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Nurs. 306 Exam 2 > Chapter 31: Skin Integrity and Wound Care > Flashcards

Chapter 31: Skin Integrity and Wound Care Flashcards

1
Q

What are 7 types of wound dressings?

A

Transparent films, hydocolloid dressings, hydrogels, alginates, foams, antimicrobials, and collagens

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2
Q

What are the primary functions of the skin?

A

Protection, temp. regulation, psychosocial, sensation, Vit. D production, immunologic responses, absorption, and elimination.

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3
Q

What do sebaceous and eccrine glands excrete?

A

Sebaceous glands excrete oils, while eccrine glands excrete sweat.

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4
Q

What is the body’s first line of defense?

A

Unbroken; healthy skin

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5
Q

What are some factors that contribute to wound integrity and healing?

A

Age, presence of illness, amt. of underlying tissue, circulation, nutritional status, hydration, immunohealth, medications.

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6
Q

What are the different wound classifications?

A

Intentional/Unintentional, Open/Closed, Acute/Chronic full/partial thickness or complex.

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7
Q

What are Intentional/Unintentional wounds

A

Intentional: A wound that is the result of a planned invasive surgery or treatment. Unintentional: Wounds that are accidental.

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8
Q

What are open/closed wounds?

A

Open wounds: wounds in which the skin surface is broken. Incisions and abrasions are two examples.
Closed wounds: Skin is intact, results from a blow, force, or strain caused by trauma such as a fall, assault, MVC. Soft tissue is damaged.

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9
Q

What are Acute/Chronic Wounds?

A

Acute wounds: Wounds that usually heal with days to weeks, a surgical incision is an example. Wound edges are well approximated.
Chronic wounds: Wounds that do not progress through the normal sequence of repair. Wound edges are not approximated, delayed healing time, increased risk of infection, and remain in the inflammatory phase of healing. Pressure wounds, venous and arterial ulcers.

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10
Q

What are partial thickness wounds?

A

Partial thickness wounds: wounds in which all or a portion of the dermis is intact.

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11
Q

What are full thickness wounds?

A

Full thickness wounds: wounds in which the entire dermis, sweat glands, and hair follicles are severed.

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12
Q

What are complex wounds?

A

Complex wound: Wound in which the dermis and underlying subcutaneous fat tissue are damaged or destroyed.

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13
Q

What are primary, secondary, and tertiary healing?

A

Primary Healing: Well approximated; skin edges together). Secondary: wounds that are NOT well-approximated (burns, trauma). Tertiary: Delayed primary closure; wound left open several days to promote drainage.

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14
Q

What are the phases of wound healing?

A

Hemostatis: (immed. after injury), Inflammatory phase: (lasts 4-6 days), Proliferation phase: Regenerative, fibroblastic or connective tissue phase-several weeks. Maturation phase: Remodeling 3 weeks after injury.

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15
Q

What is desiccation?

A

Dehydration of wound.

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16
Q

What is maceration?

A

Overhydration of wound.

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17
Q

what is epithelialization?

A

Epithelial cell migration to the wound bed.

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18
Q

What is biofilm?

A

A thick grouping of microorganisms.

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19
Q

What is tissue necrosis?

A

Death of tissue.

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20
Q

What are factors that may affect wound healing?

A

Age, pressure, desiccation, maceration, trauma, edema, infection, excess bleeding, necrosis, biofilm, circulation, oxygenation, nutritional status, wound conditions, health status, immunosuppression, and medications.

21
Q

What are some complications of wound healing?

A

Infection, dehiscence, evisceration, hemorrhage, and fistula.

22
Q

What is dehiscence?

A

Dehiscence: The partial or total separation of wound layers as a result of excessive stress on unhealed wounds.

23
Q

What is evisceration?

A

Evisceration: The most serious complication of dehiscence; the wound completely separates, with protrusion of viscera through the incisional area.

24
Q

Which patients are at greatest risk for evisceration?

A

Patients who are obese, malnourished, smoke, use anticoagulants,have infected wounds, or who are experiencing excessive coughing, vomiting, or straining.

25
Q

What is a fistula?

A

A fistula is an abnormal passage from an internal organ or vessel to the outside of the body OR from one internal organ or vessel to another.

26
Q

What is a pressure ulcer?

A

A pressure ulcer is a wound with a localized area of injury to the skin and/or underlying tissue.

27
Q

What is the significance of RYB?

A

Red: healing tissue, leave alone
Yellow: Clean me
Black: Dead tissue, take me out.

28
Q

What are the stages of pressure ulcers?

A

Stage 1: Defined area of intact skin w/non-blanchable redness of a localized area, usually over a bony prominence.
Stage 2: Partial thickness loss of dermis; presents as a shallow. open ulcer.
Stage 3: Full thickness tissue loss; SubQ fat may be visible (bone, tendon, or muscle is NOT exposed) May include tunneling and undermining.
Stage 4: Involve full thickness tissue loss w/exposed bone, tendon, or muscle. Slough or eschar may be present with tunneling and undermining.
Unstageable: When the base of the wound is covered with either slough (yellow, tan, gray, green or brown) or eschar (thick leathery scab: tan, brown, or black).

29
Q

What are some psychological effects of wounds/pressure ulcers?

A

pain, anxiety, fear, change in body image, ADL change

30
Q

What are the initial components for wound and pressure ulcer assessment (think broad scope)

A

history, duration, pain, impact on ADLs, skin assessment, and wound assessment, nutrition, recent changes in skin, activitiy/mobility, and elimination.

31
Q

When performing an overall wound assessment what do you evaluate?

A

Drainage, color, odor, pain, appearance, staples/sutures.

32
Q

When noting wound appearance, what variables should you observe?

A

Location, size, signs of dehiscence/evisceration, wound edges, and temperature.

33
Q

What are the four types of drainage?

A

Serous: clear, watery
Sanguineous: lg. # of RBCs, red/bright red
Serosanguineous: Mixture of serum, RBCs, light pink
Purulent: WBCs, thick, yellow/green, foul odor

34
Q

Which dressings adhere to the wound bed?

A

Transparent films

35
Q

Which dressings are waterproof?

A

Hydrocolloids, hydrogels, alginates, foams, collagens, contact layers, composites

36
Q

Which dressings maintain a moist wound environment?

A

Transparent films, Hydrocolloids, hydrogels, alginates, foams, collagens, composites

37
Q

Which dressings are absorbent?

A

Hydrocolloids, hydrogels, alginates, foams, collagens, composites

38
Q

Which dressings require a secondary dressing?

A

Hydrogels, alginates, foams, collagens, contact layers, composites.

39
Q

What are the types of wound drains?

A

Closed: Jackson-Pratt, Hemovacs, T-tube,
Open: Penrose, Gauze, iodoform gauze, NuGauze.

40
Q

When would you use a Penrose, Jackson-Pratt, T-tube, or Hemovac drain?

A

Penrose: Abscess incision/drainage, abd surgery
Jackson-Pratt: Mastectomy, Abd. surgery
T-tube: Cholecystectomy
Hemovac: After abd and orthopedic surgery

41
Q

How might you evaluate whether or not nursing care was effective?

A

Pts who effectively participate in preventative and treatment regimens, prev. dev. of new areas of skin breakdown, demonstrate progressive healing, improve overall phys. condition, remain free from infection, commun. need for addt’l support

42
Q

What are the causes of arterial ulcers?

A

Narrowing of arteries, decreased blood flow to extremities, skin cannot heal due to lack of blood.

43
Q

What are the causes of venous ulcers?

A

Damage to veins and valves, blood pools in legs, resulting in swelling, skin tissue is easily damaged.

44
Q

Where are venous ulcers located?

A

venous ulcers are located around the ankle bone, on the medial side and lower 1/3 of the leg.

45
Q

Where are arterial ulcers located?

A

arterial ulcers appear on the tips of toes,heels, metatarsals, lateral aspect of the lower leg,

46
Q

How are the wound bases of arterial and venous ulcers different?

A

Arterial base: dry, pale gray, or yellow. may be necrotic

Venous base: shallow, pink, beefy red, moist base, copious discharge

47
Q

Compare arterial ulcers to venous ulcers

A

Arterial: regular/demarcated border, skin is cool, pale, and thin. claudication pain at rest, continuous pain that increases with elevation, pulses absent or diminished. Min. granulation

Venous: irregular border, skin is warmer than other tissue, may be oozing, crusty, thick, edematous, pain is aching, throbbing, heaviness, and superficical stinging. Pulses present, often diminished. Lots of granulation

48
Q

What is the treatment of arterial and venous ulcers?

A

Arterial: get blood to area. needs revascularization, no elevation, no compression, dry dressing until blood flow returned.

Venous: get rid of excess fluid, Elevate, compress, use moist wound dressing that is absorbent.

49
Q

which dressing type is used for debridement?

A

transparent, hydrocolloid, and alginate

Nurs. 306 Exam 2 (4 decks)

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