question

necrosis

answer

local death of tissue from disease or injury

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stage III pressure ulcer

answer

full-thickness skin loss that looks like a deep crater and may extend to the fascia; subcutaneous tissue is damaged or necrotic; bacterial infection of ulcer is common and causes drainage from the ulcer; there may be damage to the surrounding tissue

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clean wound

answer

wound free of microorganisms

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maceration

answer

softening of tissue that increases the chance of trauma or infection

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shearing

answer

an applied force that causes a downward and forward pressure on the tissues beneath the skin

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eschar

answer

a buildup of tough, necrotic tissue

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integument

answer

term for the skin

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excellent nursing care

answer

the main factor in the prevention of pressure ulcers

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full thickness wound

answer

wound that no longer has a dermal layer, except at the wound edges; necrotic tissue must be removed so that granulation tissue can fill in the wound; it heals by contraction

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24 hours

answer

after the initial assessment, the skin is assessed for pressure ulcer risks every . . .

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diaphoresis

answer

perspiration

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symmetry

answer

the equality in size, form, and arrangement of parts on the opposite sides of a plane

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stage II pressure ulcer

answer

partial-thickness skin loss involving epidermis and/or dermis; it may look like an abrasion, a blister, or shallow crater; the area surrounding the damaged skin may feel warmer

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reactive hyperemia

answer

the process in which blood rushes to a place where there was a decrease in circulation

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ambulate

answer

to walk

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induration

answer

an area that feels hard

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staging system for pressure ulcers

answer

(1) stage I, (2) stage II, (3) stage III, (4) stage IV, (5) suspected deep tissue injury, and (6) unstageable

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gait

answer

the style of walking

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blanch

answer

when the skin turns white or, in darker skin, becomes pale

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incontinent

answer

loss of bowel or bladder control

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eschar

answer

must be removed to properly stage the ulcer

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Braden Scale

answer

scale used for predicting pressure ulcer risk

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suspected deep tissue injury pressure ulcer

answer

localized discolored intact skin that is maroon or purple or a blood-filled blister resulting from damage to underlying soft tissue from presure or shearing; the area may be painful, form, mushy, boggy, warmer, or cooler when compared to adjacent tissue

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unstageable pressure ulcer

answer

loss of full thickness of tissue; the base of the ulcer is covered by eschar in the wound bed, or the base of the ulcer contains slough

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closed wounds

answer

wounds that do not break the skin

question

partial thickness wound

answer

wound that heals more quickly; the fibrin clot that forms after an injury acts as the framework and regrowth occurs across the open wound

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risk factors for pressure ulcers

answer

(1) immobility, (2) inactivity, (3) moisture, (4) malnutrition, (5) advanced age, (6) altered sensory perception, (7) lowered mental awareness, (8) friction and shearing, (9) dehydration, (10) obesity, (11) edema

question

stage I pressure ulcer

answer

an area of red, deep pink, or mottled skin that does not blanch with fingertip pressure; in people with darker skin, discoloration of the skin, warmth, edema, or induration may be signs

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dirty wound

answer

wound containing microorganisms

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older adults

answer

age group that is at an increased risk of developing impaired skin integrity from having thinner skin, decreased subcutaneous fat, decreased sebaceous gland activity, and decreased elasticity in the skin

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18 or below

answer

Braden score that indicated pressure ulcer risk

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ways to prevent pressure ulcers

answer

(1) changing position every 2 hours when in bed; (2) use a pressure-reducing bed device or the bed or chair; (3) minimize friction and shearing; (4) keep heels of immobile patient off the bed; (5) observe the color of the skin carefully and frequently

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once an hour

answer

how often to reposition chair-bound patients

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superficial wound

answer

another name for a partial thickness wound

question

open wounds

answer

wounds that break the skin

question

stage IV pressure ulcer

answer

full-thickness skin loss with extensive tissue necrosis or damage to muscle, bone, or supporting structures; sinus tracts may be present; infection is usually widespread; the ulcer may appear dry and black, with a buildup of eschar, or it can appear wet and oozing

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full thickness wound

answer

wound that heals by contraction

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contusion

answer

wound characterized by tissue injury without breaking of skin; also called a bruise

question

puncture

answer

wound characterized by being made by a sharp, pointed object through skin or mucous membranes and underlying tissue

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ulceration

answer

wound characterized by excavation of skin and/or underlying tissue from injury or necrosis

question

incision

answer

wound characterized by the surgically made separation of tissues with clean, smooth edges

question

sprain

answer

wound characterized by wrenching or twisting of a joint with partial rupture of its ligaments; causes swelling

question

crush

answer

wound characterized by tissue significantly disrupted or compressed because of high level of force being applied; may or may not be visible lacerations or maceration of surrounding tissue

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laceration

answer

wound characterized by traumatic separation of tissues with irregular, torn edges

question

perforation

answer

wound characterized by internal organ or body cavity tissue opened, usually because of infection or a penetrating wound

question

hematoma

answer

wound characterized by tissue injury that damages a blood vessel; pooling of blood under the unbroken skin

question

avulsion

answer

wound characterized by tearing away of a structure or a part accidentally or surgically

question

abrasion

answer

wound characterized by traumatic scraping away of surface layers of skin

question

penetrating

answer

wound characterized by variable-size open wound through skin and underlying tissues made by a bullet, metal, or wood fragment; may extend deeply into body

question

types of closed wounds

answer

(1) contusion, (2) sprain, and (3) hematoma

question

types of open wounds

answer

(1) incision, (2) laceration, (3) abrasion, (4) puncture, (5) penetrating, (6) avulsion, (7) ulceration, (8) perforation, and (9) crush

question

2 primary methods of wound healing

answer

(1) replacement and (2) regeneration

question

replacement

answer

a primary method of wound healing in which the lost tissue is replaced by fibrous connective tissue

question

regeneration

answer

a primary method of wound healing that occurs when blood supply has been disrupted and necrosis occurs; new cells similar in structure and function to the dead cells are produced; not all types of cells can do this

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tissues that can regenerate

answer

skin, mucous membranes, bone marrow, muscle, bone, liver, kidney, and lung tissue

question

tissues that cannot regenerate

answer

heart muscle and nerve cells

question

phases of wound healing

answer

(1) inflammatory phase, (2) proliferation phase, and (3) maturation phase

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remodeling phase

answer

another name for the maturation phase

question

inflammatory phase

answer

1st phase of wound healing; begins immediately after injury and lasts about 3 or 4 days; includes constriction of blood vessels, platelet aggregation, and fibrin formation

question

proliferation phase

answer

2nd phase of wound healing; begins on the 3rd or 4th day after injury and lasts 2 to 3 weeks; macrophages clearing the wound of debris and stimulating fibroblasts; granulation tissue is synthesized

question

maturation phase

answer

3rd phase of wound healing; begins 3 weeks after injury; collagen lysis and collagen synthesis by the macrophages produces the strongest scar tissue possible

question

inflammation

answer

a localized protective response brought on by injury or destruction pf tissues

question

platelet aggregation

answer

clumping of platelets

question

fibrin

answer

protein essential to clotting

question

hemostasis

answer

blood clotting or vessel compression

question

phagocytosis

answer

engulfing of microorganisms or foreign particles

question

erythema

answer

redness

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macrophages

answer

monocytes that are phagocytic

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collagen

answer

fibrous structural protein of all connective tissue; it is the main ingredient of scar tissue

question

fibroblasts

answer

cells that synthesize collagen

question

lysis

answer

breakdown

question

contracture

answer

abnormal shortening of muscle tissue

question

keloid

answer

permanent raised, enlarged scar caused by collagen overgrowth

question

adhesions

answer

fibrous bands that hold together tissues that are normally separated; may grow and interfere with function of the internal organs

question

approximate

answer

to close together

question

first intention healing

answer

the way a wound heals by closing

question

second intention healing

answer

the way a wound heals in which it does not approximate, instead, it is left open and fills with scar tissue

question

third intention healing

answer

that way a wound heals that occurs when suturing is delayed and the wound is sutured after granulation tissue has begun to form

question

adipose tissue

answer

fat tissue

question

purulent drainage

answer

drainage containing pus

question

immunocompromised

answer

poorly functioning immune system

question

sanguineous drainage

answer

bloody drainage

question

abscess

answer

an accumulation of pus made up of debris from phagocytosis

question

exudate

answer

fluid accumulation containing cellular debris

question

Staphylococcus aureus

answer

the microorganism most frequently present in wound infections

question

cellulitis

answer

an inflammation of the tissue surrounding the initial wound, with redness and induration

question

fistula

answer

an abnormal passage or communication usually formed between two internal organs or leading from an internal organ to the surface of the body; may result from infection or be present at birth

question

sinus

answer

a fistula leading from a pus-filled cavity to the outside of the body

question

maintain strict asepsis

answer

the best way to prevent wound infection when performing wound care

question

dehiscence

answer

the spontaneous opening of an incision; may involve separation of the layers beneath the skin as well

question

evisceration

answer

the protrusion of an internal organ through the incision

question

vacuum-assisted closure

answer

VAC

question

serosanguineous drainage

answer

drainage containing serum and blood; often a sign of impending dehiscence when this increases

question

sloughing

answer

natural shedding of dead tissue

question

debridement

answer

removal of all foreign or unhealthy tissue from a wound

question

red wounds

answer

wounds that are clean and healthy; protection is the best method of treatment

question

yellow wounds

answer

wounds with a layer of yellow fibrous debris or exudate; needs to be frequently cleaned; should have a dressing that will absorb the drainage and debride the surface mechanically; often become infected

question

black wounds

answer

wounds containing eschar that needs to be debrided

question

sharp debridement

answer

debridement performed when there are signs of cellulitis or sepsis; it is a painful procedure and the wound bleeds afterward; usually performed by surgeon

question

chemical debridement

answer

debridement using Dakin solution or sterile maggots; occasionally used on a wound with necrotic tissue that isn't responding to other treatments

question

enzymatic debridement

answer

debridement in which topical substances are used to break down and liquify the dead tissue; useful for uninfected wounds; often performed by nurses

question

autolytic debridement

answer

debridement that uses the body's enzymes to break down nonviable tissue in the wound; wounds need to be monitored for signs of infection; best used on small, uninfected wounds

question

mechanical debridement

answer

debridement involving the physical removal of wound debris by irrigation, hydrotherapy with a whirlpool bath, or ultrasound mist

question

binders

answer

wide elasticized fabric bands used to (1) decrease tension around a wound or suture line, (2) increase patient comfort, (3) decrease lactation after childbirth, or (4) hold dressings in place

question

vacuum-assisted closure (VAC)

answer

involves applying a suction device to a special wound dressing to institute negative pressure at the wound site, drawing the edges together

question

nonocclusive dressing

answer

dressing always used for infected pressure ulcers

question

approximation

answer

the degree of closure of a wound

question

cold solution

answer

solution that lowers the wound temperature, which slows healing

question

granulation tissue

answer

connective tissue with multiple small vessels

Nursing Fundamentals: Test #7: Wound and Dressing Change – Flashcards

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