Chapter 34 - Skin Integrity & Wound Healing (Week 4 Quiz) COPY Flashcards
1
Q
The layers of the skin are:
- ______ - the outer portion of the skin (4-5 layers). It is covered by the ______ _______ which is composed of numerous thicknesses of dead cells; it functions as a barrier, restricts water loss, prevents fluid, pathogens and chemicals form entering. The innermost layer is the ______ _______, which continually produces new cells, pushing the older cells toward the skin surface.
- _______ - lies below #1 and above the subcutaneous tissue. It provides strength and elasticity to the skin and is generously supplied with blood vessels.
- The _______ _______ is composed of connective and adipose tissues. It provides insulation, protection and a reserve of calories .
A
1)
Epidermis
Stratum corneum (corn–>corn husk–> outermost part of corn)
Stratum germinativum (germanate = produce new life)
2)
Dermis
3)
Subcutaneous layer
2
Q
Deeper in the epidermis are ________, which produce _____, a pigment that gives skin its color and provides protection from UV.
A
melanocytes; melanin
3
Q
Age-related factors that affect skin:
A
Age —
older adult skin:
-oil and sebaceous glands less active,
-Reduced collagen leads to loss of elasticity; prone to injury
-drier - XEROSIS = itchy red dry cracked skin making them more prone to injury -
-areas of hyperpigmentation,
-Due to impaired mobility: Not changing positions causes ulcers, reposition every 2 hours.
Mobility status — increased pressure, shearing, and friction can lead to breakdown
infants have thin skin that is more permeable which is why they are susceptible to diaper rash.
Puberty leads to increased sebaceous and sweat gland activity (acne and body odor is the result).
4
Q
Skin condition reflects nutritional status. Adquate intake of _______, _______, ______, _____ and _____ are essential to maintaining skin integrity.
PCCCH
A
Protein: essential to maintain skin, repair minor defects & preserve intravascular volume
Cholesterol: abnormal low levels predispose patients to skin breakdown & inhibit wound healing; these fats provide fuel for wound healing and maintain waterproof barrier.
calorie intake: If you do not eat enough, of the needed nutrients, your body will use what you do eat as energy instead of for healing your skin. PROLONGED lack of calories = weight loss, loss of subcutaneous tissue & muscle atrophy
ascorbic acid (vitamin C): Involved in formation & maintenance of collagen Deficiency= delays wound healing
Hydration-poor turgor if dehydrated
p.833
PCCCH - protein, cholesterol,calories, c vitamins, and hydration
5
Q
Pts with diminished tactile senses are more prone to skin breakdown. Why?
A
- Unable to feel pressure in affected area; may not shift position to relieve pressure over bony prominences.
- May not notice cut or wound on area with reduced sensation, leading to late treatment and more chance for infection.
6
Q
______ _______ interferes with tissue metabolism and is the main cause of chronic wounds.
Impaired _______ circulation restricts activity, produces pain, leads to muscle atrophy & development of thin tissue, prone to ischemia & necrosis. Ischemia means inadequate blood brought TO tissues.
Impaired ______ circulation results in engorged tissue with high levels of metabolic waste products that are prone to edema, ulceration & skin breakdown.
A
Impaired circulation:
impaired arterial circulation (to body from heart)
impaired venous circulation (blood sends waste to various organs for removal)
Both forms of impairment delay wound healing and is one of the main causes of chronic wounds.
(always remember you need the blood to flow to the area/less flow=less healing)
7
Q
T or F: Side effects & idiosyncratic reactions to medication can affect skin integrity & delay wound healing. Any medication that causes: Itching(pruritus), Rashes(dermatoses), Photosensitivity, Alopecia, Pigmentation changes,; can result in changes that impair skin integrity or delay healing
A
True
p.833
8
Q
Exposure to moisture leads to _________ (softening of the skin) and increases likelihood of breakdown; incontinence (bowl and urine) & Fever are most common causes of it.
A
Maceration
9
Q
Bowel incontinence can lead to ________ because feces contains digestive enzymes that can destroy superficial skin layers. This can lead to _ _ _ _ , dermatitits, pressure ulcers and infection.
A
excoriation
MASD=moisture associated skin damage
10
Q
How do fevers cause skin breakdown?
A
- Leads to sweating which causes maceration.
2. Increases metabolic rate which raises tissue demand for oxygen.
11
Q
________ of a wound refers to the presence of microorganism in the wound.
A
Contamination.
All chronic wound are considered contaminated.
12
Q
As bacteria begin to increase in numbers, a wound is said to be _____, though microbes are not causing harm.
When the bacteria beging to overwhelm the body’s defenses, the wound is then referred to as ______ colonized.
A
colonized
critically colonized
13
Q
An ______ implies the microorganisms are causing harm by releasing toxins, invading body tissue & increasing the metabolic demand of tissue. This increases vulnerability to skin breakdown & impedes healing of open wounds
A
infection
14
Q
What are lifestyle habits that affect skin integrity?
A
- Tanning - exposes to UV leading to melanoma
- Bathing - overbathing rids of normal flora/dries skin; underbathing leads to bacteria build up which can infect wound
- Piercings & Tattoos - risk for scarring and infection; piercings prone to: infections, sepsis, endocardititis, hepatitis, TSS.
- Smoking - compromises O2 supply; prone to breakdown; interferes with vitamin C absorption
15
Q
Of the following factors, which would put a client at greatest risk for impaired skin integrity?
a. the medication digoxin b. moisture c. decreased sensation d. dehydration
A
Correct answer: C
Decreased sensation would greatly increase the risk for injury with a tear or break in the skin. This could lead to a delay in seeking treatment due to lack of awareness.
16
Q
T or F: Wounds are classified solely according to length of time the wound has existed.
A
False.
Wounds are classified according to length of time the wound has existed, as well as the condition of the wound (contamination, severity, etc.)
This video is graphic. Contains images of various wounds and their labels:
https://www.youtube.com/watch?v=8pBpYQkCdvY
17
Q
We can classify by skin integrity of the wound. No breaks in the skin is describe as ______.
If there is a break in the skin or mucous membranes, it is considered ____.
A
Closed
Open (Examples: abrasion, abscess, contusion, crushing, incision, laceration, penetrating, puncture, and tunnel) Table 34-1 on page 835
18
Q
If a wound is expected to be of short duration is referred to as _____.
A
acute
These wounds heal spontaneously without complications through the three phases of wound healing (inflammation, proliferation, and maturation).
19
Q
Wounds that exceed the expected length of recovery are classified as _____.
A
chronic.
The natural healing process is interrupted due to infection, continued trauma, ischemia, or edema.
Examples of Chronic Wounds:
pressure (decubitous), arterial, venous and diabetic ulcers.
20
Q
_____ wounds are uninfected wounds such as surgical wounds, with minimal inflammation
_____ ________ wounds are also surgical but have incisions that enter the GI, Resp and genitourinary tracts.
A
clean
Clean - contaminated
21
Q
______ wounds include open, traumatic wounds or surgical incisions in which MAJOR BREAK in asepsis occurs. The risk of infection for these is high.
A
contaminated
22
Q
Wounds are considered _______ when bacteria counts in the tissue are above 100,000 organisms per gram of tissue. Signs of this include: redness, swelling, fever, foul odor, severe or increasing pain, large amount of drainage, or warmth of surrounding tissue.
A
infection
23
Q
An example of a ________ wound is a scrape on your knee. Caused by friction, shearing, or burning.
_______ ______ wounds extend through the epidermis but not down to the dermis.
The ______ descriptor is sometimes added to indicate that the wound involves internal organs (examples: gunshot wound; causes pneumo/hemothorax)
A
Superficial
Partial thickness (think of it being partially as thick as the epidermis and dermis combined. Full thickness wounds are the full thickness of epi/dermis and subcutaneous tissues).
penetrating
24
Q
Types of wound healing:
- ______ is when a wound affects only the epidermal and dermis; No scar forms.
- _____ _____ involves Minimal scarring=minimal or no tissue loss. Edges of wound are either clean surgical incision or approximated (try to align the skin before sew/staple/strips). Little scarring is expected (possibly a tiny hairline scar)
- Healing by ______ ______
occurs when a wound involves either: 1) extensive tissue loss that prevents edges from approximating (they don’t come together); or 2)should not be closed due to infection (Wound left open =Heals from inner layer to surface. Fills in with beefy red granulation tissue) - _____ ______ , also called delayed primary closure, occurs when two surfaces of granulation tissues are brought together. It is closed with sutures after being allowed to heal with secondary intention. Requires strict aseptic technique during dressing changes because they are prone to infection.
A
page 837 has visual aid for healing processes
- Regeneration/Epithelial (partial thickness wounds heal this way).
- Primary intention (clean surgical incision heals this way)
- Secondary intention (pressure ulcers and infected wounds are in this category). (2nd, two, two sides don’t match up)
- Tertiary intention (clean contaminated or contaminated wounds)
25
Very important video to watch in conjunction with the next few cards.
https://www.youtube.com/watch?v=6qU-0ETo5_s
skip to 37 seconds.
Note: our book combines maturation phase and remodeling phase together... but the visual is perfect!
26
Wound healing occurs in three stages...what are they?
1. inflammatory- the cleansing phase (days 1 to 5)
2. proliferative (aka regeneration) - occurs from day 5 to 21
3. maturation (remodeling) - final phase (from second or third week through up to 6 months)
27
During the inflammatory phase (1st phase) What takes place?
1 to 5 days
hemostasis - tissues.capillaries are damaged causing blood and plasma to leak into the wound. platelets aggregate and clump. clots are activated and formed.
inflammation - characterized by swelling (edema), redness, pain, and heat. WBCs rush to area to complete phagocytosis of microbes (they eat em up like pacman). Scabs form using plasma proteins and fibrin.
28
What happens during the proliferative phase (2nd phase)?
5 to 21 days
fibroblasts (that form collagen) and endothelial cells form granulation tissue (which is easily damaged). As the clot or scab is dissolved epithelialization occurs (epithelial cells seal over wound)
29
What happens during the final stage of healing called Maturation Phase (or remodeling)?
2 weeks to 6 months
The tissues that were laid in the wound bed during the proliferative phase are broken down and remodeled into organized structures (scar tissue), increasing the strength of the tissue
30
Identify the type of wound healing (primary, secondary, or tertiary intention):
● A wound that heals from inner layer to the surface
● A wound with approximated edges
● A wound that heals by approximating two surfaces of granulation tissue
● A wound that is sutured and has minimal or no tissue loss
Answer:
Secondary intention
Answer:
Primary and tertiary intention
Answer:
Tertiary intention
Answer:
Primary intention
31
Wounds that heal by primary and tertiary (those with approximated edges) are closed in a number of ways...List some!
(Relates to slide: Nursing Interventions Related to Wound Care (Cont’d))
* adhesive strips (close superficial and closed subq wounds; left on until the separate themselves from the skin).
* sutures - "stitches" absorbent sutures that dissolve are used for organ closure or to connect tissue (anastamose). If put in skin, non absorbent and usually need removal.
staples - low risk of infection than stitches. Difficult to align.
surgical glue - used i low tension, clean wounds.
negative pressure closure - uses secondary and tertiary intention. Vacuum created, pressure reduces edema from swollen tissues/promotes granulation.
Really cool animation on how it works here:
https://www.youtube.com/watch?v=-wxyKEStuDQ
compression -
32
Drainage is the flow of fluids from a wound or cavity, and often referred to as ______, oozes as a result of inflammation.
exudate
33
Straw-colored exudate that drains from cleans wounds. Consists of serum that separates our of blood when clot is formed.
Serous exudate
34
_________ exudate is often seen with deep wounds or wounds in highly vascular areas. It is blood drainage. Fresh=bright red drainage. Old= dark red brown
Sanguineous exudate
35
________ drainage is a mix of bloody and straw-colored fluid
Serosanguineous
36
______ exudate contains pus (which is WBCs, bacteria, and cellular debris). It is commonly caused by pyogenic bacteria.
Purulent Exudate (Pu as in PUs)
37
Red tinged pus that indicate small vessels in the wound have ruptured.
purosanguineous
38
T or F: common complication of wound healing are hemorrhage, infection, dehiscence, evisceration and fistulas.
True
39
Sometimes hemostasis is delayed, when a large vessel is injured/clotting disorder exists/pt on anticoagulation therapy. The patient could be bleeding internally or externally.
Signs of internal bleeding are? External bleeding?
Called hemorrhage- a complication of wound healing....
Internal-swelling of affected part, pain, change in vitals (dec BP/elevated pulse).
External - you will see bloody drainage on dressings/in devices.Remember to look under the pt because blood will pool there.
40
Rupture (separation) of one or more layers of a wound. NOTHING YOU CAN DO.
Occurs in inflammatory phase of healing before large amount of collagen have strengthened it.
Dehiscence (dehis - detach - detached edges)
associated with abdominal wounds. POP open.
Caused by poor nutrition, inadequate closure of muscles or wound infection. Obese pt at higher risk.
41
What do you do if your pt encounters dehiscence?
Put something clean over it and call the doctor. Maintain bedrest with 20 degree head elevated and knees flexed.
associated with abdominal wounds.
42
______ is total separation of
layers of wound in which internal viscera protrude
through the incision. It is rare.
Evisceration
viscera escape = evisceration.
Google the image... you will never forget
:(
43
What do you do if your pt encounters Evisceration?
Cover wound with sterile towels or dressing soaked in sterile saline solution to prevent form drying out/becoming contaminated. Knees bent.Ready for surgical procedure.
44
A _____ is an abnormal passage connecting two body cavities.
Fig 34-6
Fistula
45
How does a fistula form?
An abscess forms which breaks down surrounding tissue and creates the abnormal passafeway.
46
The client calls the nurse to the room and states, “Look, my incision is popping open where they did my hip surgery!” The nurse notes that the wound edges have separated 1 cm at the center and there is straw-colored fluid leaking from one end. The nurse’s best action is to
a. Notify the surgeon STAT.
b. Place a clean, sterile 4 x 4 over the incision and monitor the drainage.
c. Wrap an ace bandage firmly around the area and have the client maintain bedrest.
d. Immediately cover the wound with sterile towels soaked in normal saline and call the surgeon.
B
A 1 cm separation of wound edges only in the center of a surgical incision on the hip is too small to truly be termed dehiscence. Even if there were a large separation, there are no “internal viscera” to protrude.
How to break apart this questions:
1. Pt safety - infection control first
2. color of fluid - straw colored = serous exudate which means it is a clean wound and clot was formed. Color of dehiscence is serosanguineous.
3. the part exposed does not include an internal viscera so it is not evisceration.
47
______ _______ are localized areas of injury to the skin, and possibly underlying tissue, usually over bony prominence.
Pressure ulcers (aka decubitus ulcers/bedsores)
They are caused by unrelieved pressure that compromise blood flow to an area resulting in ischemia which leads to tissue anoxia and cell death.
48
T or F: Pressure ulcers can occur in as little times as 2 hours.
True.
49
What are intrinsic (internal) factors that alter skin and tissue integrity or oxygen deliver capabilities (decreasing the amt of force required to create a pressure ulcer)?
immobility and impaired sensation, as occur w/spinalcord injury, stroke, or coma. Poor nutrition, edema, aging, low arteriolar pressure.
Poor nutrition and dehydration weakens the skin and leads to pressure ulcers. Adequate intake of calories, protein, vitamin C and zinc are necessary to prevent ulcers and promote healing.
50
What are extrinisc (external) factors that contribute to development of pressure ulcers?
Friction - damages outer layer of skin
Shearing - occurs when epidermal layer slides over the dermis, causing damage to the vascular bed. Common= sacral due to sliding down bed when head is raised; reduces the pressure needed to cause ulcer.
Moisture - reduces pressure needed to cause ulcer; caused by urine/feces; macerates skin.
Bony Prominences - skin is compressed between bone and bed or chair, reducing blood flow. Common areas: occiput (back of head), scapula, elbows, sacrum and heels.
51
Study Table 34-1 on page 835 - Types of wounds
| Study Table 34-2 - page 835 - Chronic Wounds
Also study table 34-3 p.843 Staging pressure ulcers
52
What are other ulcers besides pressure uclers?
1. venous stasis ulcers-caused by damage to veins (eg DVT); usually inside ankle and knee (not necess. over bony prom.)
2. Diabetic Foot Ulcers - Diabetes causes narrowing arteries-->decreases O2-->decreased sensation-->person continues to re-injure
3. Arterial Ulcers - tissue necrosis caused by arterial blockage; usually lower leg, ankle, or bony areas of the foot. Wound is dry pale with little drainage.
53
NPUAP (The National Pressure Ulcer Advisory Panel) recommends nurses perform a comprehensive wound assessment while....
... while identifying other health problems & impact on wound healing
54
The ______ scale used to predict pressure sore risk. It evaluates six major factors:
1. sensory perception
2. moisture
3. activity
4. mobility
5. nutrition
6. friction or shear)
Numeric values are given for each risk factor related to impaired skin integrity. A total score of 18 or less indicates risk
braden - assess risk
Norton i used to assess risk (less detail than braden)
Push used to evaluate pressure ulcer (condition of)
55
There are ____ stages in pressure ulcers.
Four
Stages I–IV: classified by tissue involvement
Stages III and IV: involve tissue necrosis
You can study page 843 Table 34-3 Staging presure ulcers or watch this great video covering ulcers:
https://www.youtube.com/watch?v=QCW2R4vnzXc
stage 1 - heat, swelling, induration
stage 2 - partial thickness (epidermsi/dermis or both)
stage 3 - full thickness (epi/dermis/subq) but not through fascia,
stage 4 - fascia, bone, and muscle damage (necrosis)
56
What is an unstageable pressure ulcer?
Involves full thickness skin loss. So much dead tissue it cannot be staged/determined.
57
A focused physical exam of skin integrity focuses on two areas....
1. inspecting the skin (color, integrity, temp, texture, turgor, mobility, moisture, lesions, and hair distribuition); check bony prominences.
2. assessing mobility and activity level
58
Assessment parameters for asssessing wounds includes...
Location (influences rate of healing - where there is no blood supply it is slower; location effects movement; location gives etiology)
type of wound - acute or chronic? sutured? closed? etc...
Size-measure length and width in cm.
Drainage - is exudate present? what color is it? how much is draining?
Is there an odor (absent/faint/moderate/strong)?
Appearance - tunneling? color?
Periwound (skin around wound - check for maceration/crepitus/blistering/ erythema/epiboly/slough/swelling
eschar) DEFINITIONS COMING UP IN A FEW CARDS FOR THIS GROUP OF WORDS! (p.846)
Painful? (This may be a sign of infection)
Nutritional status - call dietitian if necessary
59
Review Push Tool in Volume 2 - pg 823
It is a tool used to evaluate pressure ulcers.
It measure length and width (in cm - and rates with number based on cm size), exudate amount (none, light, moderate heavy - each amount if given a number), Tissue type (epithelial, granulation, slough, necrotic - each type is given a number). Numbers assigned are added up for a total score. This is done repeatedly as the ulcer heals as an indication of improvement/deterioration.
60
... will produce a boggy feel around the wound.
undermining
61
...is gas traoped under the skin (crackles). Gas producing bacter can cause this.
Crepitus
62
...is closed or rolled wound edges.
epiboly
Epithelial cells toll under wound.
Rolled up in a ball...roly poly....epiboly
63
... is usually soft, stringy, and pale yellow or gray.
slough:
- moist, devitalized tissue - deprive of strength and vigor
- necrotic
- Nursing goal = debridement
64
...is thick, hard, and black or brown.
Eschar:
- necrotic
- leathery
- Nursing goal = debridement
65
WHy is it important to know the percentage and type of tissue in the wound?
gives an idea of the severity, needed treatment option and expected healing process.
Types of tissue include: slough, eschar, granulation, clean-non granulating epithelial.
Nursing goals for each:
Debridement - slough, eschar
Clean/Protect - granulation, clean-non granulating epithelial.
see table 34-4 on p846
66
When assessing an untreated wound, make the same assessment as treated wound. Determine need for treatment. If bleeding is profuse, apply.......
direct pressure to the site. Call a dr if this last for five minutes.
Severe pain, numbness, loss of movement also requires evaluation.
67
When do you give a tetanus immunization?
1. If the person has a tetanus prone wound (compound fracture, foreign object injuries, burns, punctures, crush injuries, gunshot wounds, contaminated with soil/dirt/debris, and wounds neglected for 24 hours)
2. If the last immunization was 10+ years ago.
3. contaminated with soil/dirt/debris and last immun. was 5+ years
4. It is uncertain when the last immun was given.
68
T or F: There are no lab tests to assist in assessing pressure ulcers.
False!
Common assessment used in conjunction with physical assessments include: protein levels, CBC, erythrocyte sedimentation rate, glucose, thyroid and iron levels, coagulation studies and wound cultures (done to determine bacteria present - other tests may lead to obtaining a wound culture; use two week rule).
Critical Thinking: How would a wound heal if these tests were not within desired ranges?
Volume 2 - Ch 34 has more details if interested.
69
What are some techniques used to get a wound culture?
1. Swabbing - non invasive
2. Needle Aspiration - use needle to "suck" fluid out of wound.
3. Tissue biopsy - most accurate (considered gold standard); invasive, creates risk of sepsis. Trained person must perform.
70
What is the preferred method of wound culture that may be performed by a registered nurse?
Answer:
Needle aspiration of a wound is the preferred method for a culture obtained by nursing staff. Nurses can culture wounds by swabbing and aspirating with a needle, but not biopsy, unless certified as advanced practice.
71
T or F: The RN can delegate the initial assessment of a wound.
False!
Initial assessment, ongoing evaluation and treatment must be done by the RN.
you MAY delegate inspection for skin breakdown; NAP must report redness/warmth/drainage. the NAP can also assist with turning/position changes of the patient.
72
What is the difference in these Nursing Dx?
A. Risk for impaired skin integrity
B. Impaired Skin integrity
C. impaired tissue integrity
D. risk for Impaired tissue integrity
Critical thinking question. Use this type of breakdown for exam questions.
A. pt has several risk factors but has not yet experienced skin damage
B. has damage to epidermis or dermis
C. TISSUE versus SKIN means the level of damage is deeper than in letter B. We are not past layers of skin and have hit fascia and below.
D. This person is experiencing delayed healing. Pt is in the phase that could be grouped with B (damage to skin), but due to issues in healing (poor diet/age/etc), the diagnosis changes to state at risk for tissue issues.
For further study: review possible nursing diagnosis for at risk for skin breakdown PG 848
73
Pressure ulcers affect 15% of hospitalized clients.
What are some measures we can take to prevent pressure ulcers?
INITIAL & ongoing evaluation MUST be done by RN
Instruct NAP to notify of redness, tissue warmth or drainage
Lab evaluation: protein levels, CBC, ESR(erythrocyte sedimentation rate, BS, thyroid, iron level, PT, PTT (coagulation) & wound cultures
Assess upon admission! Take picture of ulcers upon admission! DOCUMENT! (Use braden scale or norton scale to assess and doc)
Reassess daily! - If at risk, take precautions!
REPOSITION q2 hours to minimize pressure.
Manage moisture! (if applying moisturizer to bathed skin/do not rub over bony prominences) Keep linens neat and dry.
Optimize nutrition and hydration
Use support surfaces-mattresses, integrated bed systems, mattress replacements and overlays. These are air, gel, foam, water.
PT and Fam teaching
74
Was if the "rule of 30"?
1. ELevate the head of the bed 30 degrees or less
2. when pt is on her side position at 30 degree angle (not directly over trochanter since that can cause problem. put weight more toward butt)
3. Limit time above 30 degree head of bed
75
T or F: It is best to use antiseptic solutions such as hydrogen peroxide, alcohol and iodine to cleanse wounds.
False! This is a historical way of cleansing, however research shows these methods can damage tissue and should be reserved for wounds that wont heal and infected wounds.
Normal saline is best. Liquid or foam skin cleansers that are pH balances may be used to clean periwound or incontinence effluent.
76
When irrigating a wound (lavage), the solution should be applued with a mild amount of force. The suggested practice is 4-15 psi. Why do we avoid psi above 15?
Pressures above 15 psi increase risk of driving bacteria into the tissues.
77
When irrigating, what PPE do you use and why?
gown, mask, goggles because of splattering.
SUrgical wounds require sterile technique. Most others use clean technique.
78
● Describe the wound-categorization system based on the level of contamination.
Answer:
Wounds are categorized based on four levels of contamination:
● Clean wounds are uninfected wounds with minimal inflammation. They may be open or closed and do not involve the gastrointestinal, respiratory, or genitourinary tracts (these systems frequently harbor bacteria). There is very little risk of infection for these wounds.
● Clean-contaminated wounds are surgical incisions that enter the gastrointestinal, respiratory, or genitourinary tracts. There is an increased risk of infection for these wounds, but there is no obvious infection. (Clean because surgical-Contaminated because bowel/urine/etc.)
● Contaminated wounds include open, traumatic wounds or surgical incisions in which a major break in asepsis occurred. The risk of infection is high for these wounds.
● Infected wounds are wounds with evidence of infection, such as purulent drainage or necrotic tissue. Wounds are considered infected when bacteria counts in the wound tissues are above 100,000 organisms per gram of tissue or in which there is the presence of beta-hemolytic streptococci in any number.
79
Tips for initial wound care p.852 box 34-1
If it is dirty, clean it....and so on
80
Drains prevent.....
excessive pressure form building in the tissues.
81
Which drain is a flexible latex tube that uses a clip or pin to prevent slippage and requires the RN to advance it by gradually removing it a set amount each day?
Penrose Drain
p.854
82
What are some devices that use suction?
Jackson-Pratt, Hemovac and Davol
JP Drain https://www.youtube.com/watch?v=G9N9-3QyESs
83
Watch video on hemovac
http://www.youtube.com/watch?v=72W5Z9agOPU
Has more suction than jackson pratt. Springs expand as it fills. Open valve to empty then clean valve with alcohol, compress and replug valve.
84
Identify goals for wound care before applying a dressing to a wound.
Answer:
Nursing interventions have the following goals for wound care:
● Protect wounds from further injury and infection
● Cleanse wounds to prevent infection
● Drain wounds to aid in the healing process and prevent infection
● Débride to aid in the healing process and reduce scarring
85
Identify three nursing responsibilities when caring for a client with a wound drain.
(p.854)
Answer:
Answers may include any three of the following nursing responsibilities for wound drains:
● Monitoring wound drains. The surgeon will describe the number and type of drains present.
● Describe drain placement using the positions on the clock face. Consider the patient’s head to be at the 12 o’clock position (e.g., “Penrose drain at 3 o’clock”).
● Label the drains numerically with a marker or by placing tape on the collection apparatus, so that each caregiver provides consistent care. Some patients have more than one drainage device in a wound.
● When removing dressings or irrigating wounds, take care to avoid dislodging drains. Remember, many drains are not sutured in place.
● Monitor the amount and character of the drainage and the condition of the collection apparatus. Record this information in your nursing notes and on the I&O record.
● Report to the surgeon any change in the amount or character of the drainage.
● If you suspect that a drain is occluded, check the drain line from the insertion site to the collection device. Remove any kinks in the tubing. If this does not correct the problem, notify the physician of the blockage.
● Empty the collection apparatus at a designated volume to maintain suction. As the device fills, suction pressure decreases. If there is significant drainage, you may need to empty the device several times during your shift.
86
...is the removal of devitalized tissue or foreign material from a wound.
Devitalized - deprive of strength and vigor.
debridement
87
During debridement, a biopsy of bone may be done. THe biopsy checks for osteomyelitis. What is the definition of osteomyelitis?
infection in the bone (inflammation of bone or bone marrow, usually due to infection)
88
What are the various types of debridment? Describe each of them.
1.Sharp - uses sharp instrument to remove tissue. Dr, RN and PT can do this bedside. If needs extensive debridement, may take place in OR. Preserves granulation tissue.
2.Mechanical p855:
A) nonselective- wet-to-dry dressing or hydrotherapy. You put wet coarse gauze into wound, allow it to dry, then remove it. Not commonly used because it is painful and can disrupt granulation tissue. Medicate pt if you plan to do this.
B) nonselevtive whirlpool - used for wounds with lg amt of nonviable tissue. Whirlpool contains tepid water and is used 5-15 minutes. Avoid jets. Increase risk of periwound maceration and water born infection.
3. Chemical - same as enzymatic
4. Enzymatic - proteolytic agents used (Proteolysis is the breakdown of proteins into smaller polypeptides or amino acids.); breaks down necrotic tissue without effecting viable tissue. Apply cream and cover with moisture retaining dressing 1-2xdaily.
5. Autolysis - (do not use for infected wound); uses occlusive, moisture retaining dressing and body's own enzymes and defense to break down necrotic tissue. (AUTO = self;own)
89
T or F: With loss of or damage to the skin, body cells can dehydrate and die.
True!
This is why we have to create the right wound environment to allow cells to flourish. The type of dressing used on a wound depends on the characteristics of the wound and goals of the treatment.
p.855-856
90
Identify the purposes of a wound dressing.
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Answer:
The primary purposes of dressings are as follows:
● Protect from contamination and heat loss
● Aid hemostasis
● Absorb drainage
● Débride the wound
● Splint the wound site
● Prevent drying of the wound bed
● Keep the surrounding tissue dry and intact
● Provide comfort to the patient
● Eliminate dead space
● Control odor
```
91
What should you consider when choosing a dressing?
Answer:
When choosing a dressing, ask yourself these questions. Will the dressing provide a moist wound environment? Will it contain all the wound drainage and keep it off the surrounding skin? Can it be removed without damaging fragile skin or the wound itself? Will it protect the wound from outside contamination or infection? How long should it stay in place, or how often does it need to be changed?
92
T or F: The goal of wound care is to heal the wound in the most rapid and comfortable manner, protect it from further injury and infection and minimize scarring if possible.
True
93
What is the difference between primary and secondary dressing?
Primary - touches the wound; placed in wound bed.
Secondary - covers/holds primary dressing in place.
Some dressing can act as both, touch wound and yet holds itself in place.
94
Study table 34-5 p.857
Types of wound dressings
95
____ dressings are appropriate for wounds with moderate to large amts of exudate. Do not use to pack undermining wounds or wounds not draining.
absorption dressings
96
.... dressings are ideal for lg amt of exudate, wounds with tunneling and undermining. They are made of fibers derived from brown seaweed and kelp, availble in pad or rope form. Absorb 20-40 x their own weight.
alginate
| memory tip: algi = algae = seaweed=absorbs ocean water
97
... dressing reduce and prevent infection and promote collagen deposition. Available in gause, pads, gels, foams, hydrocolloids and alginates.
antimicrobial
98
_______ ______ are used on minimal wounds. They promote a moist environment, promote autolysis. They are non absorbent, clear and semipermeable. They allow air and water vapor in and out but not bacteria
transparent film
99
... dressing stimulate wounds to produce collagen fibers and granulation tissue in the wound bed.
collagen dressing
100
..... rehydrate the wound bed.soft cooling texture promoting comfort. not used for wounds with significant exudate.
hydrogels
101
Read about foam and gauze
p.856/858
102
...dressings include wafers/pastes/powders that contain water loving particles (hydrophillic). They provide a layer against friction/caustic agents. Used for stage II ulcer and partial thickness. Decreases pain.
hydrocolloid dressing
103
Differentiate among the different categories of dressings.
Answer:
● Absorption dressings are used to soak up drainage from a wound.
● Alginate dressings are highly absorbent dressing made of fibers from brown seaweed and kelp.
● Antimicrobial dressings are topical antifungal and antibiotic agents that are available as ointments, impregnated gauzes, pads, gels, foams, hydrocolloids, and alginates.
● Collagen dressings are made from bovine or porcine sources and made into sheets, pads, powders, and gels to absorb wound drainage.
● Gauze dressings absorb wound drainage with woven and nonwoven fibers of cotton, rayon, polyester, or a combination of these.
104
What types of dressing may be used for wounds with a large amount of exudate?
Answer:
| Gauze, foam, alginates, or absorption dressings are best used for a wound with a large amount of exudate.
105
What form of dressing is appropriate for a wound with an eschar that needs to be eliminated?
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Remember:
Eschar:
-necrotic
-leathery
-Nursing goal = debridement
```
Answer:
Hydrogel is most appropriate for a wound with an eschar that needs to be eliminated. Some students may state that a wet-to-wet dressing is also appropriate, but this dressing type is difficult to maintain and may cause damage to surrounding tissue.
106
The client has a wound that is 0.4 cm long and 3.2 cm wide. There is only a light amount of exudate and granulation tissue is seen. The “PUSH” score for this would be
a. 15
b. 18
c. 9
d. 22
use pg.823 volume 2 to practice and solve!
Correct answer: A
Points: 2 length x 6 width = 12
Exudate 1
Granulation 2
107
Read about securing dressing p.859
image at bottom right side of page for placement
adhesive tape
foam tape
nonallergenic tape and paper tape
montgomery straps
108
______ and ______ are used to hold dressing in place. apply pressure to a wound to impede hemorrhage, and support and immobilize an injured area, thereby promoting healing and comfort.
Binders&bandages
binders - used to keep wound closed, immobilize body part. Used on large areas of body. Types listed on p.860
bandages - cloth gauze or elastic, wrapped in place. Types listed on p.861
109
T or F: WHen applying heat or cold: avoid direct contact. Leave it on for no more than 15 minutes at a time. Check skin frequently for redness, blistering, blanching and cyanosis. Although the temp becomes tolerable, the temp should not be changed and if it can cause injury.
True.
DO NOT MISS THIS IF SHE PUTS IT ON THE TEST AGAIN!
110
_____ i used to relieve stiffness and discomfort assoc with musculoskeltal problems. It increases blood flow to the area.
heat
111
How do the Langerhans cells protect the skin from injury? Langerhans cells:
1) contain protein that give the skin strength and elasticity.
2) are able to filter out beta ultraviolet light waves.
3) are mobile and phagocytize foreign material.
4) are located in the dermal layer of the skin.
Answer:
3) are mobile and phagocytize foreign material.
Rationale:
Langerhans cells are located in the epidermal layer of the skin. They are mobile and able to phagocytize foreign material and trigger an immune response. Keratinocytes are protein-containing cells that give the skin strength and elasticity. Melanocytes provide protection from ultraviolet light.
112
When performing an assessment for a patient with a 2-week-old wound, the nurse notes the formation of granulation tissue in the wound bed and recognizes the wound is most likely in which stage of wound healing?
1) Proliferative phase
2) Maturation phase
3) Aggregation phase
4) Inflammatory phase
nswer:
1) Proliferative phase
Rationale:
The proliferative phase occurs from days 5 to 21. It is characterized by cell development aimed at filling the wound defect and resurfacing the skin. Granulation tissue forms during this stage, as fibroblasts migrate to the wound to form collagen, and new blood and lymph vessels sprout from the existing capillaries at the edge of the wound.
113
A postsurgical patient who is morbidly obese informs the nurse that as she was coughing, she felt a "pop" at her abdominal incision site. Upon inspection, the nurse notes the sutures to the incision are intact; however, there is an increase in the amount of serosanguineous drainage. The nurse would suspect wound:
1) Evisceration
2) Fistula
3) Hemorrhage
4) Dehiscence
Answer:
4) Dehiscence
Rationale:
Wound dehiscence is a rupture of one or more layers of a wound and usually occurs in the inflammatory phase before large amounts of collagen have been deposited in the wound to strengthen it. Dehiscence is usually associated with abdominal wounds, and patients often report feeling a pop or tear, especially with sudden straining from coughing, vomiting, or changing positions in bed. Usually there is an immediate increase in serosanguineous drainage. Patients with obesity are more likely to experience wound dehiscence because fatty tissue does not heal readily, and the patient's body mass increases the strain on the suture line.
114
An older adult had a colon resection 1 week ago. When assessing the abdominal incision, the nurse notes foul-smelling brown drainage seeping from the middle of the incision site. The nurse suspects he has:
1) an infected wound.
2) wound dehiscence.
3) a hematoma.
4) a fistula.
Answer:
4) a fistula.
Rationale:
A fistula is an abnormal passage connecting two body cavities or a cavity and the skin. Based on the type of surgery and drainage present, the nurse would suspect fistula formation.
115
The most appropriate nursing diagnosis for a patient with a draining wound would be:
1) Risk for Infection related to dehiscence of wound.
2) Body Image Disturbance related to nonhealing surgical wound.
3) Risk for Impaired Skin Integrity related to wound drainage.
4) Pain related to surgical incision.
Answer:
3) Risk for Impaired Skin Integrity related to wound drainage.
Rationale:
The drainage from a wound places the patient at an increased risk for skin breakdown because of the dampness and presence of enzymes in the drainage. The risk of infection is present, but the data provided do not indicate this is a problem. There are no data indicating the patient is having a problem with body image or that he is in pain.
116
The nurse is assessing an ischial pressure ulcer on a client. She observes that the pressure ulcer is 3 cm × 2 cm × 1 cm and involves only subcutaneous tissue. The nurse also notes an area extending 3 cm from 12 o'clock to 3 o'clock under the wound edges. The nurse would document this as:
1) Stage IV pressure ulcer with undermining of 3 cm from 12:00 to 3:00.
2) Stage III pressure ulcer with undermining of 3 cm from 12:00 to 3:00.
3) Stage IV pressure ulcer with sinus tract from 12:00 to 3:00.
4) Stage III pressure ulcer with sinus tract from 12:00 to 3:00.
Answer:
2) Stage III pressure ulcer with undermining of 3 cm from 12:00 to 3:00.
Rationale:
A stage III pressure ulcer is characterized by full-thickness skin loss involving damage or necrosis of subcutaneous tissue, which may extend down to, but not through, the underlying fascia. Undermining is deeper-level damage of adjacent tissue. Sinus tracts are narrow, blind tracts underneath the epidermis.
117
To obtain the most accurate culture information of a chronic wound, the nurse would recommend:
1) tissue biopsy.
2) swab culture.
3) sterile culture.
4) needle aspiration culture.
Answer:
1) tissue biopsy.
Rationale:
A tissue biopsy, in which a piece of tissue is removed from the wound bed and analyzed, provides the most definitive information about infection status of a chronic wound. Chronic wounds are frequently colonized with bacteria; therefore, surface culture (swab) would not be accurate.
118
An older adult has a 3 cm × 2 cm eschar on the right heel. The initial treatment choice for this wound is:
1) elevate the right heel off the surface of the bed.
2) request a surgical consult for débridement of the area.
3) apply a hydrocolloid to promote autolytic débridement of the wound.
4) request an order for an enzymatic débridement medication.
nswer:
1) elevate the right heel off the surface of the bed.
Rationale:
A black wound (eschar) requires débridement of the necrotic tissue except at the heel. The Agency for Healthcare Quality and Research (AHQR) does not recommend débridement of this site. Therefore, your best treatment choice would be elevation of the heel off of the bed. This will relieve pressure to the affected area.
119
The patient with a new colostomy refuses to participate in the care of her colostomy or meet with a support member from the ostomy society. She will not look at the site and describes the colostomy as disgusting. Based on these data, the priority nursing diagnosis for Mrs. Lore is:
1) Anxiety related to colostomy.
2) Disturbed Body Image related to colostomy.
3) Disturbed Body Image related to incontinence of stool.
4) Impaired Skin Integrity related to fecal drainage.
Answer:
2) Disturbed Body Image related to colostomy.
Rationale:
Mrs. Lore is having difficulty adjusting to her colostomy. The colostomy is covered by a collection device, so there is no incontinence. There is no evidence of either anxiety or actual skin impairment.
120
The nurse will know ostomy care teaching is most likely successful when the patient with a new ostomy device:
1) demonstrates the proper method of cleansing her skin.
2) demonstrates proficiency when providing treatment to excoriated skin.
3) states she will start caring for the colostomy after she gets home.
4) proficiently performs colostomy care prior to discharge.
Answer:
4) proficiently performs colostomy care prior to discharge.
Rationale:
By performing colostomy care, Mrs. Lore's behavior reflects acceptance of her colostomy. There is no information to suggest that her skin is excoriated. Waiting until she gets home to start care is delaying acceptance and will not allow her to get assistance or further instruction. Demonstrating correct skin cleansing does not ensure that the client is actually performing colostomy care or has accepted her condition.
121
Answer includes the link to wound tutorial. It is very helpful, has lots of gross pictures and a quiz at the end. It covered a few things that the cards did not.
http://resources.fadavis.com/wilkinson/Wound_Care_Tutorial/tutorial.cfm?exercise=WoundCareTutorial&title=Wound%20Care%20Tutorial
