Ch 32 Wound Care Concepts

Question 1

Functions of the Skin

Answer 1

protection, temp regulation, psychosocial sensation, vitamin D production, immunologic, absorption and elimination

Question 2

Factors Affecting Skin Integrity

Answer 2

integrity, resistance to injury (age, amount of underlying tissues, and illness conditions). adequately nourished and hydrated body cells, and adequate circulation

Question 3

Developmental condiderations

Answer 3

Children younger than 2 (skin is thinner and weaker)
Infants skin and mucous membranes are easily injured and infected, childs skin becomes increasingly resistant to injury and infection, structure of skin changes as age. (older adults thin, easily damaged skin)

Question 4

State of Health Affecting Skin

Answer 4

very thin and obese people tend to be more susceptible, fluid loss through fever, vomiting and diarrhea, excessive moisture, jaundice, and diseases of the skin.

Question 5

wound classification

Answer 5

1. partial thickness
2. full thickness
3. unstageable

Question 6

Wound Repair

Answer 6

1. primary intention (well approximated, minimal tissue loss)
2. secondary intention (not well approximated edges, large open wounds (burns or major trauma) require more time and tissue replacement, commonly contaminated, more scar tissue)
3. Tertiary intention (delayed primary closure)- wounds that are left open for several days to allow edema or infection to resolve or drain, and then are closed.

Question 7

Vitamins Necessary for wound healing

Answer 7

A- for collagen and epithelialization
B- cofactor of enzyme reactions for healing
C- collagen synthesis, capilary formation, and resistance to infection.
K- synthesis of prothrombin
Zinc, copper, iron assist in collagen synthesis.
Manganese- enzyme activator

Question 8

Phases of Wound healing:

Answer 8

hemostasis, inflammation, proliferation , and maturation

Question 9

Hemostasis phase:

Answer 9

immediately after initial injury. blood vessels constrict, blood clotting begins. capillary permeability increases, forming exudate. swelling and pain. heat and redness.

Question 10

Inflammatory Phase:

Answer 10

2-3 days. WBC (leukocytes and macrophages) move to the wound. leukocytes ingest bacteria and debris. macrophages are essential. they release growth factor necessary for the growth of epithelial cells and new blood vessels. attracts fibroblasts to help fill in the wound.

Question 11

Proliferation Phase

Answer 11

fibroblastic, regenerative, or connective tissue phase. several weeks. new tissue is built. capillaries grow across the wound, fibroblasts form fibrin that stretches through the clot. new tissue (granulation tissue) forms the foundation for scar tissue. highly vascular, red and bleeds easily. nutrition, oxygenation, and prevention of strain on the suture line is highly important

Question 12

Maturation Phase

Answer 12

begins abt 3 weeks after injury. collagen that was deposited is remodeled, making the healed wound stronger and more like adjacent tissue. the scar is formed, strength is less than normal tissue and never fully restored.

Question 13

Factors affecting wound healing

Answer 13

Local factors, pressure, desiccation, maceration, trauma, edema, infection, , excessive bleeding, necrosis , biofilm.
Systemic Factors: age, circulation and oxygenation, nutritional status, wound etiology, medications and health status, immunosuppression, adherence to treatment plan,

Question 14

Necrotic Tissue

Answer 14

Appears:
slough: moist, yellow, stringy
Eschar: dry, black, leathery tissue

Question 15

Wound Complications

Answer 15

1. Infection
2. Hemorrhage
3. dehiscence
4. evisceration
5. fistula

Question 16

Factors in Pressure Injury Development

Answer 16

External pressure that compresses blood vessels, and friction and shearing forces that tear and injure blood vessels and abrade the top layer of skin

Question 17

risks for Pressure injury development

Answer 17

immobility, nutrition and hydration, skin moisture, mental status, and age , poor skin hygiene, diabetes mellitus, diminished sensory perception, fractures, history of corticosteroid therapy, immunosuppression, increased body temperature, microvascular dysfunction, multiple organ dysfunction syndrome, previous pressure injuries, significant obesity or thinness, terminal illness/end of life/dying process,

Question 18

Staging Pressure Injuries

Answer 18

Stage 1: visible blanching , area may be painful, firm, soft, warner, or cooler to adjacent
Stage 2: partial thickness loss of dermis and presents as a shallow, open ulcer or a ruptured/intact serum-filled blister
Stage3: full thickness tissue loss. subC tissue may be visible, and epibole may occur. slough and/or eschar may be present do not obscure the depth of tissue loss. may include undermining and tunneling.
Stage 4: full thickness loss with exposed or palpable bone, cartilage, tendon, fascia, muscle. slough or eschar may be presend, epibole, undermining and or tunneling often occur.
Unstageable: unable to visualize the extent of damage due to slough or eschar.
Suspected deep tissue injury: persistent, nonblanchable purple or maroon discoloration of intact or nonintact skin, or separation of the epidermis that revels a dark wound bed or blood filled blister. painful, firm, mushy, boggy, warmer, or cooler. from intense or prolonged pressure and shearing.

Question 19

Physiologic Effects of Wounds and Pressure Injuries

Answer 19

pain, anxiety and fear, activities of daily living, changes in body image,

Question 20

Focussed Assessment of the skin

Answer 20

the appearance, recent changes, activity/mobility, nutrition, pain, elimination

Question 21

Wound Assessment

Answer 21

sight and smell, appearance, drainage, odor, and pain.

identify barriers to the healing process and signs of complications.

Question 22

Appearance of the Wound:

Answer 22

note location, and described in relation to the nearest anatomic landmark.
note the size: length, width, and depth
not the edges, color of wound and surrounding area.

Question 23

Skill: measuring the wound

Answer 23

draw the shape and describe it, measure it.
depth. gloves, sterile flexible applicator at 90 degrees and insert, mark the deepest point. for tunneling. note the depth. note the direction of tunneling in relation to a clock/

Question 24

When to note odor of a wound:

Answer 24

only after it has been cleaned

Question 25

RYB Wound Classification

Answer 25

R: Red: protect. normal. gentle cleansing, moist dressings, change of dressing only when necessary.
Y: Yellow: Cleanse. exudate, slough, clean it. often accompanied by purulent drainage. color can be whitish yellow, creamy yellow, yellowish green, or beige. wound cleanser and irrigating the wound.
B: Black: Debride: eschar, can be brown, gray or tan. often needed to be done by advanced practice nurses. after debridement, the wound is treated as yellow, then red.

Question 26

Risk Assessment for Pressure Injuries

Answer 26

Norton Scale: physical and mental conditions, activity, mobility, and incontinence
Waterlow Scale: age and gender, build and weight, continence, skin type, mobility, nutrition, and special population specific risks.
Braden Scale: mental status, continence, mobility, activity and nutrition.

Question 27

Braden Scale:

Answer 27

19-23 no risk, 15-18 mild risk, 13-14 moderate risk, 10-12 high risk, 9 or lower, very high risk

Question 28

Diagnosing

Answer 28

Disturbed body image, deficient knowledge related to wound are, impaired tissue integrity, imparied skin integrity, risk for impaired skin integrity, risk for infection , readiness for enhanced health management,

Question 29

Wound Care/Management

Answer 29

no dressing: heals slower bc of drying produces a dried eschar or scab
Closed care: keeps wound moist and promotes healing. the best environment.

Question 30

Purpose of wound dressings:

Answer 30

provide physical, psychological and aesthetic comfort, prevent eliminate, or control infection; absorb drainage, maintain moisture balance of the wound, protect the wound from further injury, protect the skin surrounding the wound, debride (remove damaged/necrotic tissue) if appropriate; stimulate and/or optimize the healing response; consider ease of use and cost effectiveness.

Question 31

types of wound dressings

Answer 31

those that maintain moisture, those that absorb moisture, and those that add moisture.

Question 32

Autolytic debridement

Answer 32

uses occlusive dressings (hydrocolloids) or transparent films, and uses the bodys own enzymes and defense mechanisms to loosen and liquify necrotic tissue.

Question 33

Enzymatic Debridement

Answer 33

application of commercially prepared enzymes to speed up the body’s autolytic process

Question 34

Mechanical debridement

Answer 34

external physical force to dislodge and remove debris and necrotic tissue. could be achieved by wound irrigation with pulsed pressure lavage, whirlpool therapy, ultrasound or laser treatment, or with surgical debridement.

Question 35

Bandages: Figuration to use with each body part

Answer 35

Spiral Turn: wrist, fingers, and trunk
Figure of eight: joints: knees , elbow, ankle, and wrist /
Recurrent Bandages: figure eight turn to finish, used for fingers, head, and for a residual limb

Question 36

T binders

Answer 36

Used to secure a dressing on the rectum, perineum and groin. single t are used for females. double t is used for males.

Question 37

Nursing Dx for Heat or Cold

Answer 37

acute pain, ineffective tissue perfusion, chronic pain, risk for injury

Question 38

Applying Heat

Answer 38

Dry heat: hot water bag, electric heating pads, aquathermia pads, hot packs

Question 39

Moist heat

Answer 39

warm moist compress, sitz bath, warm socks,

Question 40

Applying Cold: Dry Cold

Answer 40

Ice bags, cold packs

Question 41

Applying Cold: Moist Cold

Answer 41

cold compress, usually used for injured eye, headache, tooth extraction, sometimes hemorrhoids