Surgical Asepsis/ Wound Care Ch. 36

Front 1

Corticosteriods do what to the skin?

Back 1

cause thinning of the skin

Front 2

Name 3 types of medications that increase skin sensitivity to the sun

Back 2

antibiotics, chemotherapy, & psychotherapeutic drugs

Front 3

Clean Wounds

Back 3

uninfected, minimal inflammation, the respiratory, gastrointestinal, genital, and urinary tracts are NOT ENTERED. Primarily closed wounds

Front 4

Clean-contaminated Wounds

Back 4

Surgical Wounds in which the respiratory, gastrointestinal, genital, or urinary tracts has been entered. No evidence of infection

Front 5

Contaminated Wounds

Back 5

open, fresh, accidental wounds and surgical wounds with break in sterile technique or large amount of spillage from gastrointestinal tract. INFLAMMATION

Front 6

Dirty or infected wounds

Back 6

containing dead tissue and evidence of infection (ie: purulent drainage)

Front 7

How are wounds are classified

Back 7

by depth (except pressure ulcers)

Front 8

Ischemia

Back 8

Deficiency in the blood supply to the tissue

Front 9

Reactive Hyperemia

Back 9

when the skin takes on a bright red flush after pressure has been relieved. Due to vasodilatation

Front 10

If redness doesn't disappear after pressure is relieved then?

Back 10

tissue damage has occured

Front 11

Name the 9 Risk factors for Pressure Ulcers

Back 11

Friction & Shearing, Immobility, Inadequate Nutrition, Fecal & Urinary Incontinence, Decreased Mental Status, Diminished Sensation, Excessive Body Heat, Advanced Age, and Chronic Medical Conditions

Front 12

Name 4 Hospital associated risk factors for Pressure Ulcers

Back 12

poor lifting and transferring techniques, incorrect positioning, hard support surfaces, and incorrect application of pressure-relieving devices

Front 13

What 4 things should your pressure ulcer risk assessment tool have?

Back 13

Data collection in areas of immobility, incontinence, nutrition, and level of consciousness.

Front 14

Regeneration

Back 14

healing or renewal of tissues

Front 15

Name the 4 stages of Pressure Ulcers

Back 15

I. Nonblanchable erythema
II. Partial thickness skin loss involving epidermis and possibly dermis
III. full-thickness skin loss involving damage or necrosis of subcutaneous tissue down to but not through the fascia. Deep crater without undermining.
IV. full-thickness skin loss with necrosis to muscle, or bone. Undermining.

Front 16

Primary Intention Healing

Back 16

when the tissue surfaces have been approximated(closed) and there is minimal or no tissue loss

Front 17

Secondary Intention Healing

Back 17

An extensive wound that involves considerable tissue loss, and in which the edges can not or should not be approximated

Front 18

How are primary and secondary Intention healing different

Back 18

2nd repair time is longer, scarring is greater, and greater risk of infection

Front 19

Tertiary Intention Healing

Back 19

left open for 3 to 5 days to allow edema or infection to resolve or exudate to drain. Then approximated

Front 20

maceration

Back 20

skin softened by prolonged wetting

Front 21

Exudate

Back 21

Purulent drainage

Front 22

What are the 3 phases of wound healing

Back 22

Inflammation, proliferative, and maturation or remodling

Front 23

What are the 2 processes occurring during Inflammation

Back 23

Hemostasis which results from vasoconstriction, retraction of injured blood vessels, the deposition of fibrin, and formation of blood clots.
AND
Phagocytosis

Front 24

Hemostasis

Back 24

The cessation (stopping) of bleeding

Front 25

What happens during Proliferative Phase of healing?

Back 25

Fibroblasts begin to synthesize collagen (a protein that adds strength). A healing ridge appears. Capillaries grow across the wound making a network of tissue called granulation tissue

Front 26

Eschar

Back 26

Necrotic Tissues

Front 27

What occurs during the Maturation Phase of Healing?

Back 27

Collagen fibers reorganize, making the scar stronger.

Front 28

Serous Exudate

Back 28

Made of SERUM (the clear portion of the blood). Looks clear and has few cells

Front 29

Purulent Exudate

Back 29

Has PUS

Front 30

Suppuration

Back 30

the formation of pus

Front 31

Sanguineous Exudate

Back 31

Made of large amounts of RBC. Frequently seen in OPEN WOUNDS

Front 32

Hemorrhage

Back 32

Massive Bleeding.
Internal Hemorrhage detected by swelling or distention in the area of the wound.

Front 33

Hematoma

Back 33

a localized collection of blood underneath the skin

Front 34

When is the greatest risk for Hemorrhage?

Back 34

the first 48 hours after surgery

Front 35

Dehiscence

Back 35

the partial or total rupturing of a sutured wound.
Usually involves abdominal wounds

Front 36

Evisceration

Back 36

the protrusion of internal viscera through an incision

Front 37

Slough

Back 37

yellow or white tissue that adheres to the ulcer bed in strings or clumps, or is mucinous

Front 38

Granulation Tissue

Back 38

pink or beefy red tissue with a shiny, moist, granular appearance.

Front 39

Skin assessment

Back 39

Inspection and Palpation focused on SKIN COLOR DISTRIBUTION, skin TURGOR, presence of EDEMA, characteristics of any LESIONS present.
Pay special attention to moist areas and those that receive extensive pressure

Front 40

Assessing Treated Wounds

Back 40

Look at appearance, size, drainage, and presence of swelling, pain, and status of drains and tubes.

Front 41

Minimal Drainage

Back 41

only stains dressing

Front 42

moderate drainage

Back 42

saturates without leakage prior to scheduled dressing change

Front 43

heavy drainage

Back 43

overflows dressing prior to scheduled dressing change

Front 44

Debridement

Back 44

removal of necrotic tissue

Front 45

What 8 things should be noted when a Pressure ulcer is present

Back 45

Location, size, Presence of Undermining, stage, color, condition of the wound margins, integrity of the surrounding skin, and signs of infection.