Untitled Flashcards Set

Hydrocolloid dressing

A dressing that creates a moist environment, promoting healing and protecting new tissue.

Calcium alginate dressing

Primary dressing used in wet to dry stage 3-4 wounds.

Stage 1 wound

Nonflamed skin, where the skin is intact.

Stage 2 wound

Skin barriers are broken, affecting the epidermis or dermis.

Stage 3 wound

Full thickness wound with no bone exposure, reaching the fat layer (subcutaneous tissue).

Stage 4 wound

Full thickness wound with exposure of bone and muscle, often with undermining or tunneling.

Serous drainage

Clear, watery plasma drainage from a wound.

Purulent drainage

Thick, pus-filled drainage, which can be yellow, green, tan, or brown.

Sanguineous drainage

Bloody liquid drainage that is bright red.

Seri-sanguineous drainage

A combination of serous and sanguineous drainage that appears pale red.

Inflammatory stage of healing

The initial stage of healing where the body's response to injury takes place.

Primary intention healing

Healing that occurs when a surgical wound is closed parallel and heals without complications.

Secondary intention healing

Deep wound healing that occurs from the bottom up.

Risk factors for pressure ulcers

Includes moisture, aging skin, chronic illnesses, immobility, malnutrition, incontinence, altered consciousness, and friction.

Ostomy care step

Clean the skin and stoma with soapy water and replace the adhesive, ensuring it is 1/8” larger than the stoma.

Tamponade during evisceration

Keeping organs moist and packed back inside the body cavity.

Keep head of bed

Less than 30 degrees unless medically contraindicated for skin integrity.

Enema insertion technique

Position in Sims position and hold the enema bag at 12-15 inches.

Interventions to maintain skin integrity

Reposition every 1-2 hours, inspect skin every shift, suspend heels off the bed, and use barrier cream.

Teaching for clients with constipation

Increase fiber intake, avoid eggs and dairy, and ensure adequate hydration.