Wounds
Terms
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- Term used to describle impaired skin integrity
- Pressure Ulcers
- When does tissue ischemia occur?
- When capillary blood flow is obstructed
- Is reactive blanching hyperemia good or bad?
- good
- Reactive Blanching Hyperemia
- blood vessels dilate in the area of injry and prevent tissue trauma
- Non-blanching reactive hyperemia
- indicated tissue damage
- Is non-blanching reactive hyperemia good or bad?
- bad
- Shear
- trauma to skin when the skin stays in place, and bones move
- What happens to skin with friction?
- top layer removed, irritated, abrasion
- What are some risk areas for fricton?
- heels and elbows
- What is friction?
- when two surfaces rub together
- What reduces resistance to shear and friction
- moisture
- how much should you increase protein to help promote wound healing?
- 2-4x's
- What can protein deficiency lead too?
- edema
- When do you have a negative nitrogen balance
- nitrogen is excreted from protein breakdown and exceeds protein intake
- What happens when fluids shift from extracellular volume to tissues
- edema
- What are the serum levels when a person has hypoalbuminemia?
- <3g/100mL
- How does tissue increase risk for ischemic injury?
- fever increases metabolic needs of body, creating more hypoxic tissue
- What age group is at the highest risk for skin breakdown?
- older adults
- What are pressure ulcers caused by?
- pressure exerted against skin surfaces
- What factors alter the ability of skin to respond to pressure?
- shear, friction, moisture, nutrition, infection, age
- Stage 1
- observable change in skin, changes temp, sensation, and feeling/consistency
- Stage 2
- partial-thickness skin loss
- What does the ulcer look like in Stage 2?
- superficial
- Stage 3
- full thickness skin loss involving sq tissue
- Does a stage 3 go through fascia?
- no
- Does a stage 3 have necrosis?
- maybe
- Stage 4
- full thickness skin loss with tissue necrosis, damage to bone and muscle
- What can impair the staging of ulcers?
- necrosis
- Two types of healing
- primary intention, secondary intention
- How does a wound heal when doing so by secondary intention?
- granulation
- What happens when bacteria invades a tissue?
- infection
- Dehiscence
- partial or total separation of skin and tissue
- When would dehiscence normally happen?
- 3-11 days PO
- What is evisceration?
- would layers separate below the fascial layer
- Fistula
- abnormal opening between two organs or between organ and outside of the body
- What structures do you assess when assessing for pressure ulcers?
- skin, underlying tissue, muscle
- Name for pressure ulcer scale?
- Braden
- Serous
- clear drainage
- sanguineous
- bloody drainage
- serosanguineous
- bloody streaked, watery drainage
- purulent
- yellow, green think drainage
- Do dressings influence wound healing?
- yes
- Most common type of dressing?
- gause
- wet to dry dressing
- gauze soaked in NS, covered w/dry gauze
- What type of dressing is used to debride wounds?
- wet to dry
- What type of dressing traps moisture over wound bed?
- transparent film
- What used negative pressure to promote healing
- wound vac
- Which type of dressing is a geling agent
- hydrocolloid
- What does a hydrocolloid dressing do?
- protects the wounds from surface contamination
- What type of dressing maintains a moist environment to support healing
- hydrogel
- What dressing is made from seaweed?
- calcium alginate
- What type of dressings are used for heavily draining wounds?
- calcium alginate
- What do you need to know when changing a dressing?
- type, drain placement and equipment needed
- What is the best cleansing agent for cleansing wounds?
- normal saline
- What does irrigation do?
- removes exudate and debris
- What are drainage evacuations?
- portable units that exert constant, low-pressure vacuum to remove and collect drainage
- What is the easiest way treat ulcers?
- prevent them
- what is it called when an area blanches with fingertip pressure?
- reactive blanching hyperemia
- what is it called when an area does not change color when pushed?
- nonblanching reactive hyperemia
- Doing what action might possible cause shear?
- moving a pt up in bed
- What layer of skin is friction injury contained to?
- epidermis
- Cachexia
- generalized ill health and malnutrition
- What is cachexia marked by?
- weakness and emaciation
- In what type of healing do edges of wounds approximate?
- primary intention
- Delayed primary closure
- closure of deep tissue layers and SQ fat and skin are left open
- Two mechanisms of wound healing.
- partial and full thickness repair
- when is Partial thickness repair needed?
- when there is loss of the epidermis and/or part of the dermis
- When is full thickness repair needed?
- loss of epidermis, dermis, and possible sq, bone and muscle
- Type of wound repair that includes resurfacing wound with new epidermal tissue
- partial-thickness
- When does a scab form?
- when exudate that bring WBC's to area drys
- Epidermal repair
- when epidermal cells migrate across wound
- Differentiation
- epidermis thickens, anchors to adjacent cells and resumes normal function
- Inflammation phase
- control of bleeding, clean wound environment
- What causes coagulation and vasoconstriction to stop bleeding?
- platelets
- Phases of full thickness repair?
- inflammation, proliferative, remodeling
- key events in proliferative phase
- make new tissue, epithelialization, contraction
- What forms to provide O2 and nutrients for new tissue and contributes to the synthesis of collagen
- new capillary networks
- Epithelialization
- epithelial cells migrate to cover wound
- Remodeling phase
- production of scar
- How long does the remodeling phase last
- one year
- Hemorrhage
- excessive bleeding
- hemostasis
- cessation of bleeding by vasoconstriction and coagulation
- symptoms of internal bleeding
- hypovolemic shock and swelling
- hematoma
- collection of clotted blood under tissues
- When should you be alert for dehiscence
- serosanguineous drainage
- 6 factors of braden scale
- sensory perception, moisture, activity, mobility, nutrition, friction, shear
- abrasion
- loss of dermis
- laceration
- damage to dermis, and epidermis, torn, jagged wound
- wound culture
- test to see what microbes are in a wound
- How often should skin assessment be done?
- daily
- should you massage reddened areas?
- no
- debridement
- method for removal of necrotic tissue
- maceration
- breakdown of skin from prolonged exposure to moisture
- What technique do you use when changing a dressing?
- aseptic
- What is the most likely anchor to cause skin irritation
- adhesive tape
- What solutions should not be used to clean a wound?
- betadine, hydrogen peroxide, acetic acid
- What part of the would to you begin with when cleaning?
- begin at least contaminated to most contaminated
- drainage evacuator
- protable units that connect to tubular drains that exert a low pressure
- binder
- bandages made of large pieces of material to fit a specific body part
- compress
- piece of gauze dressing moistened in warmed solution
- warm soak
- immersion of body part in warmed solution
- what does a warm soak promote?
- circulation, lessens edema, increases muscle relaxation, can apply medicated solution
- Sitz bath
- bath in which only pelvic area is submerged