Term
|
Definition
protection
thermoregulation
sensation
secretion/excretion
vitamin production
fluid balance |
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Term
| factors that alter skin integrity |
|
Definition
age
sun
hydration
soaps
nutrition
medications
mobility
impaired circulation
diminished sensation/cognition
lifestyle |
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Term
| nursing goals for skin integrity |
|
Definition
assessment (early identification)
prevention
promotion (maintenance and healing) |
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Term
|
Definition
color
temperature
moisture
odor
turgor
vascularity
edema
lesions
texture/thickness |
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Term
| intervention for client with risk for impaired skin integrity |
|
Definition
| turn/reposition, increase mobility, improve nutrition, moisturize/hydrate, maintain hygiene, use a draw sheet, relieve pressure |
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|
Term
| what type of wound is a GSW? |
|
Definition
| avulsion - partial tearing away of the skin and tissue underneath |
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Term
|
Definition
acute: trauma or surgical incision, short duration, heals w/o complication
chronic: healing process impaired - infection/circulation (--> ischemia), pressure/edema, poor nutrition. Diabetes or Peripheral vascular disease |
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|
Term
| Level of contamination: clean (definition) |
|
Definition
| minimal chance of infection |
|
|
Term
| Level of contamination: clean contaminated (definition) |
|
Definition
| wound involving body cavity that normally harbors microbes. No evidence of infection or break in sterile technique |
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|
Term
| Level of contamination: contaminated (definition) |
|
Definition
| break in sterile technique, inflammation w/o purulent drainage, known spillage from GI tract |
|
|
Term
| Level of contamination: dirty (definition) |
|
Definition
| evidence of probably infection prior to surgery |
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Term
| approximated wound: open or closed? |
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Definition
|
|
Term
| Wound healing: primary intention |
|
Definition
| uncomplicated/non-infected wounds. Skin edges approximated using sutures/staples/dermabond. minimal scarring |
|
|
Term
| Wound healing: secondary intention |
|
Definition
| wounds with extensive tissue loss (E.g. pressure injury). Wound will not be approximated |
|
|
Term
| Wound healing: tertiary intention |
|
Definition
| AKA secondary closure - for wounds with extensive drainage or infection. Wound left open, then closed after determining there is no infection |
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|
Term
| 4 steps of wound healing process |
|
Definition
Hemostasis
Inflammatory phase
proliferative/migration phase
remodeling/maturation |
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|
Term
|
Definition
Step 1 in wound healing process
injured vessels constrict, platelets form a clot to stop bleeding, clots form a matrix allowing for cells to repair |
|
|
Term
| Inflammatory Response - which step in healing process? characteristics of inflammation? |
|
Definition
| step 2 in wound healing process (approx 24 hrs) vasodilation - increased perfusion --> erythema/warmth, increased permeability --> edema increased WBC activity |
|
|
Term
Wound healing: proliferation and migration
- which step in the healing process? what's going on? |
|
Definition
| Step 3 new epithelial cells migrate from edges to cover the wound, eventually close epidermal layer. deep wounds: can last several weeks |
|
|
Term
Wound healing: remodeling/maturation
which step? what's going on? |
|
Definition
| Step 4 skin attempts to return to previous normal state, collagen continues to be deposited but in an orderly fashion |
|
|
Term
|
Definition
| both dead necrotic tissue - slough is yellowish/wet and eschar is black/dry |
|
|
Term
| types of closed drainage systems & how do they work |
|
Definition
Jackson-Pratt drain, hemovac drain
suction pulls drainage into closed device |
|
|
Term
|
Definition
| (penrose) - empties directly into a dressing |
|
|
Term
|
Definition
| partial/total separation of wound layers |
|
|
Term
|
Definition
protrusion of viscera through a wound opening
THIS IS AN EMERGENCY. Cover wound with sterile saline-soaked gauze & notify surgeon immediately |
|
|
Term
| What scale is used for evaluating pressure injury risk? |
|
Definition
|
|
Term
|
Definition
stage 1: non-blanchable erythema of intact skin
stage 2: partial-thickness skin loss, dermis is exposed
stage 3: full-thickness skin loss, adipose tissue visible
stage 4: full-thickness skin and tissue loss, muscle/tendon/bone etc visible
Unstageable: obscureed full-thickness skin and tissue loss
Deep tissue pressure injury: non-blanchable, deep red/maroon/purple discoloration or epidermal separation |
|
|
Term
|
Definition
| when you press down on skin, then let go and then blood rushes back in (normal) |
|
|
Term
| what stage of pressure injury is a blister |
|
Definition
|
|
Term
| pressure injury, visible adipose tissue. what stage? |
|
Definition
|
|
Term
| slough/eschar - what stage pressure injury |
|
Definition
|
|
Term
| visible bone/muscle/tendon/cartilage, undermining - what stage pressure injury? |
|
Definition
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|
Term
| purpose of wound cleaning/irrigation? debridement? |
|
Definition
cleaning/irrigation: remove debris from wound bed.
debridement: removal of non-viable tissue to support healing. |
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|
Term
| When would you use foam/calcium alginate dressings? |
|
Definition
| For highly exudative, deep wounds (stage 3 or 4), can be used around drains. Good for keeping wound moist but cant use for dry wounds. |
|
|
Term
| what bacteria are responsible for most cellulitis? cellulitis signs/symptoms? diagnosis? treatment? |
|
Definition
| streptococcus and staph. opportunistic infection. CBC/blood cultures/wound cultures. A/B 5x day |
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|
Term
| dietary solutions for CVA (stroke) patient |
|
Definition
|
|
Term
| difference between standard/polymeric vs elemental/hydrolyzed formulas |
|
Definition
| standard/polymeric: general formula, elemental/hydrolyzed: predigested nutrients |
|
|
Term
| Penicillin and penicillinase-resistant ABs - method and target |
|
Definition
| bactericidal, broad spectrum |
|
|
Term
| cephalospirin ABs - method and target |
|
Definition
| bactericidal, bacteriostatic, broad spectrum |
|
|
Term
| fluoroquinolone ABs - method and target. side effects? |
|
Definition
bactericidal, also massive overuse increased resistant strains of bacteria - staph, strep, enterococci, anthrax, pseudomonas, e-coli, klebsiella, enterobacter
side effects: tendon rupture |
|
|
Term
| purpose of wound cleaning/irrigation? debridement? |
|
Definition
cleaning/irrigation: remove debris from wound bed.
debridement: removal of non-viable tissue to support healing. |
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