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55 Cards in this Set

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approximated wound edges
edges lightly pulled together, appear to be touching.
dehiscence
accidental separation of edges, especially surgical wounds
ecchymosis
discoloration of an area resulting from infiltration of blood into subcutaneous tissue.
bruise
epithelialization
stage of wound healing, epithelial cells move across surface of wound----pink
erythema
redness or inflammation, resulting from dilation and congestion of capillaries
eschar
thick, leathery scab---dead cells, and dried plasma
granulated tissue
new tissue, pink/red, composed of fibroblasts and small blood vessels
ischemia
insufficient blood supply to body part due to obstruction of circulation
maceration
softening of tissue due to excessive moisture
peripheral neuropathy
condition with inflammation and degeneration of peripheral nerves. sensations include burning, tingling, numbness.
sinus tract
cavity or channel underneath wound with potential for infection
tachycardia
rapid heart rate >100
tunneling
passageway/opening maybe visible but most is under skin surface
undermining
areas of tissue destruction underneath intact skin along margins of a wound
vasoconstriction
narrowing of the lumen of a blood vessel
vasodilation
increase in diameter of blood vessel
epidermis
hair, nails, glandular structures, depends on dermis for nutrition
dermis
thicker, produces collagen and elastin home for lymphatic vessels and nerve tissues.
temp reg
dilation and constriction of blood vessels regulates body temp
skin
makes vit. D to aid in calcium absorption and phosphorous
primary intention wound
shorter healing time. wounds approximated, surgical incision
secondary intention wound
primary will become 2nd if get infected.
large with considerable tissue loss. healing by formation of granulated tissue. >infection >longer healing >scars
wound assessment
-appearance, inspection and palpation.
-size
-drainage: assess amount, color, odor, and consistency
-pain: incisional pain is usually severe for the 1st 2-3 days. if increased or acute, sign of delayed healing.
-sutures, drains, tubes
-evidence of complications
Pressure Ulcer assessment
size: draw shape and describe.
depth: steril swab w/ saline @ 90degree angle. mark pt on swab that is even with surrounding skin.
presence of undermining: tunneling, or sinus tract. saline sterile swab under wound edge.
stage I pressure ulcer
change in temp (cool/warm)
change in tissue consistency
change in sensation
pink-caucasians
blue/purple-blacks
stage II pressure ulcer
partial thickness skiin loss. presents as blister, shallow crater
stage III pressure ulcer
full thickness skin loss. damage/necrosis of dermis not to underlying fascia.
Stage IV pressure ulcer
full thickness skin loss with extensive destruction, necrosis, damage to muscle, bone, or supporting structure. sinus tracts can be associated.
turgor
elasticity of skin
hyperkeratosis
skin thickening, flaking, scales
abnormal skin color
(normal is even toned, w/o variation)
pallor-poor circulation
cyanosis-low O2
jaundice-liver disease
dermatitis
rash. if rash is all over body, usually a drug or food allergy
inflammatory phase
1st phase in wound healing.
hemostasis.
-vasoconstriction
-immediate
-blood clotting
-leukocytes
proliferative phase
second phase.
-epitheliazation
-fibroblasts (conn tissue)
-granulation
-lasts 2days-3wks
maturation phase
3rd stage
-remodeling
-collagen remodeled
-contraction
-scar
-3wks to 2 years.
scar
avascular, doesn't sweat, grow hair, or tan in sunlight.
-fire victims can't thermoregulate body
sterognosis
sensation to touch
skin assessment
-temp
-color
-moisture
-turgor
-integrity
edema
a decrease in skin mobility due to accumulation of fluid in intercellular spaces.
-not a normal finding
-document on 4-pt scale
acute wound
-surgical incision
-healing within days to weeks
-edges well-approximated
-decreased risk for infection
chronic wound
-pressure ulcers, peripheral arterial or venous ulcers
-normal healing time is delayed
-edges not approximated
-increased risk for infection
-bacterial counts >100,000 per gram of tissue impede healing
older adult: factors affecting wound healing
-slower inflammatory response
-reduced antibody productiona nd endocrine system function
-increased incidence of chronic illness such as DM and CVD that compromise circulation and tissue oxygenation
-decreased secretion of enzymes and absorption of nutrients and minerals
factors affecting wound healing
-age
-circulation and oxygenation (obese people/ few bld vessels)
-nutritional status
-wound condition
-health status: corticosteroids decrease the inflammatory process
evisceration
protrusion of viscera through the incision area.
risk factors: obesity/malnurishment, infected wounds, excessive coughing/vomiting, or straining.
-an increase in the flow of serosanguineous fluid from teh wound btwn postoperative days 4 and 5 indicates an impending dehiscence.
-cover with sterile towel soaked in NS, notify doctor
fistula
an abnormal passage from internal organ to the skin or from one internal organ to another.
signs: drainage from an opening in the skin or surgical site, pain.
-risk for fluid and electrolyte imbalance, skin breakdown, and infection
serous drainage
clear and watery
sanguineous drainage
RBC
purulent drainage
thick, foul odor, yellow or green
serosanguineous drainage
mixture of serum and RBC
dressing layers
most are 3 layers:
-contact layer allows draingage to pass into
-middle layer absorbs drainage
-outer layer keeps the two inner layers in place
gauze
-mechanical debridement (wet to dry)
-healing wounds (moist to damp) NEVER LET IT DRY OUT
-used as packing, don't pack above the surface of a wound
Transparent films
-acu-derm, bioclusive, op-site, tegaderm
-for superficial wound iwth little or no drainage
-may remain in place for 24-72 hours
-softens dry eschar by moisture (autolysis)
Hydrocolloid
-duoderm, tegasorb, restore, comfeel
-for shallow or moderate depth ulcers with minimal drainage
-absorb drainage
-maintain a moist wound environment
-decrease the risk for inf.
-remain in place for 3-5 days.
Hydrogel
-aquasorb, biolex, clearsite, nugel, vigilon
-sheets or gel
-cooling ability, nonadhesive
-for thermal burns or painful wounds w/ minimal exudate
-add moisture to dry eschar
-remain in place for 8-48 hrs.
GELS:
-maintain moist healing environment
-fill empty space
alginate
-for wounds with moderate to heavy exudate
-masses of fibers (curasorb, kaltostat, sorbsan) to form a moisture-retentive gel on contact with exudate
-high absorbent capability
-"seaweed" odor
-needs secondary dressing ot hold in place
-for infected wounds