Nursing 1 Ch 34 Skin Integrity/wound Care

Front 1

the bright red flush which appears after circulation is reestablished

Back 1

hyperactive erythema

Front 2

how long does hyperactive erythema last?

Back 2

usually one-half to three-quarters as long as the duration of impeded blood flow to the area

Front 3

other names for pressure ulcers are:

Back 3

-decubitus ulcer
-bedsores
-pressure sores

Front 4

what are the 4 terms used to describe wounds based on their relative degrees of contamination?

Back 4

-clean wounds
-clean-contaminated wounds
-contaminated wounds
-dirty or infected wounds

Front 5

skin on the legs which appears shiny, with hair loss, and easily damaged may indicate this condition

Back 5

impaired peripheral arterial circulation

Front 6

what effect does coritcosteroids have on the skin?

Back 6

they thin the skin

Front 7

an open wound caused by a sharp instrument

Back 7

incision

Front 8

a type of wound caused by a blow from a blunt object

Back 8

contusion

Front 9

an open wound caused by a surface scrape

Back 9

abrasion

Front 10

an open wound caused by tearing tissues apart

Back 10

laceration

Front 11

an open wound caused by the penetration of the skin by a sharp object in a stabbing motion

Back 11

puncture

Front 12

an open wound caused by something like a bullet or metal fragment

Back 12

penetrating wound

Front 13

a force acting parallel to the skin surface

Back 13

friction

Front 14

a combination of friction and pressure

Back 14

shearing force

Front 15

how does shearing force damage tissue?

Back 15

it moves the superficial tissue farther in a direction than the deep tissue, causing a separation of the two layers

Front 16

"partial thickness" means what when referring to wounds?

Back 16

that the damage is confined to the skin (the dermis and epidermis)

Front 17

"full thickness" means what when referring to wounds?

Back 17

that the damage goes deeper than the skin and extends into subcutaneous tissue and possibly muscle and bone

Front 18

prolonged inadequate nutrition have these effects which increase the risk for pressure ulcers

Back 18

-weight loss
-muscle atrophy
-loss of subcutaneous tissue

Front 19

stage 1 pressure ulcer is characterized by

Back 19

nonblanchable erythema

Front 20

stage 2 pressure ulcer is characterized by

Back 20

partial thickness skin loss involving the epidermis and possibly the dermis

Front 21

stage 3 pressure ulcer is characterized by

Back 21

full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia

Front 22

stage 4 pressure ulcer is characterized by

Back 22

full-thickness skin loss with tissue necrosis or damage to muscle, bone, or supporting structures

Front 23

undermining may be present in which stage(s) of pressure ulcers?

Back 23

stage 3 and stage 4

Front 24

what are the changes in skin which make older people more prone to impaired skin integrity?

Back 24

-loss of lean body mass
-generalized thinning of epidermis
-decreased strength and elasticity of skin
-increased dryness (less oil)
-diminished pain perception

Front 25

the process of softening tissue by soaking or prolonged wetting

Back 25

maceration

Front 26

a "denuded area" is an example of this

Back 26

excoriation

Front 27

macrophages engulf debris by a process known as

Back 27

phagocytosis

Front 28

macrophages secrete this, which stimulates the formation of epithelial buds at the ends of damaged capillaries

Back 28

AGF (angiogenesis factor)

Front 29

a layer of dried plasma proteins and dead cells

Back 29

eschar

Front 30

a translucent red tissure which appears during the proliferative phase characterized by its fragility and network of new capillaries

Back 30

granulation tissue

Front 31

this type of exudate consists of large amounts of red blood cells

Back 31

sanguineous exudate

Front 32

this type of exudate is thicker than serous exudate which can vary in color and can be blue, green, or yellow

Back 32

purulent exudate

Front 33

the process of pus formation is called

Back 33

suppuration

Front 34

if a bacteria causes pus, it can be said to be______..

Back 34

pyrogenic

Front 35

a clear exudate formed from serum

Back 35

serous exudate

Front 36

the clear part of the blood is called______.

Back 36

serum

Front 37

a localized collection of blood underneath the skin

Back 37

hematoma

Front 38

the cessation of bleeding is called ________.

Back 38

hemastasis

Front 39

this type of healing occurs when the edges of a wound have been approximated

Back 39

primary intention healing

Front 40

this type of healing occurs when the edges cannot or should not be approximated

Back 40

secondary intention healing

Front 41

bright sanguineous bleeding indicates this

Back 41

fresh bleeding

Front 42

during the inflammatory phase of wound healing, two major processes occur which are:

Back 42

hemostasis and phagocytosis

Front 43

hemostasis occurs because of (4 events)

Back 43

-vasoconstriction of large blood vessels
-retraction of injured blood vessels
-deposition of fibrin
-blood clotting

Front 44

true or false? after hemostasis, epithelial cells migrate into the wound from the edges.

Back 44

true. beneath the scab, epithelial cells migrate into the wound from the edges

Front 45

this type of cell arrives at the wound at about 24 hrs after injury

Back 45

macrophages

Front 46

the second phase of wound healing is called this ______.

Back 46

proliferative phase

Front 47

the proliferative phase begins at about how long after injury?

Back 47

it begins about 3 or 4 days after injury

Front 48

how long does the proliferative phase last?

Back 48

about 18 days

Front 49

a whittish protein substance secreted by fibroblasts

Back 49

collagen

Front 50

the last phase of wound healing is called______.

Back 50

maturation phase

Front 51

the maturation phase of the healing process begins at about how long after the injury?

Back 51

it begins about 21 days after injury

Front 52

how long does the maturation phase last?

Back 52

it can last one or two years after the injury

Front 53

what occurs during the maturation phase?

Back 53

-collagen continues to be synthesized
-collagen fibers are rearranged into a more orderly structure
-the wound is remodeled and contracted
-the scar becomes stronger

Front 54

true or false? a scar formed because of a wound is actually stronger than the skin that was there before the damage.

Back 54

false. the scar is never as strong as the skin that was previously there

Front 55

another name for a hypertrophic scar

Back 55

keloid

Front 56

in what ways does bacterial contamination effect wound healing?

Back 56

-bacteria depletes the new cells' O2 and nutrients
-bacteria produces by-products which can interfere with a healthy surface condition
-can lead to infection

Front 57

what distinguishes bacterial contamination from infection?

Back 57

when the microorganisms multiply rapidly or invade tissues, infection occurs

Front 58

what are some suggestions of wound infection?

Back 58

change in wound color, pain, or drainage

Front 59

the Braden scale is used to describe what?

Back 59

the level of risk that a client is at for developing pressure ulcers

Front 60

what are some signs of shock

Back 60

-rapid thready pulse
-cold clammy skin
-pallor
-lowered blood pressure

Front 61

measures to control severe bleeding include:

Back 61

-applying direct pressure over the wound
-elevating the involved extremity

Front 62

what effect does obesity have on wound healing and why?

Back 62

-slower healing
-increased risk of infection
-because adipose tissue has poor vascularization

Front 63

how does smoking influence wound healing and why?

Back 63

-slows healing
-increased risk of infection
-because smoking reduces the amount of functional hemoglobin in the blood and constricts arterioles

Front 64

how does regular exercise affect wound healing and why?

Back 64

-faster healing
-decreased risk of infection
-because those who exercise regularly tend to have good circulation

Front 65

how might prolonged use of antibiotics make a person suceptible to wound infection?

Back 65

by destroying microorganisms which compete with, or are antagonistic to, resistant organisms

Front 66

the surface temperature of a pressure ulcer should be what

Back 66

it should be the same temp as the normal skin around it. increased temp is an indication of infection or blood trapped deep to the skin

Front 67

diabetes and cvd might influence wound healing how? and why?

Back 67

-it might slow it due to impaired O2 delivery

Front 68

using the ryb color code of wounds, how would you treat a wound with all three colors?

Back 68

-debride the black first
-cleanse the yellow next
-protect the red last

Front 69

what methods might be used to perform "mechanical debridement" on a wound?

Back 69

-scrubbing
-wet to damp dressings

Front 70

what is the most selective form of debridement?

Back 70

autolytic debridement

Front 71

transparent wound barriers offer several advantages which are:

Back 71

-acts as temporary skin
-are nonporous, self-adhesive
-do not require changing
-the wound can be assessed while wearing because they are transparent
-wound remains moist and retains serous exudate, which promotes epithelial growth
-they are elastic and do not restrict mobility
-do not adhere to wound
-client can shower/bathe with them on
-they can be removed without damaging wound tissues

Front 72

this type of dressing is used to liquify necrotic tissue, rehydrate the wound bed, and to fill in dead space

Back 72

hydrogels

Front 73

this type of wound dressing is used to absorb light to moderate amts of exudate. it must have its edges taped down and requires a second dressing to obtain an occlusive environment.

Back 73

polyurethane foams

Front 74

what aspects should be assessed before teaching clients and family members to change dressings and wraps

Back 74

-their willingness and ability to change them?
-what kind of support people do they have?
-do they have proper supplies, and know where to get more supplies?

Front 75

how does the length of exposure affect a person's tolerance to heat/cold?

Back 75

tolerance increases with increased exposure to heat/cold

Front 76

how does the size of the exposed area affect tolerance of heat/cold?

Back 76

the greater the size of the exposure, the lower the tolerance

Front 77

how does intactness of skin affect tolerance to heat/cold?

Back 77

injured skin areas are more sensitive to temperature variations

Front 78

how does age influence tolerance to heat/cold?

Back 78

the very young and very old generally have the lowest tolerance to heat/cold

Front 79

True or false? the back of the hand and back of the feet are more sensitive to heat and cold than the inner aspect of the wrist and forearm.

Back 79

False. The inner aspect of the wrist and forearm and the perineum are more sensitive to heat/cold than are the backs of the feet and hands

Front 80

suture and staple removal may be done by whom?

Back 80

any liscensed personel (rn's and lpn's)

Front 81

NAII's can do what type of dressing change?

Back 81

one that does not require sterile technique....wound over 48 hrs old

Front 82

when bandaging a limb, how should the limb be positioned when bandaging?

Back 82

it should be in its normal position with the joint slightly flexed to avoid putting strain on the ligaments and muscles

Front 83

in which direction should you bandage?

Back 83

from the distal to the proximal end of the extremity to aid in return venous flow