Cards

Term Definition

What is Medical asepsis?

Term

Activities which reduce the number, growth, and transmission of pathogens

Definition

What is Surgical asepsis? What is Disinfection?

1) Practices that keep an area or objects free of all microorganisms including spores. 2) Disinfectants- destroy patogens except for spores.

Term

Definition

Define: Epidermis, Stratum corneum, Dermis Subcutaneous

Term Definition

What can help guide you in your description of skin?

location of the skin problem size of the skin problem color of the lesions, or wound. temperature change to the site. odor any drainage/ exudate/ crusts/ erosions/ scales elevation: Raised/ flat/ Smooth distribution: symmetrical vs asymmetrical vs scattered

Term

Definition

What are wet to dry wound dressings usedWet-to-dry moist dressings are used for for? wounds requiring debridement. However,this dressing is a nonselective method of debridement, and exposed healthy tissue in the wound bed may be damaged. This dressing is best used with heavily necrotic, infected wounds. Because granulation tissue is fragile and bleeds easily, damp dressings are less likely to result in tissue damage where old dressings are removed.

Term

Definition

When are transparent wound dressings Transparent dressings are used to manage used? superficial wounds. These dressings are inappropriate for moist surfaces, such as a wound bed or moist periwound skin, because the adhesive is unable to stick to wet skin.
Term Definition

What is a wound V.A.C.?

is a device that assists in wound closure by applying localized negative pressure to draw the edges of a wound together. The use of negative pressure removes fluid from the area surrounding the wound, thus reducing local peripheral edema and improving circulation to the area. In addition, after 3 to 4 days of therapy, bacterial counts in the wound drop.
Definition

Term

WHen would you use a wound V.A.C.? Wound V.A.C. may be used to treat acute and chronic wounds. The schedule for changing wound V.A.C. dressings varies. An infected wound may need a dressing change every 24 hours, whereas a clean wound can be changed 3 times a week.
Term Definition

What's the function of wound cultures? And Review culture reports (if ordered) to why should you review them? identify the presence of pathogenic organisms. Wound cultures reveal the type of organisms causing infection. Sensitivity reports indicate which antibiotics will be effective for the specific microorganism present.
Term Definition

Term

Definition

describe the different drainage?

Serous (clear, watery plasma) Sanguineous (fresh bleeding) Serosanguineous (pale, more watery drainage than sanguineous drainage) Purulent (thick, yellow, green, or

brown drainage)
Term Definition

What are signs and symptoms of a systemic infection?

Fever Chills Excessive thirst Elevated WBCs

Term

Definition

What should you look for when assessing a wound?>

Swelling Opening of wound edges Inflammation Drainage

Then palpate for tenderness along wound edges.

Term Definition

Describe STAGE I ulcer

non-blanching (darker skins don't have noticable blanching) erythema of INTACT skin (hyperemia) or motling (hypoxia to tissue) only EPIDERMIS is affectd
Definition

Term

Describe Stage II ulcer

partial-thickness skin loss involving the EPIDERMIS and DERMIS, can be a blister or abrasion
Definition

Term

Describe Stage III ulcer

full-thickness skin loss involves damage or necrosis of subcutaneous tissue and may extend to facia. (may have eschar-yellow)
Definition

Term

Describe Stage IV Ulcer

full-thickness skin loss occurs w/extensive destruction, necrosis or damage to muscle and may extend to bone. Layers of skin may be black and leathery (eschar) Debridement is required by surgery or chemicals. Often requires reconstructive surgery such as "flap" or faschiotomy)
Definition

Term

What are risk factors for pressure ulcers? immobility, friction, shearing force, poor nutrition, anemia, moisture (incontinence),

infectio-fever, altered mental status, impaired peripheral circulation, decreased sensory perception, decreased physical activity
Term Definition

What's a perfect score on a Braden scale? 20- perfect. 12- high risk for ulcers, 16What # indicated "high risk" what"s the interventions are begun. 6- minimum score minimum score one can achieve? achieved (not good)
Term Definition

What are the processes of wound healing?

1) Primary intention 2) Secondary Intention 3) Tertiary Intention

Term

Definition

What's healing by primary Intention?

Term

edges are well approximated, tightly together, have been sutured by surgeon. RISK: Risk for skin infection ACTUAL: 1) Impaired tissue intergrity, 2) Imparied tissue prefusion, 3) Acute Pain

Definition

What are some nursing diagnoses and Outcomes for Ulcers and skin impairment?

Term

Definition

What kind of drainage is the serum portion of bloos. It's water in appearance, has decreased protein count, seen with mild inflamation?
Term Definition

Serous drainage

What looks like pus and is involved with severe inflammation w/infection, contains leukocytes, liquefied dead cells, dead and living bacteria
Term Definition

Purulent drainage

What drainage involvescapillary damage, large # RBC, severe inflammation: bright red - fresh, dark red - old.
Term Definition

Sanguineous drainage

What drainage is a mixture of serous and some blood tinged, seen with surgical incisions. It appears light red and watery.
Term Definition

Serosanguineous

What are some nursing plans for impaired Maintain skin integrity, collaborate with skin integrity diagnosis or risk for....? health care teams to restore patient skin integrity, (nutritional consult and case manager consult for discharge plan)
Term Definition

What do you look for when doing a wound 1)Size of wound: LxWxD 2) presence of assessement? tunneling 3) Drainage: color, oder, quantity, thickness 4) appearance- of tissue surrounding the wound: color redness (erythema, swelling, perhaps inflamation)
Term Definition

1) What kind of wound are pressure ulcers 1) pressure ulcers are considered "dirty considered to be? wounds" 2) What do you need to do before treating you need to apply standard precautions. 2) one? ou need non sterile gloves to undress wound then don sterile to dress it.
Term Definition

Why does it help to support and position the that increases circulation and can help b/c body part affected by a pressure ulcer? decrease swelling.
Term Definition

What dressings do you need for each stage of ulceration?

1) Stage I: transparent film 2) Stage II: Hydrocolloid, Hydrogel

3) Stage III: polyurethane foam, hydrocolloid, hydrogel, calcium alginate 4) Stage IV: hydrocolloid, hydrogel, gauze roll
Term Definition

What are gauze dressing good for? it's the most common dressing. It absorbes well you can absorbe a lot of exudate. It's also good for packing
Term Definition

What are hydrocolloid dressing good for? they're used in stage II, II, VI wounds. (class note says also stage I - but not sure about that) They come in waffer, powder or paste form. THey cushion wound and provide barrier that is wet and mosit- good for healing. (They also help liquify dead tissue?)
Term Definition

What is hydrogel dressing and what's it stage II, III & IV ulcers. used for wet to moist. used for? It comes in tube and is semi-permeable.
Term Definition

1) When do you use foam dressing? 2) When do you use Alginate dressing?

1) used for full thickness wounds, deeper wounds w/ a lot of drainage. 2) used for a lot of drainage. Made of seaweed. comes in sheets or granuels, changed about 2x a week.

Term

Definition

What are some major points to rememebr keep healthy tissue dry and wound tissue 1) about wound dressing? moist. 2) if using enzymes for debridement, apply ONLY to dead tissue. 3) make sure you secure dressings 4) Place lable on dressing with date, time and initials 5) make sure patient is safe- bed- locks- call bells 6) Document. Document. Document!
Term Definition

When should use use sterile technique vs. Sterile technique when there is an acute

Clean technique?

wound. Sterile tech. is usually ALWAYS used in an acute care setting (hospital) Clean technique when there's a general wound.

Term

Definition

If you want to use an ice pack for cold therapy, do you need a Dr.'s orders?
Term Definition

yes

What is heath therapy? How does it Work? Heat therapy promotes vasodilation, When do you use it? reduces blood viscosity, reduces muscle tension, increases tissue metabolism and capillary permeability. 1) It's good for improving blood flow to body parts delivering nutrients, removing waste products and it keeps blood flowing. 2) Improves delivery of leukocytes and antibodies 3) promotes muscles relaxation and reduces pain from stiffness ans spasms.
Term Definition

What is cold therapy good for/ used for?

It is used for vasoconstriction, local anesthetic, reduces cell metabolism, increases blood coagulation, decreases muscle tension. 1) it prevents edema formation 2) reduces localized pain 3) reduces body tissue oxygen needs 4) promotes blood coagulation 5) reduces pain related to inflamation.

Term

Definition

What is the rebound phenomenon when it It's occurs after the maximum theraputic comes to heal/cold therapy? level is achieved from therapy and the opposite effect begins. It's usually after 20 30 mins.
Term Definition

What should you do in a case of dehiscence?

Position patient so that there is no stress on incision, cover area w/sterile dressing, and

call the doctor.

Term Definition

What should you do in a case of eviceration?

Do not try to put the viscera back, position patient so the incision has no stress, cover w/ sterile saline soaked gauze. Call Dr. STAT.
Definition

Term

What should you look for if you suspectIt may occur early or late in post-op period. possible hemorrhage? Observe patient for:

Blood loss Increase P Decrease B/P Decrease UO

Term

Definition

What is Seconday Intention healing?

Healing for wounds with tissue loss. Examples: burns, pressure ulcers, severe uneven laceration, or infected surgical area. Skin layers are not approximated wound left open until scar tissue or granulated tissue forms. Wet-moist dressings are usually required.

In Secondary healing, there are: More gaping wound edges than Primary More granulation filling wound from the bottom and edges More scar tissue, maybe even keloid formation Sometimes difficult to heal due to complications
Term Definition

What is tertiary or Third Intention Healing?

Healing occurs when a wound is closed at a later time, after the wound surfaces have already started to granulate. This type may be used when wounds are deep or until no more signs of

infection. (combination of secondary followed by primary). There is often a delay between wound and closure of the wound. Greater risk for infection. Late suturing. More scarring.
Term Definition

1) What are the phases of wound healing? 2) What should you expect in each phase of wound healing?
Term

Inflammatory Phase Hemostasis Phagocytosis Regeneration/Proliferative Phase Remodeling Phase Inflammatory Phase Hemostasis Phagocytosis Regeneration/Proliferative Phase Remodeling Phase

Definition

What should you expect in each of wound repair?

Term

Definition

What are the techniques fro wrapping bandages?

1) circular 2) spiral 3) spiral-reverse 4) figure eight 5) recurrent

Term

Definition

What are appropriate dressing for pressure ACTIVITY: Dressings by Ulcer Stage ulcers? Stage I Transparent film Stage II Hydrocolloid, Hydrogel Stage III Polyurethane foam, Hydrocolloid, Hydrogel, Calcium Alginate Stage IV Hydrocolloid, Hydrogel, Gauze

roll Review your Evolve Online Module, and your text and indicate: 1. How each dressing works 2. For which stage is this dressing indicated
Term Definition

Define these skin layers Epidermis Stratum corneum Dermis Subcutaneous

Term Definition

Epidermis Stratum corneum Dermis Subcutaneous

What is a macule?

A macule is a change in the color of the skin. It is flat, if you were to close your eyes and run your fingers over the surface of a purely macular lesion, you could not detect it. A macule greater than 1 cm. may be referred to as a patch.
Definition

Term

What is a papule?

A papule is a solid raised lesion that has distinct borders and is less than 1 cm in diameter. Papules may have a variety of shapes in profile (domed, flat-topped, umbilicated) and may be associated with secondary features such as crusts or scales.
Definition

Term

What is Plaque, Nodule, Wheal?

A plaque is a broad, raised area on the skin. Because it is raised, it can be felt (palpated). By definition, a skin plaque has a greater surface than its elevation above the skin surface: it is broader than it is high
Definition

Term

What's a Skin Wheal?

Wheal: A raised, itchy (pruritic) area of skin that is almost always an overt sign of allergy

Term

Definition

Urticaria?
Term

Urticaria are a kind of skin rash notable for dark red, raised, itchy bumps.
Definition

What's Excoriation?
Term

Excoriations are traumatized or abraded skin caused by scratching or rubbing

Definition

What's Bulla?

More than one bulla, a bulla being a blister more than 5 mm (about 3/16 inch) in diameter with thin walls that is full of fluid. Blisters on the skin are called bullae. Bullae on the pleura (the membrane covering the lung) are also called blebs. In Latin a bulla (plural: bullae) was a "bubble, stud or knob." It referred to any rounded protrusion, particularly one that was hollow or
Definition

Term

What is Petechiae?

Tiny punctate hemorrhages (example on left) less than 2 mm round discrete, dark, red, purple or brown in color. The lesions do not blanch and may be located on skin or mucous membranes; they are seen in thrombocytopenia, endocarditis, sepsis. This may be simply seen with bruising.
Definition

Term

What's Purpura?

Confluent and extensive patch of petechiae and ecchymosis, flat macular hemorrhage. If petechiae larger than 0.5 cm in diameter they are known as purpura. (ecchymosisbruising)
Definition

Term

What is Petechiae?

Tiny punctate hemorrhages (example on left) less than 2 mm round discrete, dark, red, purple or brown in color. The lesions do not blanch and may be located on skin or mucous membranes; they are seen in thrombocytopenia, endocarditis, sepsis. This may be simply seen with bruising.
Definition

Term

What is wound drainage and what is it's function?

Drainage - results as chemical mediators of the inflammatory

response cause vascular changes and exudation of fluid and cells from blood vessels. Function of drainage. o Dilution of toxins produced by bacteria, and dying cells. o Transport leukocytes, plasma proteins, and antibodies to the site. o Remove bacterial toxins, dead cells, and debris away from the site.
Term Definition

What is mottling?

Discoloration of skin in irregular areas, lighter may be associated with hypoxia. (could be different colors)
Definition

Term

What are two wound classifications?

OPEN wound: edges torn apart CLOSED wound: underlying soft tissue and blood vessle damage w/ot edges or epiderms torn. (sutured closed)

Term

Definition

Describe variations in Intentional Wounds:

Clean: Closed surgical wound not entering GI, Rasp., uninfected GU, genital, and/or oropharyngeal cavities. Cleancontaminated: surgery into resp. GU, and alimentary under controlled conditions. Contaminated: major break in aseptic technique, spillage from GI, or incision into infected areas.

Open: surgical incision left open usually due to infected site or nature of surgery, with draining wound.

Closed: part of body being injured by blunt object, a twisted limb, tearing of

visceral organs. Infected - bacterial organisms present in wound > 105 Colonized - containing Microorganisms ( usually multiple but < 105
Term Definition

Name teh different types of drains used for wound drainage.

J.P - (Jackson-Pratt) - Closed suction drainage system Hemovac - Closed suction drainage system JP and Hemovac - closed suction drainage system, empty when 1/2 full JP - compress bulb when spout open then close to cause vacuum. Holds 100-200 ml Hemovac larger than J.P, holds 500 ml similar J.P principles apply

Term

Definition

What are the Signs of infection?

temperature >100.6, redness, swelling, drainage, pain, tachycardia, flushed, and increased WBC. is it local or systemic?
Definition Definition

Term Term

WHen Should you apply heat or cold applications if indicated?

Heat and cold applications are often used for closed wounds such as a sprain. The rule of thumb after a closed wound injury is ice for the 1st 24 hours after an injury and heat thereafter. For open infected wounds, sometimes a warm soak or whirlpool to clean a wound.
Definition

Term

What are Hot and Cold Treatments for Wounds Nursing Implications?

1. Assess equipment for safety 2. Protect skin from extreme temp. Note: pallor, redness, numbness, pain at treated site 3. Maintain patient comfort and safety

4. Record observations 5. Never apply directly to skin (cover equipment) 6. Use cautiously on the debilitated, unconscious, and children 7. Assess skin q 5 - 10 min
Term Definition

What is the concept behind a pressure The skin and SC tissue can tolerate some ulcer? pressure, however, when pressure is > the pressure in the capillary bed, and if the capillaries get closed off and cause hypoxia, the vessels collapse and thrombus forms. If pressure is relieved before that critical point, than circulation is restored through reactive hyperemia. Capillary closing pressure is about 16-37 mm hg. Reactive hyperemia - the body's response of vasodilation to the lack of blood flow to the tissues. If you press on a red area and it blanches, that is a good sign. Reactive hyperemia lasts less than one hour. So if you turn someone and their coccyx area is reddened, it would be hyperemia, but should be gone within an hour.
Term Definition

Where are copies of the Braden Scale and Examples of the Braden Scale and the Norton Scale found? Norton Scale may be found in your Potter & Perry textbook on page 1288-1289.
Term Definition

What's the Braden Scale? How is it scored? Braden Scale - (more commonly used) sensory, moisture, activity, mobility, nutrition, friction and shear A perfect score on either scale is "20"

"12" - high risk for ulcers < "16" - interventions are begun "6" - minimum score achieved
Term Definition

IMPLEMENTATION: What is the treatment for pressue ulcers?

Change positions q 2 hours Provide appropriate nutritional support (vitamins - A, B complex, C, K and minerals, high protein) Frequently reassess wound for healing and for other areas of breakdown Cleaning or Irrigating Dressings (with or without topical agents) Specialty beds (dependent)

Term

Definition

What type dressing goes on which stage of pressure ulcer?

Stage I Transparent film Stage II Hydrocolloid, Hydrogel

Stage III Polyurethane foam, Hydrocolloid, Hydrogel, Calcium Alginate Stage IV Hydrocolloid, Hydrogel, Gauze roll
Term Definition

What are the basic ways of treating theComprehensive treatment of the client using client with a chronic wound such as a the principles of moist wound healing, pressure ulcer? keeping wound bed clean, antibiotic therapy for infections, removal of pressure, and nutritional support to achieve the calories and protein levels needed to get the serum albumin up to a normal range are the basic ways of treating the client with a chronic wound such as a pressure ulcer.
Term Definition

What is SBAR?

The SBAR (Situation-BackgroundAssessment-Recommendation) technique provides a framework for communication

between members of the health care team about a patient's condition. SBAR is an easy-to-remember, concrete mechanism useful for framing any conversation, especially critical ones, requiring a clinicians immediate attention and action. It allows for an easy and focused way to set expectations for what will be communicated and how between members of the team, which is essential for developing teamwork and fostering a culture of patient safety