Term
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Definition
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Term
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Definition
inner layer of the skin that provides tensile strength and mechanical support
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Term
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Definition
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Term
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Definition
| localized injury to the skin and underlying tissue over a body prominence |
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Term
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Definition
| normal red tones of light-skinned patients are absent |
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Term
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Definition
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Term
| factors that contribute to pressure ulcer development |
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Definition
| pressure intensity, pressure duration, tissue tolerance |
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Term
| idnetify the risk factors that predispose a pt to pressure ulcer formation |
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Definition
- pressure duration
- tissue tolerance
- impaired sensory preception
- impaired mobility
- alteration in level of conciousness
- shear, friction
- moisture
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Term
| staging systems for pressure ulcers are based on the depth of tissue destroyed. breifly describe each stage. |
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Definition
- non blanchable redness of intact skin
- partial thickness skin loss or blister
- full thickness skin loss (fat visible)
- full thickness tissue loss (muscle/bone visible)
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Term
| define: Granulation tissue |
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Definition
| red, moist, composed of new blood vessels |
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Term
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Definition
| soft yellow or white tissue (stringy substance) |
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Term
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Definition
| black or brown necrotic tissue attached to wound. needs to be removed before healing |
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Term
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Definition
| amount, color, consistency and odor of wound drainage |
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Term
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Definition
| clean surgical incision, wound with little tissue loss |
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Term
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Definition
| loss of tissue such as a burn, pressure ulcer, left open until it becomes filled with scar tissue |
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Term
| identify three components involved in the healing process of a partial-thickness wound |
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Definition
a. inflammartory response
b. epithelial proliferation
c. migration and restablishment of tissue layers |
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Term
| what are the four stages of healing process of a partial thickness wound |
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Definition
a. hemostasis
b. inflammatory phase
c. proliferative phase
d. remodeling |
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Term
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Definition
| control blood loss, establish bacterial control and seal the defect injured blood vessels |
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Term
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Definition
damaged tissue and mast cells secrete histamine, vasodialation of surrounding cappilaries
localized redness, edema, warmth and throbbing |
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Term
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Definition
last from 3-24 days filling wound with granulation tissue, contraction of wound and resurfacing
Collagen=strength |
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Term
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Definition
| maturation, sometimes takes longer than a year, scar tissue, collagen remodel and reorgranize |
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Term
| some complications of wound healing |
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Definition
hemorrhage
hematoma
health care associated infection
dihiscence
eviceration |
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Term
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Definition
| extrernally or internally bleeding of a wound site |
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Term
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Definition
| localized collection of blood underneath the tissue. change in color, swelling, sensation |
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Term
| health care associated infection |
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Definition
wound infection is the second most common
partial or total separation of wound layers |
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Term
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Definition
| total separation of wound layers. emergency surgical repair |
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Term
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Definition
| layers of skin and tissue separate. this occurs before collagen formation |
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Term
| the braden scale was developed for assessing pressure ulcer risks. identify the subscales of this tool |
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Definition
sensory perception
moisture
activity
mobility
nutrition
friction and shear |
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Term
list the factors that influence pressure ulcer formation
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Definition
nutrition
tissue perfussion
infection
age
psychological impact of wound |
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Term
| identify emergency setting wounds |
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Definition
abrasion
laceration
puncture |
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Term
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Definition
| superficial with little bleeding and is considered partial thickness wound, often appears weepy due to plasma leakage from capilaries |
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Term
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Definition
| bleeds more perfusely depending on the depth and location of the wound |
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Term
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Definition
| bleed in relation to depth and size of wound. internal bleeding and infection dangers |
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Term
| explain how nurse's assess wound appearance |
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Definition
| edges are closed, surgical incisions should heal by primary intention, 2-3 days edges are inflammed |
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Term
| explain how nurse's assess character of wound drainage |
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Definition
| amount, color and odor, color and consistensy vary, depending on components |
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Term
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Definition
serous: clear
purulent: puss/yellow
serosanguineous: clear and red (blood)
sanguineous: red (bloody) |
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Term
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Definition
| inserts when there is alot of drainage exercise caution when changing dressings |
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Term
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Definition
| staples, sutures, wound closures. first 2-3 days after surgery is edematous |
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Term
| list potential or actual nursing diagnosis r/t impaired skin integrity |
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Definition
risk for infection
imbalanced nutrition
acute or chronic pain
impaired physical mobility
impaired skin integrity
risk for impaired skin
ineffectice peripheral tissue perfusion
impaired tissue integrity |
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Term
| list possible goals to achieve wound improvement |
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Definition
higher percentage of granulation in wound base
no further skin breakdown
increase chloric intake by 10% |
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Term
| identify three major areas of nursing interventions for preventing pressure ulcers |
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Definition
skin care and management of incontinence
mechanical loading and support devices
proper positioning and therapeutic surfaces |
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Term
| list principles to address to maintain a healthy wound environment |
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Definition
prevent and manage infection
clean the wound
remove nonviable tissue
manage exercise
maintain wound in moist environment
protect the wound |
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Term
explain the rationale for debriding a wound
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Definition
| to rid the wound of a source of infection |
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Term
identify four methods of debridement
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Definition
mechanincal
chemical
autolytic
sharp/surgical |
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Term
| types of first aid for wounds |
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Definition
hemostasis
cleansing
protection |
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Term
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Definition
| control bleeding by applying direct pressure, make sure to change dressings |
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Term
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Definition
| appropriate solution and gently clean to avoid further injury |
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Term
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Definition
| apply sterile or clean dressings and immobilizing the body part |
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Term
| what are some purposes of dressings |
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Definition
protects from microorganism contamination
aids in homeostasis
absorbing drainage and debriding wound
supports wound site
protects pt from seeing wound
promotes thermal insulation
moist environment |
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Term
| list clinical guidelines to use when selecting the appropriate dressing |
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Definition
maintain moisture
pressure ulcer
allows drainage
mechanincally debride |
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Term
advantages of transparent film dressing
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Definition
adheres to undamaged skin
barriers to external fluid and bacteria but still allows it to breath
promotes a moist environment
can be removed without damaging underlying tissue
does not require a secondary dressing |
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Term
| list the functions of hydrcolloid dressings |
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Definition
absorbs drainage
maintains wound moisture
slimmy liquid ties to necrotic debris
impermeable to bacteria
self adhesive and molds well
preventive dressing for high risk friction
may be left in place for 3-5 days |
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Term
| list advantages of hydrogel dressing |
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Definition
soothing and can reduce wound pain
provides moist environent
debrides decrotic tissue
does not adhere to wound
base is easy to remove
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Term
| list the guidelines to follow during a dressing change procedure |
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Definition
dressing skin beneath tape
performing hand hygiene
wearing sterile gloves
removing dressings when they are wet |
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Term
| summarize the principles of packing a wound |
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Definition
| assess size, depth, shape, and make sure material is appropriate |
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Term
| breifly describe how the wound vaccum-assisted closure (wound VAC) device works |
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Definition
| negative pressure of a wound through suctuion to a facillitate healing and collect wound fluid |
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Term
| identify three principles that are important when cleaning an incision |
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Definition
clean from least contaminated
use gentle friction
when irrigating allow solution to flow from least to most contaminated |
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