Save
Busy. Please wait.
Log in with Clever
or

show password
Forgot Password?

Don't have an account?  Sign up 
Sign up using Clever
or

Username is available taken
show password


Make sure to remember your password. If you forget it there is no way for StudyStack to send you a reset link. You would need to create a new account.
Your email address is only used to allow you to reset your password. See our Privacy Policy and Terms of Service.


Already a StudyStack user? Log In

Reset Password
Enter the associated with your account, and we'll email you a link to reset your password.
focusNode
Didn't know it?
click below
 
Knew it?
click below
Don't Know
Remaining cards (0)
Know
0:00
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.

  Normal Size     Small Size show me how

3802 #3

Circulation Part 1: Wound Care

QuestionAnswer
The first four out of seven functions of the integumentary system are: 1. protection, barrier 2. insulation 3. receives sensory stimuli 4. controls heat regulation
The last three out of seven functions of the integumentary system are: 5. excretion 6. method of medication administration 7. displays emotions and physical identity
T or F Thinning of dermal layers is not an age related change F- thinning of dermal layers is an age related change
T or F increased elasticity is an age related changes F decreased elasticity is an age related change
T or F decreased sensation is an age related change T
T or F less padding over bony prominences is an age related change True
Four common age related changes include: 1. thinning of dermal layers 2. decreased elasticity 3. decreased sensation 4. less padding over bony prominences
The replacement of lost cells and tissues with cells of the same type tissue regeneration
healing as a result of lost cells being replaced by connective tissue tissue repair
Tissue repair occurs by _____, _____ or _____ intention - primary - secondary - tertiary
A surgical wound heals by _____ intention when the skin edges are approximated, or close, scarring is minimal, and the risk of infection is low primary
A wound involving loss of tissue, such as a burn, pressure ulcer, or severe laceration, heals by ____ intention because the wound is left open until it becomes filled by scar secondary
A surgical incision wound that is sutured or stapled is an example of ____ intention primary
Pressure ulcers and surgical wounds that have tissue loss are examples of ____ intention secondary
T or F nutritional deficiencies delay would healing True
T or F adequate blood supply and corticosteroid drugs are factors that delay would healing False- inadequate blood supply delays would healing
T or F infection delays wound healing True
T or F Poor general health and mechanical friction are factors that delay would healing True
decrease vascularization due to ____ is a factor that delays wound healing obesity
T or F Anemia does not delay wound healing False- anemia delays wound healing
T or F Diabetes mellitus delays wound healing True
Nurtional Therapy to promote wound healing should include: 1. high fluid intake 2. diet high in protein 3. Vitamins A, C, zinc
What should you primarily use to clean a wound normal saline
The following should be assessed on a wound? 1. location 2. size 3. draiange 4. color of wound 5. pain 6. tunneling 7. undermining
pocketing beneath the skin tunneling
breakdown of SQ tissue around the wound undermining
removal of nonviable, necrotic tissue debridement
type of debridement - use of wet to dry dressing; not commonly used because it devitalized and viable tissue are both removed mechanical debridement
type of debridement - uses synthetic dressing over a wound to allow eschar to be self-digested by the action of enzymes that are present in wound infections autolytic debridement
type of debridement - use of topical enzyme prepartion, Dakin's solution, or sterile maggots chemical debridement
type of wound drainge - clear, watery plasma serous
type of wound drainage - thick, yellow, green, tan, or brown purulent
type of wound drainage - pale, red, watery: mixture of clear and red fluid serosanguineous
type of wound drainage - bright red: indicates active bleeding sanguineous
Wound Classification - typically indicates granulation tissue: wound is in the inflammatory or proliferation phase of wound healing; protect the wound and keep in moist Red (pale pink to beefy red)
If a wound is red in color what two phases could it potentially be in? inflammatory or proliferation
Wound Classification - indicates presence of slough (dead but moist tissue); actively generates wound fluid and may need to be debrided; may need treatment of infection yellow (page ivory to various shades of yellow green brown)
Wound Classification - indicates the presence of dead tissue that is dehydrated; may be covered with eschar; the wound cannot be assessed until the eschar is removed; eschar is an excellent medium for facterial proliferation black (black/brown, tan)
Can a wound be assessed with the presence of eschar? NO
Necrotic tissue should always be removed with the exception of what are of the body? heel- debridement could cause infection and lead to osteomylitits
To confirm a wound infection, common diagnostic procedure and test are - swab culture (by nurse) - biopsy (done only by MD)
prior to taking a wound culture, the wound must be cleaned with normal saline
___ is caused by compression of soft tissue between two hard surfaces pressure ulcer
factors that dictate severity of pressure ulcer include: 1. pressure intensity 2. pressure duration 3. tissue intolerance
occlusion of capillary closing pressure is a cause of pressure ulcers
Pressure ulcers causes the tissue to become ischemic and die
T or F decreased mobility and poor nutrition contribute to pressure ulcers True
T or F fecal and urinary continence have no affect on development of pressure ulcers False
Decreased sensory perception can lead to ___ pressure ulcers
Complete or partial arterial blockage may lead to tissue necrosis and / or ulceration - not caused by pressure -ex. PVD - common in feet Arterial Ulcer
_____are wounds that are thought to occur due to improper functioning of valves in the veins usually of the legs and are not caused by pressure. Venous ulcers (or varicose ulcers)
To prevent pressure ulcers, ensure pt avoid pressure of the ____ if pt is on his/her side trochanter
To prevent pressure ulcers, limit what position while patient is in bed? limit the sitting position; limit time HOB is elevated to avoid pressure on sacral area
T or F You should massage areas that are susceptible to pressure ulcers False- this creates shearing and/or friction; two causes of pressure ulcers
While a pt is sitting chair, how often should the nurse shift their weight every 15 minutes
due to high glucose levels and poor circulation, diabetic pts are at increased risk for developing ______ on the feet pressure ulcers
Treatment for Wounds with the following guidlines 5-6 days/wk X 1 month very flammable wear cotton gown Hyperbaric Oxygen Therapy
T or F Stages of Pressure Ulcers can go backwards False
Stage __ Pressure Ulcer and Interventions - skin is intact, but will have nonblanching redness -releive pressure, change mattress, ambulate patient Stage I
Stage __ Pressure Ulcer - affects dermis and epidermis - top layer of skin is broken, shallow - protect skin with dressing Stage II
Stage ___ Pressure Ulcer - wound continues to open and affect SQ Stage III
Stage ___ Pressure Ulcer - wound continues all the way through the fascia and beyond Stage IV
- skin feels spongy in this area of the body when skin begins to break down heel
most common type of debridement is ____; fastest method of heeling surgical
ice is used to vasoconstriction heat is used for vasoconstriction
T or F Tissue regeneration does not cause scarring True
T or F corticosteroids prolong healing process True
Benefits of VAC therapy 1. removes fluids 2. removes infectios materials 3. helps protect the wound environment 4. helps promote perfusion 5. helps draw wound edges together 6. promotes moist wound healing environment
Created by: Black88cat
Popular Nursing sets

 

 



Voices

Use these flashcards to help memorize information. Look at the large card and try to recall what is on the other side. Then click the card to flip it. If you knew the answer, click the green Know box. Otherwise, click the red Don't know box.

When you've placed seven or more cards in the Don't know box, click "retry" to try those cards again.

If you've accidentally put the card in the wrong box, just click on the card to take it out of the box.

You can also use your keyboard to move the cards as follows:

If you are logged in to your account, this website will remember which cards you know and don't know so that they are in the same box the next time you log in.

When you need a break, try one of the other activities listed below the flashcards like Matching, Snowman, or Hungry Bug. Although it may feel like you're playing a game, your brain is still making more connections with the information to help you out.

To see how well you know the information, try the Quiz or Test activity.

Pass complete!
"Know" box contains:
Time elapsed:
Retries:
restart all cards