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37 Cards in this Set
- Front
- Back
abrasion
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a superficial wound with little bleeding and is considered a partial-thickness wound. May appear weepy.
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Approximated
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the skin edges are closed as in a surgical insicision (no tissue is lost)
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Blanching
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turns light in color. A normal characterists for lightly pigmented skin.
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Debridement
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the removal of nonviable necrotic tissue.
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Mechanical Debridement
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1. use of wet-to-dry saline gauze dressings
2. high pressure irrigation 3. whirlpool |
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Autolytic debridement
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uses synthetic dressings over a wound that allow the necrotic tissue (eschar) to be digested by the body's enzymes. ex.transparent film dressings.
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chemical debridement
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employ the use of topical enzymes to breakdown the necrotic tissue. ex: sterile maggots and Dakin's solution.
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surgical debridement
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surgical removal of necrotic tissue. used when client has cellulitis or sepsis.
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Dehiscence
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the partial or total separation of wound layers.
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Dermis
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the inner layer of the skin it proveds support to the epidermis and protection to the muscles, contains connective tissue and collagen.
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epidermis
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the top layer of the skin
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erythema
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red discoloration of the skin, may indicate circulatory changes
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eschar
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necrotic tissue, usually black or brown in color.
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edema
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swelling
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evisceration
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a protrusion of viseral organs through a wound opening.
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exudate
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describes the amount, color, odor, and consistency of wound drainage.
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granulation tissue
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red moist tissue
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slough
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stringy sbstance attached to wound bed that must be removed before wound can heal.
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friction
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the mechanical force that is created when skin is dragged across a coarse surface.
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Shearing force
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example: The head of the bed is elevated and the sliding of the skeleton starts, but the skin is fixed becuase of friction with the bed.
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Hematoma
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a localized collection of blood underneath the tissues.
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homeostasis
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equilibrium
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ischemia
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an inadequate blood supply to an organ or part of the body. resulting from collapsed capillaries= vessel occluding
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Necrosis
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dead cells
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purulent
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consistingof, containing, or discharging of pus.
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pressure ulcer
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impaired skin integrity related to unrelieved, prolonged pressure.
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Norten Scale
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It scores 5 risk factors for pressure ulcers. total score ranges from 5 to 20.
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Braden Scale
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most commonly used. Composed of 6 sudscales: sensory perc., moisture, mobility, nutrition, friction and shear. A lower score indicates a higher risk.
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Sanguinous
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Bright red wound drainage; indicates active bleeding.
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Serosanguinous
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Pale red, watery: mixture of clear and red fluid.
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Purulent
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Thick, yellow, green, tan or brown.
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Serous
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Clear watery plasma.
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Stage I pressue ulcer
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No open skin areas, does not blanch, compare to adjacent skin; temp., tissue consistancy(firm or boggy), sensation(itching or pain)
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Stage II Pressure Ulcer
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Skin is not intact. There is a partial thickness loss of the epidermis or dermis. Ulcer is superficial
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Stage III Pressure Ulcer
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Skin loss is full thickness. Subcutaneous tissue damage/necrotic. Deep crater-like appearance or eschar present
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Stage IV Pressure Ulcer
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Skin loss is full thickness with extensive destruction, necrosis, or damage to muscle or bone. underming is present. Sinus tracts may develope.
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Undermining
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seperation of the skin layers at the wound margins.
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