Ch. 46. Skin integrity/Wound Care

Question 1

3 causes of pressure injuries

Answer 1

1) Pressure intensity
2) Pressure duration
3) Tissue tolerance

Question 2

Risk factors for pressure ulcer development

Answer 2

Impaired sensory perception
Impaired mobility
Alterations in level of consciousness
Shear
Friction
Moisture
Nutrition
Tissue perfusion
Infection
Pain 
Age

Question 3

Psychosocial effect of having a wound

Answer 3

Assess effect on body image, sexuality, and self-concept
Scars
Drains
Odour from drainage
Temporary or permanent prosthetics

Question 4

Classic Signs on Wound infection

Answer 4

• pain/tenderness
• erythema (red)
• edema (swelling)/induration (increased firmness)
• inflammation of edges
• purulent discharge
• warmth surrounding
• fever/chills
• foul odour
• delayed healing
• elevated WBC

Question 5

Stages of a Pressure Injru

Answer 5

Suspected deep tissue injury
Discoloured intact skin

Stage 1
Intact skin with nonblanchable redness

Stage 2
Partial thickness loss of skin with exposed dermis

Stage 3
Full-thickness tissue loss with visible fat, rolled wound edges

Stage 4
Full-thickness tissue loss with exposed bone, muscle, or tendon

Unstageable
Full-thickness tissue loss, in which the base of the ulcer is covered by slough or eschar in the wound bed

Question 6

Partial-thickness wound repair 

Answer 6

Inflammatory phase - caused by trauma, caused redness/swelling

Proliferative phase - epithelial regenerated providing new cells, starts at wound edge

Reestablishment phase – new epithelium only a few cells thick

Question 7

Full-thickness wound repair 

Answer 7

Inflammatory phase – body’s reaction to wounding, lasts abut 3 days. Bleeding stops and inflammation occurs

Proliferative phase – new blood vessels appear, lasts 3-24 days. Fills with gradulation tissues, wound retracts and resurfacing occurs

Remodelling phase – can take up to 2 years. Collagen scars reorganize and gain strength. Lighter colour and weaker than original skin

Question 8

What to look for to describe wound exudate

Answer 8

Amount, colour, odor and consistency

Question 9

4 Character of wound drainage

Answer 9

Serousa
Sanguineous
Serosanguineous
Purulent

Question 10

Wound closures

Answer 10

Staples
Sutures
Dermabond

Question 11

How to get a wound culture

Answer 11

Clean wound with saline, use sterile swab, rotate swab in 1cm of clean open wound tissue , put back in applicate and bag it

Question 12

Body fluid risk for skin breakdown:
Low
Moderate
High

Answer 12

Low - saliva, serosangenous drainage
Moderate - bile, stool, urine, ascitic feud, purulent exudate
High - gastric drainage, pancreatic drainage

Question 13

Prevention of skin breakdown

3 Keys

Answer 13

1) Skin care – hygiene and moisture management
2) Mechanical Loading/supporting devices
>Positioning (not over 30º)
>Therapeutic surfaces (air mattresses)
3) Education

Question 14

Documentation of a wound includes

Answer 14

Location, stage, size, tissue type, amount of exudate, suurounding skin condition

Question 15

Wound management includes

Answer 15

• prevention
• cleaning
• remove tissue
• exudate manegment
• moisture management
• protection
• nutritional factors (protein)
• hemoglobin (need 02 in RBC)

Question 16

Dressing Purpose

Answer 16

• protects from contamination,
• absorbs drainage,
• splints wound site,
• promotes thermalinsulation,
• provides moist environment,
• lets patient not see wound

Question 17

Types of Dressings

Answer 17

• Wet-to-dry (discouraged),
• Woven gauze, - packing/cleaning wound
• Transparent film – trap moisture promote healing, left in place for awhile
• Nonadherent contact layer, - provide protection without sticking to wound
• Soft silicone, - designed for placed over open wound without causing trauma on wound removal
• Hydrocolloid, - self adhesive for low wounds
• Hydrogel, - give woundbed moisture to promote healing
• Foam – useful for wounds with lots of draining cause lots of space to absorb
• Calcium alginate, - seaweed and used to absorb drainage
• Composite – combo of 2 dressing types for absoption and autolysis

Question 18

Changing dressings

Answer 18

• Type of dressing is based on current assessment.
• “Reinforce dressing prn” is a common order after surgery.
• The nurse should note placement of drains and equipment needed.
• Clean or sterile technique should be used.
• Administer required analgesic
• Explain steps of procedure to patient
• Gather all necessary supplies
• Recognize normal signs of healing
• Answer patient’s questions, and document care provided

Question 19

3 principles for cleaning wound

Answer 19

1) Clean from least to most contaminated (from edge to middle), Clean from wound out in an organized manner
2) Use genetal friction
3) Let irrigation flow from least to most contaminated

Question 20

Benefit of bandage/binder

Answer 20

• create pressure over body part
• imobalize a body part
• support a wound
• reduce or preventing edema
• securing a splint
• securing a dressing

Question 21

Application of bandages and binders

Answer 21

Inspect underlying skin.
Inspect any surgical dressing.
Cover exposed wounds.
Use appropriate technique to apply.
Assess patient’s comfort.
Assess skin of areas distal to bandage.