nursing

Card Set Information

Author:
bpayton
ID:
105352
Filename:
nursing
Updated:
2011-09-30 01:23:02
Tags:
theory test
Folders:

Description:
wound care
Show Answers:

Home > Flashcards > Print Preview

The flashcards below were created by user bpayton on FreezingBlue Flashcards. What would you like to do?


  1. What is the bodys first line of defense?
    intact skin
  2. What are the functions of the skin?
    • 1. to protect
    • 2. regulate body temperature
    • 3. sense organs
  3. what is a wound?
    A disruption of antamonical structure & function that results from pathological processes that can begin internally or externally.
  4. What is a lesion?
    A pathological or traumatic discontinuity of normal tissue or loss of function of a part of wounds, sore, ulcer, tumors, cataracts, and any tissue damage.
  5. What is a Rash?
    any eruption that appears on skin transiently
  6. whats the difference between petechiae and ecchymosis?
    • Petechiae are small hemorrhagic spots on the vein.
    • Ecchymosis is a bruise from superficial bleeding under skin
  7. A scar that forms at the site of an injury or incision and spreads beyond the borders of the original lesion is what?
    Keloid
  8. A chronic skin disorder in which red, scaly plaques with sharply defined borders appear on the body surface is what?
    Psoriasis
  9. Bacteria that enters skin via a cut or break and results in an infection of connective tissue with severe inflammation of dermal and subcutaneous layers causes?
    Celluitis
  10. What is the function of the epidermis?
    Prevents microorganisms, foreign material, and chemicals from penetrating the body.
  11. What are the 3 functions of the dermis?
    • 1.gives structure and felxibility to skin
    • 2.supplies nutrients and removes wastes
    • 3.senses pain, touch, pressure, and temperature
  12. What is the eitology of lesions?
    • injuries
    • pathological changes
    • allergies
    • bites
  13. What are the classifications of wounds?
    • cause (intentional/unintentional)
    • open/closed
    • severity (superficial/deep)
    • cleanliness
    • thickness
    • color
  14. What does it mean for edges to be approximated?
    Edges are right next to each other. So that new tissue can grow and connect tissue w/ minimal scarring.
  15. What is the difference between intentional and unintentional?
    • intentional= is caused by surgical procedure or treatment. Can be clean/sterile. edges are approximated
    • unintentional= is caused by accidental injuries or trauma, animal bites, violence, adverse effects. Can be dirty/unsterile. Edges are not approximated
  16. What is the difference between open and closed wounds?
    • open=disruption or break in the skin
    • closed=no disruption or break in skin
  17. What is the difference between superficial and deep wounds?
    • superficial=wounds on the surface layer of the skin
    • deep=wounds that are deepto the layers of the skin or deep within the body cavity peneterating internal organs
  18. Whats the difference between clean and dirty wounds?
    • clean=a surgical incision wound is free of infectious organisms
    • dirty=a trauma wound a with microorganisms
  19. Whats the difference between partial thick and full thickness in a wound with burn injuries?
    • Partial thickness= extend through the epidermis and into, but not through the dermis.
    • Full thickness= extend through the epidermis and dermis and subcutaneous tissue, muscle, and bone
  20. What does EXUDATE means in regards to wound drainage?
    Fluid and blood cells that have escaped from blood vessels during the inflammatory response and remain in the surrounding tissues.
  21. What are the 3 phases of the wound healing?
    • 1.inflammatory includes hemostasis
    • 2.proliferative
    • 3.maturation
  22. Explain hemostasis in the 1st phase of wound healing?
    Occurs within minutes of injury. Controls bleeding. Formation of clot which forms a fibrin matrix that serves as a structure for cellular repair.
  23. What are the signs of inflammation?
    • pain
    • heat
    • edema
    • erythema
    • and loss of function (b/cuz of excessive edema)
  24. Explain the inflammation phase.
    Occurs within 3-4 days. This is normal for wound healing. Initial clean up crew.
  25. Explain the proliferative phase.
    Last 4-21 days. Collagen fills the wound bed, new blood vessels develop, granulation tissue is formed, wound looks bright red
  26. Explain the maturation phase?
    Occurs by 3-4 weeks. Scar may not achieve maximum strength up to 2 years. Tissue is always at risk.
  27. What are the types of wound healing?
    • Primary intention=minimal tissue loss. edges approximated by staples, sutures, steri-strips. Occurs in first 14 days. Lower risk of infection
    • secondary intention=extensive wound. edges not approximated. Greater tissue loss. Higher risk for infection. Prolonged healing and a large scar.
    • teritary intention=Occurs in wounds that may be contaminated, infected, are left open 3-5 days to allow edema or infection to resolve.
  28. What factors impair wound healing?
    • impaired tissue circulation
    • impaired immune response
    • prolonged inflammatory response
    • impaired cellular proliferation & collagen synthesis
    • Aging
    • Chronic stress
    • Nutritional deficiencies
  29. What is a pressure ulcer?
    Any lesion caused by unrelieved pressure that results in ischemia and tissue damage of underlying tissue
  30. What causes a pressure ulcer?
    devlope when soft tissue is compressed between a part of the body and a external surface (bed or floor).
  31. How many stages are there for pressure ulcers?
    4 stages
  32. Name some of the common sites for pressure ulcer.
    back of head, ears, back, heels, saccral, forearms, etc
  33. Patient with localizied, non-blanchable redness, intact skin, color and/or temperature different from rest of the body ulcer. Which stage is this ulcer in?
    Stage I
  34. Patient with a blister, partial thickness loss of the epidermis and dermis. With no slough or eschar on ulcer. Which stage is this ulcer in?
    Stage II
  35. Patient has a ulcer that has full thickness

What would you like to do?

Home > Flashcards > Print Preview