Smu Nursg 120 Wounds

Front 1

Adhesion

Back 1

band of scar tissue between or around organs

Front 2

Dehiscence

Back 2

a separation and disruption of previously joined wound edges

Front 3

Evisceration

Back 3

separation and disruption of previously joined wound edges to the extent that an internal organ protrudes through the wound

Front 4

Debridement

Back 4

removal of dirt, foreign objects, damage tissue, and cellular debris from a wound or burn to prevent infection and promote healing

Front 5

Erythema

Back 5

redness occurring in patches of variable size and shape that may be accompanied by increased temp. and localized inflammation

Front 6

Eschar

Back 6

thick, dry, black necrotic tissue

Front 7

Exudate

Back 7

fluid and leukocytes that move from the circulation to the site of injury

Front 8

Ischemia

Back 8

restriction of blood flow resulting in the damage of tissue

Front 9

Maceration

Back 9

softening and whitening of skin kept constantly wet, leaving it vulnerable to infection or damage by tearing

Front 10

Necrosis

Back 10

premature death of cells and tissue

Front 11

Pressure ulcer

Back 11

tissue necrosis caused by unrelieved pressure that occludes blood flow to the tissues

Front 12

Reactive hyperemia

Back 12

increase in organ blood flow that occurs following a brief period of ischemia

Front 13

Shear

Back 13

when pressure is placed on the skin and the layers of skin slide in the direction of body movement

Front 14

Slough

Back 14

shedding of the superficial layer

Front 15

Undermining

Back 15

tunneling when wound has a “lip”

Front 16

How are wounds measured?

Back 16

Wounds are measured in cm, head to toe, side to side and the depth. Tunneling and undermining are documented with respect to a clock with 12 o’clock being toward the patients head

Front 17

Stage I pressure ulcer characteristics

Back 17

defined area of persistent redness in light pigmented skin and red, blue or purple in darker pigmented skin

Front 18

Stage II pressure ulcer characteristics

Back 18

partial-thickness skin loss involving epidermis, dermis or both and presents as an abrasion, blister or shallow crater

Front 19

Stage III pressure ulcer characteristics

Back 19

full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to the underlying fascia and presents as deep crater w/ or w/o undermining

Front 20

Stage IV pressure ulcer characteristics

Back 20

full-thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone or supporting structures w/ or w/o undermining and sinus tracts

Front 21

Inflammatory response

Back 21

sequential reaction to cell injury, which neutralizes and dilutes the inflammatory agent, removes necrotic materials and establishes an environment suitable for healing and repair

Front 22

Vascular response

Back 22

cell injury > cell death > release of kinins, histamine & prostaglandins > local vasodilation > hyperemia > increased capillary permeability > fluid exudate

Front 23

Cellular response

Back 23

cell injury > chemotaxis or margination and diapedesis of blood leukocytes > migration of leukocytes to injury site > WBC's > phagocytosis > cellular exudate

Front 24

Exudate formation

Back 24

fluid and leukocytes that move from the circulation to the site of injury

Front 25

Local manifestations of inflammation

Back 25

redness, heat, pain, swelling and loss of function

Front 26

Primary intention healing

Back 26

takes place when wound margins are neatly approximated (surgical incision or paper cut)

Front 27

Secondary intention healing

Back 27

wounds that occur from trauma, ulceration and infection have large amounts of exudate and wide irregular margins w/ extensive tissue loss

Front 28

Tertiary intention healing

Back 28

healing occurs w/ delayed suturing of a wound in which two layers of granulation tissue are sutured together (contaminated wound is left open and sutured after infection is controlled)

Front 29

Factors that delay wound healing

Back 29

nutritional deficiencies, inadequate blood supply, corticosteroids, infection, smoking, mechanical friction, advanced age, obesity, diabetes and anemia

Front 30

Common complications of wound healing

Back 30

hypertrophic scars, keloids, contracture, dihiscence, excess granulation tissue and adhesions

Front 31

Nursing interventions that promote wound healing

Back 31

observation, cleaning wound, treating infection and protecting wound from further damage

Front 32

Inflammation drug therapy

Back 32

used to decrease the inflammatory response

Front 33

Inflammation nutritional therapy

Back 33

high fluid intake, protein, carbs and vitamins w/ moderate fat intake

Front 34

Inflammation nursing interventions

Back 34

observation, vital signs, RICE (rest, ice, compression and elevation)

Front 35

Arterial ulceration characteristics

Back 35

small deep punched out lesions, smooth edges, necrotic tissue, pale wound beds, appear on tips of toes or fingers or heels and ankles

Front 36

Venous ulceration characteristics

Back 36

superficial, irregular shaped, usually not painful, usually occur on medial aspect of legs, legs appear hard and wooden-like, edema, often heavily draining

Front 37

Arterial ulceration characteristics

Back 37

Small deep punched out lesions, smooth edges, necrotic tissue, pale wound beds, appear on tips of toes or fingers or heels and ankles

Front 38

Calcium alginate dressing

Back 38

used for wounds w/ large amounts of drainage, absorbs 30x its weight, made from seaweed, maintains moist wound environment, forms a hydrophilic gel, can last 24-72 hours

Front 39

Hydrocolloid dressing

Back 39

used for venous ulcers, pressure ulcers, neuropathic ulcers and 1st/2nd degree burns, highly absorbent polyurethane gel, oxygen and water vapor permeable, adhesive & elastic, can last 72 hours

Front 40

Venous ulceration characteristics

Back 40

superficial, irregular shaped, usually not painful, usually occur on medial aspect of legs, legs appear hard and wooden-like, edema, often heavily draining