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Details

Fundamentals
Skin Integrity and Wound Care
38
Nursing
Undergraduate 3
08/28/2015

Additional Nursing Flashcards

 


 

Cards

Term
dermal-epidermal junction
Definition
separates dermis and epidermis
Term
epidermis
Definition
top layer of skin
Term
dermis
Definition

inner layer of skin

collagen

Term
risk factors for ressure ulcer development
Definition

impaired sensory perception

alterations in levels of conciousness

impaired mobility (cannot shift position)

shear

friction

moisture (incontinence)

Term
shear
Definition
force exerted parallel to skin
Term
stage 1
Definition
intact skin with non-blanchable redness
Term
blanchable
Definition
turns white or pale with applied pressure
Term
erythmia
Definition
redness
Term
stage 2
Definition

partial-thickness skin loss involving epidermis, dermis, or both

(blister or abrasion)

Term
stage 3
Definition

full-thickness tissue loss with visible fat

 

stops before fascia and muscle

Term
stage 4
Definition
full-thickness tissue loss with exposed bone, muscle, or tendon
Term
ischemia
Definition
inadequate blood supply to tissue
Term
primary
Definition

surgical incision, apprximated edges, purposeful

 

heals with sutures, limited scar tissue

Term
secondary
Definition

burn, pressure ulcer, laceration

 

heals with scar tissue, takes longer ot heal

Term
tertiary
Definition
wound kept oen for period of time to take care of infection
Term
full-thickness wound repair
Definition

hemostasis (coagulation)

inflammatory phase (vasodialation and exudation)

proliferative phase (eithelialization)

remodeling (collagen)

Term
serous
Definition
clear, watery plasma
Term
purulent
Definition
thick, yellow, green, tan, or brown
Term
serosanguineous
Definition
pale pink, watery, mixture of clear and red fluid
Term
sanguineous
Definition
bright red, indicates active bleeding
Term
wound debridement
Definition

removal of nonviable, necrotic tissue

 

must have contact with wound bed to treat so neccessary

Term
mechanical debridement
Definition

wet to dry, placing a moist dressing, allow it to dry and tissue to adhere to the gauze then peeling off

 

Term
autolytic debridement
Definition
body's own process of getting rid of dead tissue, assisted with dressing
Term
chemical debridement
Definition
use of enzymatic chemicals
Term
surgical debridement
Definition
surgical removal of dead tissue
Term
eschar
Definition

black or brown necrotic tissue

heels especially

leathery

must be removed

Term
slough
Definition

yellow or white. stringy substance in wound

 

necrotic and needs to be removed

Term
granulation
Definition

red, moist tissue

 

indicates healing

Term
complications of wound healing
Definition

hemorrhage

hematoma

infection

dehiscence (separation of wound layers)

evisceration (protrusions of visceral organs through wound)

Term
dehiscence
Definition

separation of wound layers

 

emergency

Term
evisceration
Definition

protrusion of visceral organs through wound

 

emergency

Term
priority in case of dehiscence or evisceration
Definition

place sterile saline-soaked towels on the area to keep moisturized

 

then call whoever

Term
nutrition influencing wound healing
Definition

1500 kcal/day

Vitamin A & C

Protein

Term
Factors influencing pressure ulcer formation and wound healing
Definition

nutrition

tissue perfusion (O2 saturation)

Infection

Age

Psychosocial impact of wounds

Term
assessment
Definition

skin

pressure ulcers

predictive measures

mobility

nutritional status

body fluids

pain

Term
boggy
Definition

mushy

infection underneath

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