TERMINOLOGY
The primary function of the skin
What is protection
A disruption in the normal skin integrity
What is a WOUND
The stage of wound healing where the wound contracts, granulation tissue is evident, epithelization occurs (faster when wound is kept hydrated)
What is PROLIFERATIVE
The best nursing intervention to prevent pressure injuries.
Reposition the patient/remove the pressure
Soft, moist, devitalized (necrotic) tissue that may be white, yellow or tan. The nurse would document this as ________________
What is SLOUGH
TISSUE SOFTENED BY PROLONGED WETTING OR SOAKING.
What is MACERATION
3 clinical manifestations of an infected wound
Bright red, warm to touch, purulent drainage
Phase of wound healing where swelling, warmth, pain and redness are most evident
*problematic if this stage is prolonged
What is INFLAMMATORY
Partial-thickness loss of dermis; open but shallow with no slough evident.
What is a STAGE 2 PRESSURE ULCER
Accurate measurement of a patient's immediate protein stores is reflected in ____________________
What is PREALBUMIN
Comprised of connective and adipose tissue it provides insulation, protection and a reserve of calories in the event of malnutrition.
What is subcutaneous tissue
Erosion of the skin by mechanical means (define)
What is EXCORIATION
The base of the wound is predominately obscured by slough or eschar.
What is UNSTAGEABLE PRESSURE INJURY
The purpose of obtaining a wound culture
What is to determine what antibiotic the organism is sensitive to and resistant to
AN ABDOMINAL SUTURED WOUND RUPTURED (define)
What is DEHISCENCE
"I CUT MY LEG ON A PIECE OF SHARP METAL." The nurse would document ___________________ as the objective finding?
What is LACERATION.
A PATIENT SMOKES 3 PACKS A DAY AND IS DIABETIC WITH HISTORY OF RENAL FAILURE.
What is INHIBITS WOUND HEALING
Part of the Braden Scale missing:
sensory/perception, moisture, activity, mobility, friction/shear
What is NUTRITION
A wet-to-dry dressing is a form of __________________ debridement
What is MECHANICAL
TISSUE SURFACES THAT HAVE BEEN CLOSED WITH SURGICAL GLUE ARE CONSIDERED TO BE _______ ______ HEALING
What is PRIMARY INTENTION
When bacteria are present, increase in number but do NOT cause harm to the body
What is COLONIZATION
A type of medication that can prolong wound healing
corticosteroids
Localized area of intact skin with nonblanchable redness, usually over a bony prominence
What is STAGE I
Removing necrotic tissue to promote healing
What is debridement