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83 Cards in this Set

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the bright red flush which appears after circulation is reestablished
hyperactive erythema
how long does hyperactive erythema last?
usually one-half to three-quarters as long as the duration of impeded blood flow to the area
other names for pressure ulcers are:
-decubitus ulcer
-pressure sores
what are the 4 terms used to describe wounds based on their relative degrees of contamination?
-clean wounds
-clean-contaminated wounds
-contaminated wounds
-dirty or infected wounds
skin on the legs which appears shiny, with hair loss, and easily damaged may indicate this condition
impaired peripheral arterial circulation
what effect does coritcosteroids have on the skin?
they thin the skin
an open wound caused by a sharp instrument
a type of wound caused by a blow from a blunt object
an open wound caused by a surface scrape
an open wound caused by tearing tissues apart
an open wound caused by the penetration of the skin by a sharp object in a stabbing motion
an open wound caused by something like a bullet or metal fragment
penetrating wound
a force acting parallel to the skin surface
a combination of friction and pressure
shearing force
how does shearing force damage tissue?
it moves the superficial tissue farther in a direction than the deep tissue, causing a separation of the two layers
"partial thickness" means what when referring to wounds?
that the damage is confined to the skin (the dermis and epidermis)
"full thickness" means what when referring to wounds?
that the damage goes deeper than the skin and extends into subcutaneous tissue and possibly muscle and bone
prolonged inadequate nutrition have these effects which increase the risk for pressure ulcers
-weight loss
-muscle atrophy
-loss of subcutaneous tissue
stage 1 pressure ulcer is characterized by
nonblanchable erythema
stage 2 pressure ulcer is characterized by
partial thickness skin loss involving the epidermis and possibly the dermis
stage 3 pressure ulcer is characterized by
full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia
stage 4 pressure ulcer is characterized by
full-thickness skin loss with tissue necrosis or damage to muscle, bone, or supporting structures
undermining may be present in which stage(s) of pressure ulcers?
stage 3 and stage 4
what are the changes in skin which make older people more prone to impaired skin integrity?
-loss of lean body mass
-generalized thinning of epidermis
-decreased strength and elasticity of skin
-increased dryness (less oil)
-diminished pain perception
the process of softening tissue by soaking or prolonged wetting
a "denuded area" is an example of this
macrophages engulf debris by a process known as
macrophages secrete this, which stimulates the formation of epithelial buds at the ends of damaged capillaries
AGF (angiogenesis factor)
a layer of dried plasma proteins and dead cells
a translucent red tissure which appears during the proliferative phase characterized by its fragility and network of new capillaries
granulation tissue
this type of exudate consists of large amounts of red blood cells
sanguineous exudate
this type of exudate is thicker than serous exudate which can vary in color and can be blue, green, or yellow
purulent exudate
the process of pus formation is called
if a bacteria causes pus, it can be said to be______..
a clear exudate formed from serum
serous exudate
the clear part of the blood is called______.
a localized collection of blood underneath the skin
the cessation of bleeding is called ________.
this type of healing occurs when the edges of a wound have been approximated
primary intention healing
this type of healing occurs when the edges cannot or should not be approximated
secondary intention healing
bright sanguineous bleeding indicates this
fresh bleeding
during the inflammatory phase of wound healing, two major processes occur which are:
hemostasis and phagocytosis
hemostasis occurs because of (4 events)
-vasoconstriction of large blood vessels
-retraction of injured blood vessels
-deposition of fibrin
-blood clotting
true or false? after hemostasis, epithelial cells migrate into the wound from the edges.
true. beneath the scab, epithelial cells migrate into the wound from the edges
this type of cell arrives at the wound at about 24 hrs after injury
the second phase of wound healing is called this ______.
proliferative phase
the proliferative phase begins at about how long after injury?
it begins about 3 or 4 days after injury
how long does the proliferative phase last?
about 18 days
a whittish protein substance secreted by fibroblasts
the last phase of wound healing is called______.
maturation phase
the maturation phase of the healing process begins at about how long after the injury?
it begins about 21 days after injury
how long does the maturation phase last?
it can last one or two years after the injury
what occurs during the maturation phase?
-collagen continues to be synthesized
-collagen fibers are rearranged into a more orderly structure
-the wound is remodeled and contracted
-the scar becomes stronger
true or false? a scar formed because of a wound is actually stronger than the skin that was there before the damage.
false. the scar is never as strong as the skin that was previously there
another name for a hypertrophic scar
in what ways does bacterial contamination effect wound healing?
-bacteria depletes the new cells' O2 and nutrients
-bacteria produces by-products which can interfere with a healthy surface condition
-can lead to infection
what distinguishes bacterial contamination from infection?
when the microorganisms multiply rapidly or invade tissues, infection occurs
what are some suggestions of wound infection?
change in wound color, pain, or drainage
the Braden scale is used to describe what?
the level of risk that a client is at for developing pressure ulcers
what are some signs of shock
-rapid thready pulse
-cold clammy skin
-lowered blood pressure
measures to control severe bleeding include:
-applying direct pressure over the wound
-elevating the involved extremity
what effect does obesity have on wound healing and why?
-slower healing
-increased risk of infection
-because adipose tissue has poor vascularization
how does smoking influence wound healing and why?
-slows healing
-increased risk of infection
-because smoking reduces the amount of functional hemoglobin in the blood and constricts arterioles
how does regular exercise affect wound healing and why?
-faster healing
-decreased risk of infection
-because those who exercise regularly tend to have good circulation
how might prolonged use of antibiotics make a person suceptible to wound infection?
by destroying microorganisms which compete with, or are antagonistic to, resistant organisms
the surface temperature of a pressure ulcer should be what
it should be the same temp as the normal skin around it. increased temp is an indication of infection or blood trapped deep to the skin
diabetes and cvd might influence wound healing how? and why?
-it might slow it due to impaired O2 delivery
using the ryb color code of wounds, how would you treat a wound with all three colors?
-debride the black first
-cleanse the yellow next
-protect the red last
what methods might be used to perform "mechanical debridement" on a wound?
-wet to damp dressings
what is the most selective form of debridement?
autolytic debridement
transparent wound barriers offer several advantages which are:
-acts as temporary skin
-are nonporous, self-adhesive
-do not require changing
-the wound can be assessed while wearing because they are transparent
-wound remains moist and retains serous exudate, which promotes epithelial growth
-they are elastic and do not restrict mobility
-do not adhere to wound
-client can shower/bathe with them on
-they can be removed without damaging wound tissues
this type of dressing is used to liquify necrotic tissue, rehydrate the wound bed, and to fill in dead space
this type of wound dressing is used to absorb light to moderate amts of exudate. it must have its edges taped down and requires a second dressing to obtain an occlusive environment.
polyurethane foams
what aspects should be assessed before teaching clients and family members to change dressings and wraps
-their willingness and ability to change them?
-what kind of support people do they have?
-do they have proper supplies, and know where to get more supplies?
how does the length of exposure affect a person's tolerance to heat/cold?
tolerance increases with increased exposure to heat/cold
how does the size of the exposed area affect tolerance of heat/cold?
the greater the size of the exposure, the lower the tolerance
how does intactness of skin affect tolerance to heat/cold?
injured skin areas are more sensitive to temperature variations
how does age influence tolerance to heat/cold?
the very young and very old generally have the lowest tolerance to heat/cold
True or false? the back of the hand and back of the feet are more sensitive to heat and cold than the inner aspect of the wrist and forearm.
False. The inner aspect of the wrist and forearm and the perineum are more sensitive to heat/cold than are the backs of the feet and hands
suture and staple removal may be done by whom?
any liscensed personel (rn's and lpn's)
NAII's can do what type of dressing change?
one that does not require sterile technique....wound over 48 hrs old
when bandaging a limb, how should the limb be positioned when bandaging?
it should be in its normal position with the joint slightly flexed to avoid putting strain on the ligaments and muscles
in which direction should you bandage?
from the distal to the proximal end of the extremity to aid in return venous flow