanguinous
Pale red, watery: mixture of clear and red fluid.
Purulent
Thick, yellow, green, tan or brown.
Serous
Clear watery plasma.
Stage I pressue ulcer
No open skin areas, does not blanch, compare to adjacent skin; temp., tissue consistancy(firm or boggy), sensation(itching or pain)
Stage II Pressure Ulcer
Skin is not intact. There is a partial thickness loss of the epidermis or dermis. Ulcer is superficial
Stage III Pressure Ulcer
Skin loss is full thickness. Subcutaneous tissue damage/necrotic. Deep crater-like appearance or eschar present
Stage IV Pressure Ulcer
Skin loss is full thickness with extensive destruction, necrosis, or damage to muscle or bone. underming is present. Sinus tracts may develope.
Undermining
seperation of the skin layers at the wound margins.