question

Functions of the skin

answer

Protection, body temperature regulation, psychosocial, sensation, vitamin D production, immunological, absorption, and elimination

question

Phases of wound healing

answer

Hemostasis Inflammatory Proliferation Maturation

question

Factors affecting the skin

answer

Dehydration, malnutrition, diabetes, bedrest, casts, application of heat and cold, and age

question

Intentional wound

answer

Result of a planned invasive therapy or treatment

question

Unintentional wound

answer

Accidental, such as stabbing or gunshot

question

Open wound

answer

Occurs from intentional or unintentional trauma; skin is broken

question

Closed wound

answer

Results from a blow, force, or strain caused by trauma; skin is not broken

question

Wound repair occurs by

answer

Primary, secondary, and tertiary intention

question

Primary intention

answer

Well approximated, minimal tissue loss, and approximated edges

question

Example of primary intention

answer

Surgical incision

question

Secondary intention

answer

Infected primary intention Large, open wound, and often contaminated Take longer to heal

question

Example of secondary intention

answer

Burns

question

Tertiary intention

answer

Wounds opened for days Allow for edema and infection

question

Hemostatsis

answer

Occurs immediately after the initial injury Blood vessels constrict and blood clootting begins

question

Exudate

answer

Liquid formed during hemostasis once blood vessels dialate and capillary permeability increases

question

The accumulation of exudate causes

answer

Swelling and pain

question

Inflammatory phase

answer

Last about 4 to 6 days White blood cells move toward wound

question

Inflammatory phases caused

answer

Pain, heat, swelling, and redness; sometimes a mild temperature

question

Proliferation phase

answer

Last for several weeks Granulation tissue forms

question

Granulation tissue

answer

Forms the foundation for scar tissue development

question

Maturation phase

answer

Begins 3 weeks after initial injury and continues for months Scar is formed

question

Wound complications

answer

Infections, hemorrhage, dehiscence, evisceration, and fistula

question

Dehiscence

answer

Partial or total separation of wound layers as a result of excessive stress on wounds that are not healed

question

Evisceration

answer

Wound completely separated with protrusion of viscera through the incisional area

question

Most serious complication of dehiscence

answer

Evisceration

question

Fistula

answer

Abnormal passage from an internal organ to the outside of the body from one internal organ to another

question

Psychological effects of wounds

answer

Pain, anxiety, fear, and change in body image

question

Pressure ulcer

answer

Wound with localized area of tissue necrosis

question

Ischemia

answer

Deficiency of blood in a particular area

question

Pressure ulcers are commonly classified according to

answer

Six stages

question

Stages of pressure ulcers

answer

Suspected Stage 1, 2 3, and 4 Unstagable

question

Eschar

answer

Thick, leathery scab or dry crust that is necrotic

question

Nutritional status

answer

Albumin level Prealbumin level Body weight

question

Albumin level

answer

< 3.2 mg/dL

question

Prealbumin level

answer

< 19 mg/dL

question

Body weight

answer

decrease of > 15%

question

Wound assessment

answer

Inspect and palpate

question

Inspect for

answer

Sight and smell

question

Palpate for

answer

Appearance, drainage, odor, and pain

question

Wound drainage

answer

Serous Sanguineous Serosanguineous Purulent

question

Serous drainage

answer

Composed primarily of clear portion of blood; clear and watery

question

Sanguineous drainage

answer

Consists of large numbers of RBCs and looks like blood

question

Serosanguineous draingage

answer

Mixture of serum and RBC; light pink

question

Purulent drainage

answer

Made of WBC, liquefied dead tissue, and living and dead bacteria; thick, musty, and various in color (dark yellow or green)

question

Red wounds

answer

Are in proliferate stage of healing

question

Yellow wounds

answer

Indicate presence of exudate

question

Black wounds

answer

Indicate the presence of eschar

question

Presence of infection is suspected if wound is

answer

Swollen, deep red, hot, draining, has an odor, and/or its edges are dehisenced

question

Examples of wound dressings

answer

Hydrocolloid, hydrogel, and alginates

question

Hydrocolloids

answer

Minimal to moderate absorption Facilitate autolytic debridement May be left for 3 to 7 days

question

Hydrogels

answer

Minimal absorption Facilitate autolytic debridement Reduce pain

question

Alginates

answer

Facilitate autolytic debridement Requires secondary dressing Can be left in place for 1 to 3 days

question

Types of draining systems

answer

Open and closed

question

Open draining systems

answer

Penrose

question

Closed draining systems

answer

Jackson-Pratt and Hemovac

question

Precaution used in wound care

answer

Standard

question

Would cleansing

answer

Clean from top to bottom at the incision with 0.9% sodium chloride

question

Purpose of wound dressing

answer

Provides physical, psychological, and aesthetic comfort Removes necrotic tissue and absorbs drainage Prevents, eliminates, and controls infection Maintains a moist wound environment Protects wound from further injury Protect skin surrounding wound

question

Types of wound dressings

answer

Telfa, gauze, and transparent

question

Types of binders

answer

Straight, T-binder, and sling

question

Straight binder

answer

Used for chest and abdomen

question

T-binder

answer

Used for rectum, perineum, and groin area

question

Sling

answer

Used to support an arm

question

Montgomery straps

answer

Protect the patient's skin

question

Types of pressure ulcers

answer

Decubitus, pressure sore, and bed sore

question

Stage I

answer

Nonblancable erythema

question

Stage II

answer

Partial-thickness skin loss

question

Stage III

answer

Full-thickness skin loss

question

Stage IV

answer

Full-thickness skin loss with extensive destruction

question

Unstagable

answer

Base of ulcer covered by slough and or eschar in wound bed

question

Risk assessment scales

answer

Norton and Braden

question

19-23

answer

No risk

question

15-18

answer

Mild risk

question

13-14

answer

Moderate risk

question

10-12

answer

High risk

question

9 or lower

answer

Very high risk

question

Measurement of a pressure ulcer

answer

Size, depth, and tunneling

question

Would culture is a

answer

Sterile procedure

question

Nutritional needs to wound healing

answer

Protein, vitamin C, vitamin A, and Zinc

question

Factors affecting hot and cold treatment response

answer

Method and duration, degree of hot and cold, age, physical condition, and amount of body surface

question

Effects of applying heat

answer

Dilates peripheral blood vessels, increases tissue metabolism, reduces blood viscosity, reduces muscle tension, and helps relieve pain

question

Ostomy care

answer

Replace bag every 3-7 days Assess stoma and skin

question

Cut opening of stoma appliance

answer

1/8 larger

question

Suture removal

answer

Sterile technique

question

Staple removal must have

answer

Physician order

Fundamentals of Nursing: Skin Integrity and Wound Care – Flashcards

Unlock all answers in this set

Haven't found what you were looking for?

Search for samples, answers to your questions and flashcards