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Flashcards in Skin Integrity & Wound Care Deck (67)
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1

tool used to predict pressure sore risk used in conjuction with nursing judgment...low score= high risk...15-18 low risk, 13-14 moderate risk, 10-12 high risk, <9 very high risk

Braden Scale

2

removal of necrotic tissue

Debridement

3

partial or total separation of layers of skin and tissue above the fascia in a wound that is not healing properly (obese pt at high risk, most common in abdominal wounds post-surgery)...BE ALERT WHEN SEROSANGUINEOUS DRAINAGE INCREASES!

Dehiscence

4

thick layer of dead, dry tissue that covers a pressure ulcer or thermal burn; slough present in stage IV ulcers (may be allowed to naturally remove or may be surgically removed)

Eschar

5

occurs when wound layers separate below the fascial layer and visceral organs protrude through the wound opening...medical emergency requiring placement of sterile towels soacked in sterile saline over the extruding tissues to reduce chances of bacterial invasion & drying before surgery

Evisceration

6

surface damage caused by the skin rubbing against another surface that often results in an abrasion

Friction

7

red, moist tissue consisting of blood vessels and connective tissue

Granulation Tissue

8

softening of the skin caused by moisture

Maceration

9

impaired skin integrity resulting from pressure

Pressure Ulcer

10

force exerted against the skin while the skin remains stationary and the bony structures move

Shearing Force

11

healing that occurs in a wound with little or no tissue loss such as a clean surgical incision; the skin edges approximate and risk for infection is minimal

Primary Intention

12

healing that occurs in wounds involving loss of tissue such as a severe laceration or chronic wound; skin edges cannot come together because of the extensive tissue loss and healing occurs gradually

Secondary Intention

13

healing that occurs when a wound is later brought together some type of closure material; occurs in wounds that are fairly deep and contain extensive draining & tissue debris; "delayed primary healing"

Tertiary Intention

14

sensitive vascular layer of skin directly below the epidermis composed of collagenous and elastic fibrous connective tissues that give it it's strength and elasticity

Dermis

15

16

fluid, cells or other substances that have been slowly discharged from cells or blood vessels through small pores or breaks in cell membranes

Exudate

17

clear, watery plasma drainage

Serous Drainage

18

fresh bleeding drainage

Sanguinous Exudate

19

pale, more watery, combination of plasma and red blood cells, blood-streaked drainage

Serosanguinous Exudate

20

thick, yellow/green/brown drainage indicating presence of dead or living organisms and white blood cells

Purulent Exudate

21

act of forming pus

Suppuration

22

closing together of wound edges in which an injury has been caused on the skin by abrasion

Approximated Excoriation

23

24

occurs when epithelial tissue grows from edges and covers over the granulation (new skin/scar)

Epithelialization

25

abnormal passage from an internal organ to the body surface or between two internal organs

Fistula

26

decreased blood supply to a body part, such as skin tissue, or to an organ, such as the heart

Ischemia

27

the death of tissue in response to disease or injury

Necrosis

28

discoloration of the ski nor bruise caused by leakage of blood into subcutaneous tissues as a result of trauma to underlying tissues

Ecchymosis

29

present in Stage IV ulcers...a narrow canal underneath surface

Tunneling/Undermining

30

abdominal binder used to support large incisions that are vulnerable to stress when the patient moves or coughs

Montgomery Straps