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z_NUR112: MIDTERM_LAST LEG > Ch 48_ Skin Integrity and Wound Care > Flashcards

Ch 48_ Skin Integrity and Wound Care Flashcards

1
Q

What is a pressure ulcer?

A

A local injury to the skin over a bony prominence due to pressure and other factors

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2
Q

How does pressure result in an ulcer forming?

A

• If pressure over a capillary exceeds normal capillary pressure and the vessel is occluded (obstructed) for a prolonged time, tissue ischemia (shortage of blood supply/O2) occurs which can cause tissue death.

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3
Q

What is “blanching”

A

Normal red tones of skin are abscent when area is pressed and released.

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4
Q

What is “non-blanching”?

A

When an reddish area is pressed and released and no blanching occurs. Indicative of an ulcer/pressure issue.

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5
Q

What are the 6 risk factors for pressure ulcer development?

A
  1. Impaired sensory perception - unable to feel pressure or pain 2. Alterations in LOC - Confused and unable to verbalize 3. Impaired mobility - unable to change position independently 4. Shear (sliding of skin) 5. Friction (dragging of skin) 6. Moisture
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6
Q

How many stages are there in the classification of pressure ulcers?

A

4 only

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7
Q

Describe a Stage 1 pressure ulcer.

A

Intact skin with non-blanchable redness

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8
Q

Describe a Stage 2 pressure ulcer.

A

Partial-thickness skin loss involving epidermis, dermis, or both

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9
Q

Describe a Stage 3 pressure ulcer.

A

Full-thickness tissue loss with visible fat

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10
Q

Describe a Stage 4 pressure ulcer.

A

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

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11
Q

What is the term for an ulcer that defies clear indentification of the 4 stages of pressure ulcer classification?

A

Non-stageable

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12
Q

Define unstabeable ulcer.

A

Pressure ulcer with full-thickness tissue loss in which the depth is obscured by slough and/or eschar in the wound bed.

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13
Q

What are the colors of slough?

A

• yellow • tan • gray • green • brown

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14
Q

What are the colors of eschar?

A

• tan • brown • black

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15
Q

Define a suspected deep tissue injury

A

A purple or marron localized area of discolored intact skin or blood-filled blister caused by damage to underlying tissue from pressure and/or shear.

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16
Q

Wound healing occurs by _____ or _____ intention.

A

Primary, secondary

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17
Q

When checking on wound healing, what are the items we are assessing? REEDA

A

• Redness • Ekymosis • Edema • Drainage • Approximation

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18
Q

Define the primary intention healing process

A

• This occurs when the would edges are approximated • ex. surgical incision is sewn up and winds up with minimal to no scarring

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19
Q

Define the secondary intention healing process

A

Secondary intention occurs when the would heals with non-approximated edges and leaves a scar

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20
Q

A surgical incision heals by _____ intention.

A

primary

21
Q

A burn, pressure ulcer, or severe laceration heals by _____ intention.

A

secondary

22
Q

Describe tertiary intention.

A

• occurs when the wound is left open for several days • while open, it is observed for signs of infection • closure is delayed until infection is resolved

23
Q

What are the 4 types of wound drainage?

A
  1. Serous 2. Sanguineous 3. Serosanguineous 4. Purulent
24
Q

Describe Serous wound drainage.

A

• This type of drainage is plasma that’s thin, clear and watery • During the inflammatory stage, a small amount of this bloody leakage is natural. • When this type of exudate occurs during other wound healing stages, it may be an indicator that the wound bed has undergone trauma, such as during dressing changes, which can hinder healing.

25
Q

Describe Sanguineous wound drainage.

A

Drainage that is fresh blood and prevalent among deep wounds of full and partial thickness

26
Q

Describe Serosanguineous wound drainage

A

• Leakage is thin and watery, and it’s pink in color (it can also be a darker red). • The pink tinge is the effect of red blood cells in the fluid, which is a sign that there is damage to the capillaries. • Such damage generally occurs during wound dressing changes and can disrupt the healing process.

27
Q

Describe Purulent wound drainage.

A

• Wound appears milky • It’s generally gray, green or yellow • Most commonly thick in consistency, though some purulent exudate can be thin. • This may be a sign that the wound has an infection

28
Q

What are five types of wound complications?

A
  1. Hemorrhage 2. Hematoma 3. Infection 4. Dehiscence 5. Evisceration
29
Q

The Braden Scale is used for…

A

predicting pressure ulcer risk

30
Q

What are the six categories used in the Braden Scale Score?

A
  1. Sensory perception 2. Moisture 3. Activity 4. Mobiility 5. Nutrition 6. Friction and shear
31
Q

A Braden Scale Score of 23 indicates what level of risk for developing a pressure ulcer?

A

No Risk

32
Q

A Braden Scale Score of 15-18 indicates what level of risk for developing a pressure ulcer?

A

At risk

33
Q

A Braden Scale Score of 13-14 indicates what level of risk for developing a pressure ulcer?

A

Moderate Risk

34
Q

A Braden Scale Score of 10-12 indicates what level of risk for developing a pressure ulcer?

A

High Risk

35
Q

A Braden Scale Score of ≤ 9 indicates what level of risk for developing a pressure ulcer?

A

Very High Risk

36
Q

How do we check for overall tissue perfusion?

A

• At the peripheral pulse • If pulse week, perfusion will be low • If pulse strong, perfusion will be high

37
Q

On the Braden Scale, the higher the number the _____ the risk.

A

lower

38
Q

What are four other factors (not on the Braden Scale) that can influence pressure ulcer formation?

A
  1. Tissue perfusion 2. Infection 3. Age 4. Psychosocial impact of wounds
39
Q

What is the Jackson-Pratt Drainage Device?

A

A closed-suction medical device that is commonly used as a post-operative drain for collecting bodily fluids from surgical sites.

40
Q

What are the nursing responsibilities regarding the JP Drainage Device?

A

• Measure output • Assess T.A.C.O • Check tubing to make sure its not kinked or dislodged • If its coming apart call MD

41
Q

What are the three types of Nursing Implementation?

A
  1. Independent 2. Dependent 3. Collaborative
42
Q

How does the Nurse know what kind of dressing to use on a wound?

A

The doctor will indicate

43
Q

What are five types of wound dressings?

A
  1. Dry/Moist 2. Film Dressing 3. Hydrocolloid 4. Hydrogel 5. Vacuum assisted closure (VAC)
44
Q

Describe a film dressing. What stage ulcer is it used for?

A

• transparent to permit viewing of wound without opening it • adheres to undamaged skin • does not require secondary dressing • traps moisture over wound • Used for stage I and II ulcers

45
Q

Describe a hydrocolloid dressing. What stage ulcer is it used for?

A

• Wafer dressing • protects wound from surface contamination • Used for Stage II and III ulcers

46
Q

Describe a hydrogel dressing. What stage ulcer is it used for?

A

• gel-based wound care dressing • protects and provides a moist wound-healing environment • helps remove dead tissue from the wound bed during the healing process. • used for stage III and IV ulcers

47
Q

How does a VAC work?

A

• uses a negative pressure to support healing

48
Q

What are the Nurse responsibilities when a VAC is in use?

A

• Tell patient not to pull on it • Checked tubing to make sure its not dislodged • Beeping is a leak, call surgical team

z_NUR112: MIDTERM_LAST LEG (11 decks)

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