Ch. 25, 26, 27 Nursing Fundamentals

Front 1

Debridement

Back 1

The removal of dead or damaged tissue, foreign objects, and cellular debris from a wound

Front 2

Deep tissue injury

Back 2

A purple or maroon localized area of discolored intact skin or blood-filled blister resulting from damage to underlying soft tissue from pressure and/or shear

Front 3

Erythema

Back 3

A redness or inflammation of the skin or mucous membranes that is a result of dilation and congestion of superficial capillaries

Front 4

Example of erythema

Back 4

Sunburn

Front 5

Eschar

Back 5

A thick layer or dead, dry tissue that covers a pressure ulcer or thermal burn

Front 6

Exudate

Back 6

The discharge from small pores or breaks in cell membrane

Front 7

Ischemia

Back 7

A decreased blood supply to a body part (skin) or an organ (heart)

Front 8

Maceration

Back 8

To soften or break down

Front 9

Necrosis

Back 9

Localized tissue death

Front 10

Pressure ulcer

Back 10

An inflammation, sore, or ulcer in the skin over a bony prominence, developing as a result of prolonged, unrelieved pressure

Front 11

Reactive hyperemia

Back 11

The return of blood to an area of tissue upon the release of externally applied pressure

Front 12

Shear

Back 12

Applied force or pressure exerted against the surface and layers of the skin as tissues slide in opposite but parallel planes

Front 13

Slough

Back 13

Shedding of dead tissue cells

Front 14

Topical agents

Back 14

Drugs or treatments applied to the body surface

Front 15

Undermining

Back 15

A condition of a wound in which the loss of underlying tissue is greater than the loss of skin

Front 16

Dead space

Back 16

A cavity remaining in a wound

Front 17

Dehiscience

Back 17

A separation of a wound's edges revealing underlying tissue

Front 18

Epithelialization

Back 18

The stage of wound healing by which epidermal cells migrate (move) over the wounds surface to close the top or "resurface" the wound

Front 19

Evisceration

Back 19

The protrusion of visceral organs through a surgical wound

Front 20

Excoriation

Back 20

An injury to the skins surface caused by abrasion

Front 21

Granulation

Back 21

The presence of red, granular, moist tissue that appears during the healing of open wounds

Front 22

Hydrocolloid

Back 22

A substance that forms a gel in the presence of water, examples of which are used in surgical dressing and in various industrial applications

Front 23

Hydrogel

Back 23

A gel in which the liquid component is water

Front 24

Negative Pressure Wound Therapy (NPWT)

Back 24

Therapeutic technique using a vacuum dressing to promote healing in acute or chronic wounds and enhance healing of first and second degree burns

Front 25

Neovascularization

Back 25

Formation of functional microvascular networks with red blood cell perfusion

Front 26

Occlusive dressing

Back 26

air-tight / water-tight trauma dressing

Front 27

Pressure dressing

Back 27

Dressing by which pressure is exerted on the area covered to prevent the collection of fluids in the underlying tissue

Front 28

Primary dressing

Back 28

Applied directly on the wound

Front 29

Secondary dressing

Back 29

Applied over the primary dressing

Front 30

Compress

Back 30

A pad of absorbent material pressed onto part of the body to relieve inflammation or stop bleeding

Front 31

Conduction

Back 31

The process by which heat or electricity is directly transmitted through a substance when there is a difference of temperature or of electrical potential between adjoining regions, without movement

Front 32

Cryotherapy

Back 32

The use of extreme cold in surgery or other medical therapy

Front 33

Evaporation

Back 33

A change from liquid form to gas form

Front 34

Insulator

Back 34

A substance that does not readily allow the passage of heat or sound

Front 35

Neuropathy

Back 35

Disease or dysfunction of one or more peripheral nerves, typically causing numbness or weakness

Front 36

Piloerection

Back 36

Involuntary erection or bristling of hairs due to a sympathetic reflex usually triggered by cold, shock, or fright or due to a sympathomimetic agent

Front 37

Sitz bath

Back 37

A bath in which only the buttocks and hips are immersed in water

Front 38

Vasoconstriction

Back 38

The constriction of which blood vessels, which increases blood pressure

Front 39

Vasodilation

Back 39

Dilation of blood vessels, which decreases blood pressure

Front 40

Pressure ulcers also inaccurately called

Back 40

Decubitis ulcers, pressure sores, or bed sores

Front 41

Where do pressure ulcers occur?

Back 41

On areas of skin subjected to pressure; bony or nonbony

Front 42

When assessing a pressure ulcer with a PUSH tool, when will the nurse measure exudate?

Back 42

After removing a dressing and before topical agent

Front 43

Prevention of pressure ulcers requires

Back 43

Early identification of at-risk patients and implementation of prevention strategies

Front 44

What to look for with pressure ulcers

Back 44

Redness, dryness, wetness, edema, heat, color, enduration (can't see it but you can feel it)

Front 45

Back 45

Stage 3 pressure ulcer

Front 46

Back 46

Stage 4 pressure ulcer

Front 47

Back 47

Stage 1 pressure ulcer

Front 48

Serous wound drainage

Back 48

Clear, watery plasma

Front 49

Purulent wound drainage

Back 49

Thick yellow, green, tan, or brown

Front 50

Serosanguieous wound drainage

Back 50

Pale, red, and watery: mixture of serous and sanguineous

Front 51

Sanguineous wound drainage

Back 51

Bright red: indicates active bleeding

Front 52

Back 52

Transparent dressing

Front 53

Back 53

Abdominal binder

Front 54

Back 54

Aquathermia pad

Front 55

Back 55

Cold compress application

Front 56

Factors that delay wound healing in an older adult

Back 56

Aging affects all phases of wound healing. The most significant change includes a diminished inflammatory response

Front 57

Factors that delay wound healing in an obese patient

Back 57

Fatty subcutaneous tissue is less vascular

Front 58

Factors that delay wound healing in a diabetes patient

Back 58

Vascular changes reduce blood flow to peripheral tissues; leukocyte malfunction results from hyperglycemia, resulting in high risk for infection

Front 59

Factors that delay wound healing in compromised circulation

Back 59

Vascular changes decrease the delivery of oxygen and nutrients

Front 60

Factors that delay wound healing in patients with malnutrition

Back 60

Inadequate nutrition slows healing because of lack of nutrients needed for wound healing

Front 61

Factors that delay wound healing in patients with immunosuppressive therapy

Back 61

Immunosuppression decreases inflammatory response and collagen synthesis

Front 62

Factors that delay wound healing in chemotherapy patients

Back 62

Chemotherapy interferes with leukocyte production and immune response

Front 63

Factors that delay wound healing in patients with high levels of stress

Back 63

Increased cortisol levels reduce number of lymphocytes and decrease inflammatory response