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