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Flashcards in Wound Care Intro Deck (60)
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1
Q

Skin function

A
Metabolism
Protection
Thermoregulation
Sensation
Social interaction
Skin immune system
2
Q

Epidermis complete renew

A

Every 3-4 weeks

3
Q

Epidermis layers

A
Stratum consumer
Stratum lucidum
Stratum granulosum 
Stratum spinosum
Stratum basale
4
Q

Key cells in epidermis

A

Keratinocytes
Malnocytes
Langerhans

5
Q

Basement membrane

A

Anchors epidermis to dermis
Laminate lucida and lamina densa
Semipermeable filter which regulates transfers of nutrients and cells b/n dermis and epidermis

6
Q

What layer affected when a blister (bulla) forms

A

Basement membrane

7
Q

Dermis

A

2-4mm
Papillary dermis and reticular dermis
Contains elastin and collagen

8
Q

Dermis contains

A
Hair follicles
Sweat glands
Sebaceous glands
Blood vessels
Lymph vessels
Nerves
9
Q

Key cells in dermis

A

Fibroblast
Lymphocytes
Macrophages
Mast cells

10
Q

Skin pigmentation

A

Effects the appearance of skin damage

11
Q

Primary would closure

A

Immediate

12
Q

Delayed primary wound closure

A

Wound is temporarily left open;
Closed in 4-7 days using sutures
Closure delayed to tx local infection or contamination or to allow edema to reduce

13
Q

Secondary wound closure

A

Closes by new tissue formation w/ subsequent contraction and/or epithelialization

14
Q

Phases of healing

A

Hemostasis (0-3 days)
Inflammation (4-6)
Proliferation (4-24)
Remodeling (3wks to 2 years)

15
Q

Hemostasis

A

Vasoconstriction
Platelet aggregation
Fibrin seals lymph vessels
Migration of leukocytes

16
Q

Inflammation

A

Release of histamine
Neutrophils early
Macrophages late
Phagocytosis

17
Q

Proliferative phase

A
Fibroblast proliferation
Fibroplasia
Angiogenesis
Reorganization of EC matrix
Epithelialization
18
Q

Maturation phase

A

3wks -2 years
Collagenase breaks down inappropriately oriented collagen molecules
New collagen, initially laid down in a chaotic way, becomes oriented along the lines of controls stress; has more tensile strength

19
Q

Scar tissue strength

A

<80% as strong as original tissue

20
Q

Chronic wound inflammation

A
“Dirty”
Cellulitis
Odor
Escobar
Drainage
21
Q

Chronic wound proliferation

A
“Clean”
Granulation
Epithelialization
Contracture
Closure
22
Q

Periwound

A
Blanchable
Callous
Cellulitis
Dermatitis
Edema
Erythema
Infection
Ischemia
Macerated
23
Q

Blanchable

A

Turns white w/ pressure, then color returns

24
Q

Callous

A

Extra layers of skin

Usually due to pressure

25
Q

Cellulitis

A
Inflammation of tissue;
presents with edema,
erythema, pain, and
heat, often with
induration and a
demarcation of the
red area; usually
signifies spreading
infection
26
Q

Dermatitis

A

Inflammation of the skin

27
Q

Edema

A

Increased fluid in interstitial space

28
Q

Erythema

A

Redness; caused by capillary hypermedia

29
Q

Infection

A

Invasion and multiplication of microorganism in body tissue resulting in cellular injury

30
Q

Ischemia

A

Impair blood supply

31
Q

Macerated

A

Softening or sogginess of skin due to retention of excessive moisture; presents as white, moist skin

32
Q

Wound base

A
Abscess
Autolysis
Contraction
Dehiscence
Demarcation
Dermis
Desiccated
Epithelialization
Eschar
Ecchymotic
Enterocutaneous fistula
Friable
Granulation
Hypergranulation
Necrosis
Sinus tract
Slough 
Undermining
33
Q

Abscess

A

Hole or localized collection of purulent fluid; outside closes off and inside fills w/ purulent fluid

34
Q

Autolysis

A

Natural, spontaneous progress of deviatlized tissue being separated from viable tissue

35
Q

Contraction

A

Myofibroblast pulls would edges together, occurs in proliferative phase of wound healing

36
Q

Dehiscence

A

Bursting open of a surgical incision, usually due to infection

37
Q

Demarcation

A

Line b/n viable and non viable tissue

38
Q

Desiccated

A

Dry dead tissue

39
Q

Epithelialization

A

Part of proliferation phase of wound healing;

Characterized by new pink tissue

40
Q

Eschar

A

Necrotic tissue which is tough and leathery or hard

41
Q

Ecchymotic

A

Purple, damaged tissue

42
Q

Enterocutaneous fistula

A

An abnormal connection b/n the intestines and skin

43
Q

Friable

A

Fragile tissue that bleeds easily, used t describe unhealthy granulation tissue

44
Q

Granulation

A

Beefy red tissue comprised of new blood vessels and collagen

45
Q

Hypergranulation

A

Granulation tissue which forms above the level of the surrounding skin, preventing epithelial cells from growing across the wound
May also describe irregular granulation tissue

46
Q

Necrosis

A

Dead tissue

47
Q

Sinus tract

A

A vertical or oblique narrow channel or opening that leads away from the base of the wound and may penetrate the fascia; has potential for abscess

48
Q

Slough

A

Yellow, gray, or green necrotic tissue; may be
viscous or fibrinous and tough; is often strongly
adherent to wound base

49
Q

Undermining

A

Yellow, gray, or green necrotic tissue; may be
viscous or fibrinous and tough; is often strongly
adherent to wound base

50
Q

Exudate

A

Serosanguineous
Serous
Sanguineous
Purulent

51
Q

Serosanguineous exudate

A

Pink/yellow, thin

52
Q

Serous exudate

A

Clear, watery, consistency

53
Q

Sanguineous exudate

A

Bloody, red

54
Q

Purulent exudate

A

Containing pus, opaque, cloudy

55
Q

Autolysis debridement

A

Body’s own enzymes destroy necrotic tissue

56
Q

Enzymatic debridement

A

Enzyme breaks down protein in necrotic tissue;
Used primarily for slough
With eschar, score prior to application

57
Q

Mechanical debridement

A

Nonselective (whirlpool, pulsating lovage, wet to dry dressing, scrubbing)

58
Q

Sharp debridement

A

Use of sharp instruments to debridement

59
Q

Pairing callous

A

Shaving down callous at wound edges and periwound

60
Q

Scoring eschar

A

Cutting perpendicular lines in necrotic tissue w/ sharp instrument to allow moisture to permeate the tissue