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59 Cards in this Set
- Front
- Back
- 3rd side (hint)
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A localized injury to the skin and other underlying tissue, usually over a bony prominence, as a result of pressure, shear, or friction.
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pressure ulcer
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When the skin is injured, the ____ functions to resurface the wound, and restore the barrier from invading organisms
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epidermis
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When skin is injured, the _____ responds to restore the structural integrity and physical properties of the skin.
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dermis
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The epidermis and dermis are separated by the ______.
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dermal-epidermal junction
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True/False
Pathogenesis for pressure ulcers includes: -pressure intensity -blanching -pressure duration -tissue tolerance |
True
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What are some risk factors for development of a pressure ulcer?
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-impaired sensory perception
-alterations in LOC -impaired mobility -shear -friction -moisture |
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True/False
A surgical incision can be staged |
false
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What stage of pressure ulcer is this?
-Intact skin with nonblanchable redness |
Stage 1
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What stage of pressure ulcer is this?
-Full thickness tissue loss with exposed bone, muscle or tendon. |
Stage 4
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What stage of pressure ulcer is this?
-Full thickness tissue loss with visible fat |
Stage 3
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What stage of pressure ulcer is this?
-Partial thickness skin loss involving epidermis, dermis, or both |
Stage 2
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True/False
You can stage black necrotic tissue. |
False
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True/False
Granulated tissue is pink and healthy looking. |
True
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True/False
Undermining is a term used to describe tissue that expands underneath a pressure ulcer |
True
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True/False
Tunneling refers to an infection underneath tissue that produces "holes" on the surface of the pressure ulcer. |
True
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True/False
In reference to wound healing methods Primary Intention refers to the use of sutures and staples |
True
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True/False
In reference to wound healing methods Secondary Intention refers to a wound in which the edges are approximated |
False
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Edges are not approximated which makes measurement more difficult. Also the granulated tissue closes the wound from the inside out
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True/False
In reference to wound healing, Tertiary Intention refers to a wound being left open for several days and closed at a later time. |
True
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Lots of drainage would cause damage to the wound if it were closed prematurely
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True/False
Length, width and depth are measured in cm |
True
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True/False
A hemorrhagic sanguineous appearance of the wound indicated severe damage to the capillaries |
True
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True/False
A serosangiuneous appearance is clear and blood tinged drainage |
True
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True/False
A purosanguineous appearance presents as pus and blood |
True
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What are some factors influencing ulcer formation and wound healing?
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-nutrition
-tissue perfusion -infection -age -psychosocial impact if wounds |
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True/False
The hypodermis decreases in size with age. So older clients have little subcutaneous tissue padding over bony prominences. |
True
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The ____ scale uses 5 risk factors with a total score of 5-20 to calculate skin integrity. A lower score indicates a higher risk for pressure ulcer development
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Norton
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Risk factors are:
-physical condition -metal condition -activity -mobility -incontinence |
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The _____ scale uses six risk factors to determine skin integrity. Total range is from 6-23, where a lower score indicates a high risk for pressure ulcers.
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Braden
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The risk factors include:
-sensory perception -moisture -activity -mobility -nutrition -friction and shear |
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What are some nursing diagnosis related to skin integrity and wound care?
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-risk for impaired skin integrity
-impaired skin integrity -impaired tissue integrity -risk for infection -pain |
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Some types of implementation for skin integrity and wound care could be?
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-using topical skin care
-positioning -use of support surfaces |
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______ is the removal of necrotic nonviable tissue.
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debridement
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______ describes the amount of pressure needed to collapse a capillary
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Pressure intensity
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_____ occurs when pressure is applied to capillaries and occludes the vessel over a prolonged period of time
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Tissue ischemia
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____occurs when the normal red tones of the light skinned client are absent upon pressure
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Blanching
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Blanching is not present in a dark skinned client. The skin will instead look purple in color or darker than surrounding skin.
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True/False
Patients who are restless or have uncontrollable movements such as spastic conditions are at risk for friction induced wounds |
True
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Shear occurs more from force exerted parallel to skin resulting from gravity and resistance pushing down on the body. It effects skin deeper than just the epidermis as friction does.
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Black or brown necrotic tissue is called ____.
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eschar
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____ is the final stage of healing and can take up to a year
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Remodeling
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Stages of wound healing are:
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1) Inflammatory
2) Proliferative 3) Remodeling |
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The _____ stage of wound healing occurs when granulation tissue begins to cover the wound and epithelialization occurs.
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proliferative
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____ describes total separation of wound layers, and the protrusion of visceral organs
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Evisceration
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______ is the partial of total separation of wound layers
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Dehiscence
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A _____ is an abnormal passage between two organs or an organ and the outside of the body
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fistula
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A _____ dressing includes gauze
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dry or moist
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_____ protects the wound from surface contamination
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Hydrocolloid
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_____ maintains a moist surface to support healing
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Hydrogel
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A ____ uses negative pressure to support healing
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wound V.A.C.
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vacume assisted closure
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True/False
Pressure ulcers usually develop within the first two weeks of hospitalization |
True
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True/False
At least 1500 kcal/day are required for nutritional maintenance of a post operative individual |
True
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____ in serum protein test is the best measure of nutrition intake, absorption and digestion.
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Pre-albumin
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Vitamin ___ is best for collagen synthesis, capillary wall integrity, and immunologic function
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C
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100-1000mg/day
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Vitamin ___ is best for epithelialization, wound closure, inflammatory response, angiogenesis, and collagen formation
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A
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1600-2000 retinol equivalents per day
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___ is best for collagen formation, protein synthesis, cell membrane and host defensses
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Zinc
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15-30 mg
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True/False
You should never clean a wound prior to collecting a specimen for culture |
False- a wound should be cleaned first because organisms that have nothing to do with the infection can grow on the outside of a wound
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You can only clean pressure ulcers with ______ wound cleansers
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noncytotoxic
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True/False
Hydrogen peroxide is called a cytotoxic cleanser and should not be used to cleaning granulated wounds |
True
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True/False
Wound irrigation is done with a 19-guage needle or angiocatheter and a 35-ml syringe that delivers saline pressure at 8psi |
True
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True/False
Dry necrotic heel pressure ulcer should be removed. |
False
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If the heel is dry, and stable, black eschar should not be removed as long as it is non-tender, nonfluctuant, non suppurative and nonerythematous
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True/False
Increased protein intake helps heal a wound, especially since the seepage actually causes loss of protein in the process |
True
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Most traditional dressings have 3 layers, they are:
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1)primary layer
2)absorbent layer 3)outer layer |
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Heat should only be applied for ____ or less, because it will start to reduce blood flow by causing vasoconstriction.
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1 hour or less
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The application of a ____ compress will initially diminish swelling and pain. Prolonged exposure results in reflux vasodilation.
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cold
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