Term
| Functions of the skin are? |
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Definition
| Protection, sensation, temp regulation,Excretion & secretions |
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Term
| What are Skin changes with aging? |
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Definition
*Loss of elastic fibers causes skin to wrinkle and sag
*Skin becomes thinner, fragile, and slower to heal
*Decreased sebaceous activity leaves skin dry and itchy; temperature control is altered by decreased sebaceous gland activity and thinner skin
*Hair becomes thinner, grows more slowly, and loses its color from loss of melanocytes |
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Term
| How often is mouth care for the unconscious done? |
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Definition
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Term
local interference with circulation
(Skin blanches or becomes pale) skin become Necrotic. What are these called?? |
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Definition
| Skin, pressure, Decubitus ulcers |
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Term
| Name some ulcer Risk Factors.... |
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Definition
Immobility
Incontinence
Diaphoresis
Inadequate nutrition
Lowered mental awareness
Excessive diaphoresis
Extreme age
Edema |
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Term
| Scale for predicting pressure sore risk |
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Definition
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Term
| low scores on the Braden scale means what? |
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Definition
| High risk for Pressure ulcers |
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Term
| Pressure points in supine position are? |
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Definition
Sacrum and coccyx
occiput
Dorsal thoracic area
rim of ear
elbow
heel |
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Term
| Pressure points in side lying position are? |
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Definition
Side of head
shoulder
anterior knee
Malleolus
Trochanter
Perineum |
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Term
| Pressure points in Sitting in wheel chair are? |
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Definition
Shoulder blade
Sacrum/Coccyx
Ischial Tuberosity |
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Term
| Name and describe Stages of pressure ulcers.... |
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Definition
Stage I: area of reddened skin that does not blanch when touched
Discoloration in people with dark skin; warmth, edema, or induration (area feels hard)
Stage II: partial-thickness skin loss
May look like an abrasion, blister, or shallow crater; surrounding skin may feel warmer
Stage III: full-thickness skin loss
Looks like a deep crater; may extend into the fascia; subcutaneous tissue damaged or necrotic
Stage IV: full-thickness skin loss
Extensive tissue necrosis or damage to muscle or supporting structures; may appear dry and black |
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Term
T/F
Always run reddened skin and over bony Prominence |
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Definition
| F. Do NOT massage reddened skin or over a bony prominence |
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Term
| Pt. with newly placed indwelling cath. is hospitalize. To prevent Nosocomial infections the nurse should do what? |
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Definition
| Freq. cleaning of perineal area and proper cath. care |
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Term
| What should be included in diabetic foot care? |
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Definition
| Daily foot inspection, Wash with warm water and dry thoroughly,Use moisturizer, and always check shoes for for foreign objects b/c of decreased sensation to provide safety. |
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Term
| If a pt. is exhausted today after her morning routine. what would you as a nurse plan to do for the next day's morning care? |
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Definition
| plan for additional time for several rest periods |
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Term
What type of wound?
Contusion (bruise)
Hematoma
Sprain |
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Definition
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Term
What type of wound?
Incision
Laceration
Abrasion
Puncture
Penetrating
Avulsion
Ulceration |
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Definition
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Term
Superficial wounds
Heal more quickly by producing new skin cells
Fibrin clot forms framework for growing new cells |
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Definition
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Term
No dermal layer present except at margins of wounds
All necrotic tissue must be removed
Wound heals by contraction |
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Definition
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Term
| 3 stages of wound healing are?? |
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Definition
1. Inflammatory phase
2. Proliferation or reconstruction phase
3. Maturation or remodeling phase |
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Term
Begins immediately and lasts 1 to 4 days
Swelling or edema of the injured part
Erythema (redness) resulting from the increased blood supply
Heat or increased temperature at the site
Pain stemming from pressure on nerve receptors
A possible loss of function resulting from all these changes |
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Definition
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Term
Begins on 3rd or 4th day; lasts 2 to 3 weeks
Macrophages continue to clear the wound of debris, stimulating fibroblasts, which synthesize collagen
New capillary networks formed to provide oxygen and nutrients to support the collagen and for further synthesis of granulation tissue
Tissue is deep pink
A full-thickness wound begins to close by contraction as new tissue is grown
Scarring influenced by degree of stress o |
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Definition
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Term
Final phase begins about 3 weeks after injury
May take up to 2 years
Collagen is lysed (broken down) and resynthesized by the macrophages, producing strong scar tissue
Scar maturation, or remodeling
Scar tissue slowly thins and becomes paler |
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Definition
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Term
First intention
A wound with little tissue loss
Edges of the wound approximate, and only a slight chance of infection
Second intention
A wound with tissue loss
Edges of wound do not approximate; wound is left open and fills with scar tissue
Third intention
Occurs when there is delayed suturing of a wound
Wounds sutured after granulation tissue begins to form |
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Definition
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Term
| Factors affecting wound healing.... |
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Definition
Age
Children and adults heal more quickly than the elderly
Peripheral vascular disease
Impaired blood flow
Decreased immune system function
Antibodies and monocytes necessary for wound healing
Reduced liver function
Impairs the synthesis of blood factors
Decreased lung function
Reduces oxygen needed to synthesize collagen and new epithelium
Nutrition
Proteins, carbohydrates, lipids, vitamins, and minerals needed for proper wound healing
Lifestyle
The person who does not smoke and who exercises regularly will heal more quicklyDecreased lung function
Reduces oxygen needed to synthesize collagen and new epithelium
Nutrition
Proteins, carbohydrates, lipids, vitamins, and minerals needed for proper wound healing
Lifestyle
The person who does not smoke and who exercises regularly will heal more quicklyDecreased lung function
Reduces oxygen needed to synthesize collagen and new epithelium
Nutrition
Proteins, carbohydrates, lipids, vitamins, and minerals needed for proper wound healing
Lifestyle
The person who does not smoke and who exercises regularly will heal more quicklyMedications
Steroids and other anti-inflammatories, heparin, and antineoplastic agents interfere with the healing process
Infection
Wound infections slow the healing process
Bacterial infections often cause wound drainage and should be assessed for color, consistency, and odor
Chronic illnesses
Diabetes, cardiovascular disease, or immune system disorders may slow wound healing |
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Term
| Signs and symptoms of hemorrhage are?? |
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Definition
| Decreased BP; increased pulse rate; increased respirations; restlessness; diaphoresis; cold, clammy skin |
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Term
Wound Complications:
Inflammation of tissue surrounding the
wound, characterized by redness and induration |
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Definition
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Term
Inflammation of tissue surrounding the Wound Complications:
wound, characterized by redness and induration created from infection is called? |
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Definition
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Term
Wound Complications:
A canal or passageway leading to an abscess |
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Definition
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Term
The spontaneous opening of an incision
A sign of impending dehiscence may be an increased flow of serosanguineous drainage |
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Definition
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Term
Protrusion of an internal organ through an incision
What do you do once this happens? |
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Definition
Evisceration
Lay pt. on their back and cover organ with sterile wet dressing
(Sterile saline or n/s) |
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Term
| Removing necrotic tissue from a wound so that healing can occur... this is called what?? |
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Definition
Débridement
performed with scissors and forceps
enzymatic, in which an enzyme is used to liquefy dead tissue or Mechanical débridement uses wet-to-dry dressings or whirlpool treatments |
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Term
| Drainage system that looks like an accordion |
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Definition
| Hemovac-type drainage system (Active) |
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Term
| Drainage system that looks like a Bomb |
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Definition
| Jackson-Pratt–type drainage device (Active) |
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Term
| Wound dranage system that works by passively. Tube w/ safety pin. |
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Definition
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Term
| Woulds should be cleaned with what?? |
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Definition
| Warmed Isotonic solution....N/S or Lactated Ringer |
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Term
| how often should a dressing be inspected? |
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Definition
| every 8hrs or at least once a shift |
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Term
| Wound drainage amount should be recorded where? |
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Definition
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Term
Wound drainage:
Watery and clear or slightly yellow |
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Definition
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Term
Wound drainage:
Watery and appears pink streaked or tinged |
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Definition
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Term
Wound drainage:
Serum is thick and appears bright red |
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Definition
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