Fundamentals of Nursing: Foundations: Fundamentals of Nursing, Chapter 48 Skin Integrity and Wound Care Flashcards

Excessive vasodilation and induration, skin is bright pink to red, no blanching with fingertip pressure, can last 1 hour to 2 weeks, stage I pressure ulcer;

Superficial wound with little bleeding, considered a partial-thickness wound. Often appears "weepy" because of plasma leaking from damaged capillaries;

Closed;

When normal red tones of light skinned patients are absent as when pressing a patient's fingertips to test capillary refill - blanching of the skin does not occur in darkly pigmented skin;

A tough fibrous protein;

Skin that remains unchanged (does not blanch) when pressure is applied on a bony prominence;

Removal of nonviable, necrotic tissue;

Partial or total separation of wound layers - this happens when wounds fail to heal properly - occurs before collagen formation;

Convenient, portable units that connect to tubular drains lying down within a wound bed and exert a safe, constant, low-pressure vacuum to remove and collect drainage;

The natural act of healing by secondary intention, the proliferation, or rapid reproduction, of new epithelium into an area devoid of it but that naturally is covered by it;

Black or brown necrotic tissue - has to be removed before healing can occur;

Protrusion of visceral organs through a wound opening;

Amount, color, consistency, and odor of wound drainage;

Provides a framework for cellular repair. Protein involved in the clotting of blood form a "mesh" that forms a hemostatic plug or clot in conjunction with platelets over a wound site;

Abnormal passage between two organs or between an organ and the outside of the body - caused by diseases, radiation, and trauma that prevents tissue layers from closing properly allowing a fistula tract to form. Increase risk of infection and fluid and electrolyte imbalances from fluid loss. Chronic drainage of fluids through a fistula all predispose a person to skin breakdown.;

Occurs when skin is dragged across a coarse surface, such as bed linens, usually affecting the top layer of epidermis of skin.;

Red, moist tissue composed of new blood vessels which indicated progression toward healing;

Localized collection of blood underneath the tissues;

Bleeding from a wound site;

Injured blood vessel constrict and platelets gather to stop bleeding;

Abnormal firmness or hardness of tissue with margins as a result of edema or inflammation;

A break or opening in the skin that may be smooth or jagged. Bleed more depending on location and depth.;

Redness-localized vasodilation, blanching with fingertip pressure; lasts less than 1 hour;

Impaired skin integrity related to unrelieved prolonged pressure;

Wound healing with skin edges that are approximated, or closed, risk of infection is low, healing occurs quickly with minimal scar formation as long as infection and secondary breakdown is prevented; similar to a surgical wound;

Caused by an object piercing the skin and creating a hole, bleeding determined by depth and size, primary dangers are internal bleeding and infection;

Thick, yellow, green, tan or brown pus or drainage;

Bright red which indicates active bleeding;

Wound is left open until it fills with scar tissue, wound healing takes longer and chance of infection is greater. If scarring s severe often a permanent loss of tissue function occurs, usually burns, pressure ulcers, or severe lacerations;

Pale, red, watery; mixture of clear and red fluid;

Clear, watery, plasma;

Force exerted parallel to skin resulting from both gravity pushing down on the body and resistance, or friction, between the client and a surface. Example: when the head of the bed is elevated and the sliding of the skeleton starts but the skin is fixed because of friction with the bed.;

String substance attached to a wound bed - has to be removed before wound can heal properly;

Threads or metal used to sew body tissues together;

When living tissue is deprived of oxygen - depriving tissue of adequate blood flow is the same as depriving tissue of oxygen;

Device that assists in wound closure by applying localized negative pressure to draw the edges of a wound together;

Disruption of the integrity and function of tissues in the body;

The shrinkage and spontaneous closure of open skin wounds. Begins almost concurrently with collagen synthesis centripetal movement of wound edges that facilitates closure of a wound, maximal 5 - 15 days after injury;

Excessive vasodilation and induration, skin is bright pink to red, no blanching with fingertip pressure, can last 1 hour to 2 weeks; stage I pressure ulcer;

Superficial wound with little bleeding, considered a partial-thickness wound. Often appears "weepy" because of plasma leaking from damaged capillaries;

Closed;

When normal red tones of light skinned patients are absent as when pressing a patient's fingertips to test capillary refill - blanching of the skin does not occur in darkly pigmented skin;

A tough fibrous protein;

Skin that remains unchanged (does not blanch) when pressure is applied on a bony prominence;

Removal of nonviable, necrotic tissue;

Partial or total separation of wound layers - this happens when wounds fail to heal properly - occurs before collagen formation;

Convenient, portable units that connect to tubular drains lying down within a wound bed and exert a safe, constant, low-pressure vacuum to remove and collect drainage;

The natural act of healing by secondary intention, the proliferation, or rapid reproduction, of new epithelium into an area devoid of it but that naturally is covered by it;

Black or brown necrotic tissue - has to be removed before healing can occur;

Protrusion of visceral organs through a wound opening;

Amount, color, consistency, and odor of wound drainage;

Provides a framework for cellular repair. Protein involved in the clotting of blood form a "mesh" that forms a hemostatic plug or clot in conjunction with platelets over a wound site;

Abnormal passage between two organs or between an organ and the outside of the body - caused by diseases, radiation, and trauma that prevents tissue layers from closing properly allowing a fistula tract to form. Increase risk of infection and fluid and electrolyte imbalances from fluid loss. Chronic drainage of fluids through a fistula all predispose a person to skin breakdown.;

Occurs when skin is dragged across a coarse surface, such as bed linens, usually affecting the top layer of epidermis of skin.;

Red, moist tissue composed of new blood vessels which indicated progression toward healing;

Localized collection of blood underneath the tissues;

Bleeding from a wound site;

Injured blood vessel constrict and platelets gather to stop bleeding;

Abnormal firmness or hardness of tissue with margins as a result of edema or inflammation;

A break or opening in the skin that may be smooth or jagged. Bleed more depending on location and depth.;

Redness-localized vasodilation, blanching with fingertip pressure; lasts less than 1 hour;

Impaired skin integrity related to unrelieved prolonged pressure;

Wound healing with skin edges that are approximated, or closed, risk of infection is low, healing occurs quickly with minimal scar formation as long as infection and secondary breakdown is prevented, similar to a surgical wound;

Caused by an object piercing the skin and creating a hole, bleeding determined by depth and size, primary dangers are internal bleeding and infection;

Thick, yellow, green, tan or brown pus or drainage;

Bright red which indicates active bleeding;

Wound is left open until it fills with scar tissue, wound healing takes longer and chance of infection is greater. If scarring s severe often a permanent loss of tissue function occurs; usually burns, pressure ulcers, or severe lacerations;

Pale, red, watery, mixture of clear and red fluid;

Clear, watery, plasma;

Force exerted parallel to skin resulting from both gravity pushing down on the body and resistance, or friction, between the client and a surface. Example: when the head of the bed is elevated and the sliding of the skeleton starts but the skin is fixed because of friction with the bed.;

String substance attached to a wound bed - has to be removed before wound can heal properly;

Threads or metal used to sew body tissues together;

When living tissue is deprived of oxygen - depriving tissue of adequate blood flow is the same as depriving tissue of oxygen;

Device that assists in wound closure by applying localized negative pressure to draw the edges of a wound together;

Disruption of the integrity and function of tissues in the body;

The shrinkage and spontaneous closure of open skin wounds. Begins almost concurrently with collagen synthesis centripetal movement of wound edges that facilitates closure of a wound, maximal 5 - 15 days after injury;