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49 Cards in this Set

  • Front
  • Back
Any abnormal opening in the skin is a ...
The primary nursing responsibility for skin care is to...
prevent breakdown; when it occurs, report & treat it as ordered.
The most common types of wounds encountered are (3)...
trauma wounds, surgical incisions and pressure ulcers.
A _____ is any disruption in the skin's intactness.
Two types of wounds...
accidential or unintentional
A wound that occurs accidentally is ___; intentional wounds are ____.
contaminated; sterile
Wound healing occurs by 3 intentions...
First, Second and Third intentions.
First intention healing occurs...
with minimal tissue loss (incisions) and edges are approximated (close to each other). Scarring/infection rates are low.
Second intention healing occurs...
with tissue loss (deep lacerations, burns & PU) openings fill with granulation tissue. Scarring/infection risk greater.
Third intention healing occurs...
when there is a delay in the time beteween the injury and the closure ofthe wound. (Left open to allow for drainage or removal of infect. mat'l) Scarring common.
Wounds are covered with dressings to (3)...
protect from contamination, collect wound exudate (drainage) and protect from damage during healing.
Wound drainage
The type of wound and its condition determine the ...
type of dressing and the frequ. of dressing chg's.
Type of dressing most often used for wound healing by primary intention.
Dry, sterile or dry-to-dry dressing.
Dress a clean, uncontaminated, or unifected wound (incision) with a...
dry, sterile dressing.
____ are most commonly used for wounds healing by secondary intension.
Wet-to-dry dressings
Removal or infected tissues is called...
Using wet-to-dry dressing is a common technique for...
Packing is placed in a wound most commonly in thecase of...
a puncture wound or wounds with sinus tracts.
___ are used on clean, open wounds or on wounds that are granulating.
Wet-to-wet dressings
_____ dressings provide warmth and moisture, which aide the healing process and make the client more comfortable.
Wet-to-wet dressings
____ dressings aid in healing by providing a moist environment and also sealing the wound.
Commercially prepared gel dressings (DuoDerm)
Commercially prepared gel dressings (ex. DuoDerm) interacts with the moisture on theskin to produce a gel. This type of dressing is also called a...
Hydro-colloid dressing
Sometimes gel dressing (hydro-colloid dressings) are covered with a transparent dressing, such as...
Tegaderm or OpSite
_____ may be attached to a wound drain to cause more repid and complete evacuation of the wound materials.
A gentle suction device, such as a HemoVac
Wounds, eventhough draining or infected are irrigated using...
sterile technique
A sterile ____ _____ is done to remove debris from an open, infected wound.
wound irrigation
3 major types of wound irrigation are:
manual irrigation, continuous irrigation, intermittent irrigation.
Manual irrigation is done by...
a hand-held syringe.
Continous irrigation is done with...
an infustion-type setup.
Intermittent irrigation is done...
alone or combined with gentle suction, such as with a HemoVac.
Disruption of skin integrity, commonly called...
skin breakdown.
Lack of blood supply.
____ are the end result of constant skin pressure.
Pressure ulcers, decubitus ulcer or bedsores.
The danger of ____ ____ inceases if a client must lie in one position or has a cast, splint or disease that affects circulation.
Presure areas
External force great enough to occlude blood in capillaries resulting in tissue anoxia.
Interaction of gravity and friction against the skin's surface.
Superficial abrasion resulting from the skin rubbin another surface.
Unintential removal of the epidermis by mechanical means such as with adhesive removal.
Causes of wounds in the perianal skin.
Urine or stool
Causes wounds in areas where moisture can get trapped (eg. skin folds).
Causes wounds in feet, toes and lower leg.
Arterial insufficiency
Causes wounds under pendulous breasts or folds of abdomen.
Prevention for wounds caused by maceration...
wash thoughly each day, apply powder/med. cream, wear a bra, if possible.
Prevention of wounds caused by arterial insufficiency...
avoid compression, protect from injuries, provide moisturizing, take sp. care of those at increased risk (eg. diatetics)
When applying medication to a wound...
apply only to the wound itself, not to the skin's edges (may damage surrounding tissues).
Wounds that open
Pressure ulcer prevention focuses on...
eliminating all causes.
A common cause of skin breakdown is...
pressure against tissues that causes ischemia and tissue death.