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59 Cards in this Set

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A localized injury to the skin and other underlying tissue, usually over a bony prominence, as a result of pressure, shear, or friction.
pressure ulcer
When the skin is injured, the ____ functions to resurface the wound, and restore the barrier from invading organisms
epidermis
When skin is injured, the _____ responds to restore the structural integrity and physical properties of the skin.
dermis
The epidermis and dermis are separated by the ______.
dermal-epidermal junction
True/False
Pathogenesis for pressure ulcers includes:
-pressure intensity
-blanching
-pressure duration
-tissue tolerance
True
What are some risk factors for development of a pressure ulcer?
-impaired sensory perception
-alterations in LOC
-impaired mobility
-shear
-friction
-moisture
True/False
A surgical incision can be staged
false
What stage of pressure ulcer is this?
-Intact skin with nonblanchable redness
Stage 1
What stage of pressure ulcer is this?
-Full thickness tissue loss with exposed bone, muscle or tendon.
Stage 4
What stage of pressure ulcer is this?
-Full thickness tissue loss with visible fat
Stage 3
What stage of pressure ulcer is this?
-Partial thickness skin loss involving epidermis, dermis, or both
Stage 2
True/False
You can stage black necrotic tissue.
False
True/False
Granulated tissue is pink and healthy looking.
True
True/False
Undermining is a term used to describe tissue that expands underneath a pressure ulcer
True
True/False
Tunneling refers to an infection underneath tissue that produces "holes" on the surface of the pressure ulcer.
True
True/False
In reference to wound healing methods Primary Intention refers to the use of sutures and staples
True
True/False
In reference to wound healing methods Secondary Intention refers to a wound in which the edges are approximated
False
Edges are not approximated which makes measurement more difficult. Also the granulated tissue closes the wound from the inside out
True/False
In reference to wound healing, Tertiary Intention refers to a wound being left open for several days and closed at a later time.
True
Lots of drainage would cause damage to the wound if it were closed prematurely
True/False
Length, width and depth are measured in cm
True
True/False
A hemorrhagic sanguineous appearance of the wound indicated severe damage to the capillaries
True
True/False
A serosangiuneous appearance is clear and blood tinged drainage
True
True/False
A purosanguineous appearance presents as pus and blood
True
What are some factors influencing ulcer formation and wound healing?
-nutrition
-tissue perfusion
-infection
-age
-psychosocial impact if wounds
True/False
The hypodermis decreases in size with age. So older clients have little subcutaneous tissue padding over bony prominences.
True
The ____ scale uses 5 risk factors with a total score of 5-20 to calculate skin integrity. A lower score indicates a higher risk for pressure ulcer development
Norton
Risk factors are:
-physical condition
-metal condition
-activity
-mobility
-incontinence
The _____ scale uses six risk factors to determine skin integrity. Total range is from 6-23, where a lower score indicates a high risk for pressure ulcers.
Braden
The risk factors include:
-sensory perception
-moisture
-activity
-mobility
-nutrition
-friction and shear
What are some nursing diagnosis related to skin integrity and wound care?
-risk for impaired skin integrity
-impaired skin integrity
-impaired tissue integrity
-risk for infection
-pain
Some types of implementation for skin integrity and wound care could be?
-using topical skin care
-positioning
-use of support surfaces
______ is the removal of necrotic nonviable tissue.
debridement
______ describes the amount of pressure needed to collapse a capillary
Pressure intensity
_____ occurs when pressure is applied to capillaries and occludes the vessel over a prolonged period of time
Tissue ischemia
____occurs when the normal red tones of the light skinned client are absent upon pressure
Blanching
Blanching is not present in a dark skinned client. The skin will instead look purple in color or darker than surrounding skin.
True/False
Patients who are restless or have uncontrollable movements such as spastic conditions are at risk for friction induced wounds
True
Shear occurs more from force exerted parallel to skin resulting from gravity and resistance pushing down on the body. It effects skin deeper than just the epidermis as friction does.
Black or brown necrotic tissue is called ____.
eschar
____ is the final stage of healing and can take up to a year
Remodeling
Stages of wound healing are:
1) Inflammatory
2) Proliferative
3) Remodeling
The _____ stage of wound healing occurs when granulation tissue begins to cover the wound and epithelialization occurs.
proliferative
____ describes total separation of wound layers, and the protrusion of visceral organs
Evisceration
______ is the partial of total separation of wound layers
Dehiscence
A _____ is an abnormal passage between two organs or an organ and the outside of the body
fistula
A _____ dressing includes gauze
dry or moist
_____ protects the wound from surface contamination
Hydrocolloid
_____ maintains a moist surface to support healing
Hydrogel
A ____ uses negative pressure to support healing
wound V.A.C.
vacume assisted closure
True/False
Pressure ulcers usually develop within the first two weeks of hospitalization
True
True/False
At least 1500 kcal/day are required for nutritional maintenance of a post operative individual
True
____ in serum protein test is the best measure of nutrition intake, absorption and digestion.
Pre-albumin
Vitamin ___ is best for collagen synthesis, capillary wall integrity, and immunologic function
C
100-1000mg/day
Vitamin ___ is best for epithelialization, wound closure, inflammatory response, angiogenesis, and collagen formation
A
1600-2000 retinol equivalents per day
___ is best for collagen formation, protein synthesis, cell membrane and host defensses
Zinc
15-30 mg
True/False
You should never clean a wound prior to collecting a specimen for culture
False- a wound should be cleaned first because organisms that have nothing to do with the infection can grow on the outside of a wound
You can only clean pressure ulcers with ______ wound cleansers
noncytotoxic
True/False
Hydrogen peroxide is called a cytotoxic cleanser and should not be used to cleaning granulated wounds
True
True/False
Wound irrigation is done with a 19-guage needle or angiocatheter and a 35-ml syringe that delivers saline pressure at 8psi
True
True/False
Dry necrotic heel pressure ulcer should be removed.
False
If the heel is dry, and stable, black eschar should not be removed as long as it is non-tender, nonfluctuant, non suppurative and nonerythematous
True/False
Increased protein intake helps heal a wound, especially since the seepage actually causes loss of protein in the process
True
Most traditional dressings have 3 layers, they are:
1)primary layer
2)absorbent layer
3)outer layer
Heat should only be applied for ____ or less, because it will start to reduce blood flow by causing vasoconstriction.
1 hour or less
The application of a ____ compress will initially diminish swelling and pain. Prolonged exposure results in reflux vasodilation.
cold