Chapter 48 Flashcards
Tough fibrous protein
Collagen
Is localized injury to the skin and other underlying tissue, usually over a body prominence, as a result of pressure or pressure in combination of shear and or friction.
Pressure ulcer
Does not blanch
Dark pigmented skin
Inner layer of the skin that provides tensile strength and mechanical support
Dermis
Normal red tones of light skin patients are absent
Blanching
Top layer of the skin
Epidermis
Identify the 3 factors that contribute to pressure ulcer development?
> pressure intensity
pressure duration
pressure tolerance
What are hue he risk factors for pressure ulcer development?
- Impaired sensory perception
- Alterations of levels of consciousness
- Impaired mobility
- Shear
- Friction
- Moisture
Red moist tissue composed of new blood vessels which indicates wound healing
Granulation tissue
Stringy substance attached to wound bed that is soft, yellow, or white tissue
Slough
Black or brown necrotic tissue
Eschar
Describes the amount, color, consistency, and odor of wound drainage
Exudates
Wound that is closed closed by epitheliazation with minimal scar formation
Primary intention
Wound that is left open until it becomes filled by scar tissue, chance of infection is greater
Secondary infection
Pressure applied exceed s the normal capillary pressure and the vessel is occluded for a longed period of time.
Tissue ischemia
If the pressure is relieved and the blood flow returns the skin turns ____.
Red
The effect of this redness is vasodilation ( blood vessel expansion) it is called ______.
Hyperemia
Evaluate an area of hypermedia by pressing a finger over affected area. If it blanches ( turns lighter in color) and the erythema returns when you remove your finger, the hyperemia is transient and is an attempt to overcome the ischemic episode, is called ______.
Blanching hyperemia
If the erythematosus does not blanch (non blanching erythema) when you apply pressure, ________ tissue damage is probable
Deep
Occurs when the normal red tones of the light skinned patient are absent
Blanching
Extended pressure occludes blood flow and nutrients and contributes to cell death
Pressure duration
The ability of tissue to endure pressure depends on the integrity of the tissue and supporting structures.
Tissue tolerance
Is the sliding movement of skin and subcutaneous tissue while the underlying muscle and bone are stationary.
Shear
> when shear is present, the skin and subcutaneous layers adhere to the surface of the bed! and the layers of muscle and bone slide in hue he direction of body movement.
The force of two surfaces moving across one another such as mechanical force exerted when skin is dragged across a coarse surface as bed lines is called______.
Friction
Originates from wound drainage, excessive perspiration, and fecal or urinary incontinence.
Skin moisture
Intact skin with nonblanchable redness
Stage 1- the are maybe painful, firm, soft, warmer, or cooler than adjacent tissue. Hard to identify I with dark skin people which makes them at high risk.
Partial-thickness skin loss involving epidermis, dermis, or both
Stage 2-open ruptured/ serum-filled or serosanguinous filled blister.
Presents as a shiny or dry or dry shallow ulcer without slough or bruising.
Full-thickness tissue loss with visible fat
Stage 3-areas of significant adiposity can develop extremely deep.
Full thickness tissue loss with exposed bone, muscle, or tendon
Stage 4- slough and Escher might be present
How do you assess pressure ulcer?
Assessment includes depth of tissue involvement ( staging)
Type and approximate percentage of tissue in wound bed, wound dimension, exudate description, and condition of surrounding skin.
What is the major drawback of the wound staging system?
It cannot stage an ulcer covered with necrotic tissue because the necrotic tissue is covering the he depth of the ulcer.
Full thickness skin or tissue loss- depth unknown
Unstageable/unclassified ulcer
Purple or maroon localized area of dis colored intact or blood-filled blister caused damage of underlying soft tissue from pressure and/or shear
Suspected deep tissue injury
Is a disruption of the integrity and function of tissues in the body.
Wound
True or false: it is imperative for the nurse to know that all wounds are not created equal.
True- understanding of etiology of a wound is important because treatment for it varies, depending on the underlying disease process.
Wound that proceeds through an orderly and timely reparative process that results in sustained restoration of anatomical and functional integrity.
Acute- caused by trauma or a surgical incision
Wounds are usually cleaned and repaired.
Wound edges are clean and intact.
Wound that is closed.
Caused by surgical incision that is sutured or stapled
Healing occurs by epitheliazation, heals quickly with minimal scar formation.
Primary intention.
Wound edges are not approximated (closed).
Pressure ulcer, burns, surgical wounds that have tissue loss.
Wound heals by granulation tissue formation, wound contraction, and epitheliazation.
Secondary intention- takes longer to heal and chance of infection is greater.
What are there 3 components in the he healing process of a partial-thickness wound?
Inflammatory response
Epithelial proliferation (reproduction) and migration
Reestablishment of the epidermal layers.
Causes redness and swelling to the area with moderate amount of serous exudate to the first 24 hours after wounding.
Inflammatory response
Starts at both wound edges and the epidermal cells lining the epidermal appendages, allowing for quick resurfacing within 6-7 days if left open to air and 4 days if kept moist
Epithelial proliferation.
What are the phases involved in the healing process of a full thickness wound ?
Hemostasis
Inflammatory
Proliferation
Remodeling
A series of event designed to control blood loss, establish bacterial control, and seal the defect occurs when there is an injury.
Hemostasis- injured blood vessels constrict, and platelets gather to stop bleeding
Damage tissue and mast cells secrete histamine, resulting vasodilation and surrounding capillaries badge exudation of serum and WBC into damaged cells.
Inflammatory phase
Begins and last from 3-24 days where the filling of there wound with granulation tissue, contraction of hyena wound, and the resurfacing of the wound by epitheliazation.
Proliferative phase
Maturation and the final stages of healing
Remodeling
What are the the complication of healing?
Hemorrhage Hematoma Infection Dehiscence Evisceration
Bleeding from the wound site (normal)
Hemorrhage
Ex surgical suture slips from a blood vessel
You detect internal bleeding by looking for dis tension or swelling of the affected body part, a change in the he type and amount of drainage from a surgical drain, or signs of hypo olefin shock.
Is a localized collection of blood underneath the tissues.
Hematoma- it appears as a swelling, changed in color, sensation, or warmth or mass that often takes on a bluish discoloration.
A hematoma near a major artery or vein is dangerous because pressure from the expanding hematoma obstructs blood flow.
Is the second most common health-care associated nosocomial
Infection- the chances of wound infection are greater when the wound contains dead or necrotic tissue, there are foreign bodies near the wound, and the blood supply and local tissue defenses are reduced.
Tue or false: bacterial wound infection inhibits wound healing
True
How long does surgical wound infection usually develop?
4th or 5th postoperative day. Patient usually shows fever, tenderness, and pain at the wound site, and elevated WBC count.
Edges of the wound appear inflamed.
Odorous and purulent which causes a yellow, gee, or brown color full of pus.
Is the partial or total separation of wound layers.
Dehiscence-when a wound fails to heal properly, the layers of skin and tissue separate. People wit the poor nutritional status, infection or obesity are at higher risk.
Obese people are at higher risk because of the constant strain placed on the wounds and the poor healing of fat tissue.
Total separation of wound layers with protrusion of visceral organs
Evisceration- this is an emergency surgical repair. When this occursc the nurse must place sterile towel soaked in sterile saline over the extruding tissues to reduce chances of bacterial invasion and drying of the tissues. If the organs protrude through the wound, blood supply to the tissues is compromised. Immediately contact the surgical team, do not allow the patient anything by mouth (NPO), observe the patient for signs and symptoms of shock, and prepare him or her for emergency surgery.
Was developed based on risk factors in a nursing home population and is composed of six subscales: sensory perception, moisture, activity, mobility, nutrition, and friction/shear.
The Braden Scale
6-23. A lower total score indicates a higher risk for pressure ulcer
How much kcal/day of nutritional maintenance does a person need to be well nourished?
1500 kcal
What kinds of vitamins does a person need for wound healing?
Vitamin A and C including proteins and trace minerals and copper.
Is a protein formed from amino acids acquired by fibroblasts from protein ingested in food.
Collagen
Essential for synthesis of collagen
Vitamin C
Reduces the negative effects of steroid in wound healing
Vitamin A
Examples of trace element that can help with epitheliazation and collagen synthesis and ____ for fiber linking.
Zinc and copper for collagen fiber linking
Why are proteins essential for wound healing?
Proteins increased for tissue repair and growth
Oxygen fuels the cellular functions essential to the healing process therefore the ability to _____ the tissues with adequate amounts of oxygenated blood is critical to wound healing.
Perfusion
True or false: patients with peripheral vascular disease are at I risks for poor tissue perfusion because of poor circulation.
True- bec oxygen requirements depend on the phase of poor circulation ( ex chronic tissue hypoxia is associated with impaired collagen synthesis and reduced tissue resistance to infection.)
What are the factors of infection?
Wound infection prolongs the inflammatory phase, delays collagen synthesis, prevents epithelialization and increase the production of pro inflammatory cytokines which leads to additional tissue destruction.
What are the indications of wound infection?
Presence of purulent drainage, reed ness, change in odor, volume, character of wound drainage, fever or pain.
When checking for skin integrity ask for 4 things?
Sensation, mobility, continence, and presence of wound
Who are the vulnerable for pressure ulcers?
The neurologically impaired patient, the chronically ill patient in the ltc, patient with diminished mental status and patients at the icu, oncology, hospice, orthopedic patients
Abnormally large amount of blood in any body part
Hyperemia- when you note of this, document the location, size, and color and reassess the area after 1 hour.
True or false: a loss of 5% of usual weight! weight less than 90% of ideal body weight and a decrease of 10 lbs in a brief period are all signs of actual or potential nutritional problems.
True
True or false: exposure to urine, Nile, stool, ascetic fluid, purulent wound exudates carries a moderate risk for skin breakdown, especially in patients who have other risk factors such as chronic illness or poor nutrition.
True- additionally exposure too gastric and pancreatic drainage has the highest risk for skin breakdown.
True or false: Maintaining adequate pain control and patient comfort increases the patient’s willingness and ability to increase mobility, which in turn reduces pressure ulcer risk.
True
A nurse assess wounds under two conditions:
At the time of injury before treatment and after therapy when the wound is relatively stable.
When you judge a patient’s condition to be stable because of the presence of spontaneous breathing, clear airway, and a strong carotid pulse what should you do next?
Inspect the wound for bleeding.
Is a superficial with little bleeding and is considered a partial thickness wound. The wound often appears “weepy” because of plasma leakage from damaged capillaries.
Abrasion
____ sometimes bleeds more profusely! depending on the depth and location of the wound.
Laceration
Ex. Lacerations greater than 5 cm (2 inches) long or 2.5 cm (1 inch) deep cause serious bleeding.
Bleeds in relegation to the depth and size if the wound.
Puncture wounds
Ex. Nail puncture does not cause as much bleeding as a knife wound. The primary dangers of puncture wounds are internal bleeding and infection.
True or false : If the wound is covered by a dressing and the health care provider has not ordered it changed, do not directly inspect it unless you suspect serious complications but under what circumstances?
True but if patient has sacral pressure ulcer and voided and dressing is soiled, nurse can go ahead and change it. But in such situation inspect only the dressing and any external drains. If the health care provider prefers to change the dressing he or she can assess the wound atlst daily.
Consider giving analgesics 30 mins before exposing a wound.
Clear, a watery plasma appearance is called?
Serous
Thick, yellow, green, tan or brown appearance is called?
Purulent
Pale, pink, watery, mixture of clear and red fluid
Serosanguineous
Bright red indicates active bleeding
Sanguine pus
What are the characteristics of a dark skin impaired skin integrity?
> Color- color remains unchanged when pressure is applied. If patient previously has a pressure ulcer, that area of skin may be lighter than original color.
Temperature- circumscribed area of intact may be warm to touch. As tissue changes color, intact skin feels cool to touch.
Inflammation is detected by making comparisons to surrounding skin.
Appearance- edema may occur with induration and appear taut and shiny.
Localized area of skin may be purple/blue or violet instead of red.
Is a slightly bluish grayish slate like or dark purple discoloration of the skin caused by the presence of a at least 5 g of reduced hemoglobin in arterial blood.
Cyanosis
True or false: in dark-skinned patients, you need to know the individual’s baseline skin tone. You should not confuse the normal hyper pigmentation of Mongolian spots that are seen on the sacrum of dark skinned patients.
True- observe the patient’s skin in on glare daylight.
_____ is a useful tool for assessment for identifying changes in is in color that increase the patient’s risk for pressure ulcers..
Nursing assessment of skin color ( GNASC)
T/F: it is difficult but possible to detect cyanosis in the dark-skinned patient.
True- examine body sites with the least melanin such as under the arm for underlying color identification.
True or false: it is usually the health care provider’s responsibility to pull or advance the drain as drainage decreases to permit healing deep within the drain site.
True page 1190
What do you need to do when there is a sudden decrease in drainage through the tubing that may indicate a blocked drain?
Notify health care provider.
What are some type of suction devices to drain wound fluids?
Hemovac or Jackson-Pratt - these devices are often referred as self-suction.
T/F :When the evaluator device is unable to maintain a vacuum on its own, notify surgeon, who then orders a secondary vacuum system ( such as wall suction).
True
If loud accumulates within the tissues, wound healing does not progress at an optimal rate, and this increases the risk of infection.
True or false: never collect a wound culture sample from old drainage.
True page 1191
Resident colonies of bacteria from the skin grow within exudate and are now always true causative organisms of a wound infection.clean a wound first with normal saline to remove skin flora. Aerobic organisms grow in superficial wounds exposed to the air, anaerobic organisms tend to grow within body cavities.
What is the gold standard of wound culture?
Tissue biopsy
What is your goal for wound healing and usually how long is the expected healing?
2 weeks
Outcomes and goals will include:
Higher percentage of granulation tissue in the wound base.
No further skin breakdown in any body location
An increase in the caloric intake by 10%
Teamwork and collaboration planning:
Anticipating the patient’s discharge wound care needs and related equipment and resources such as referral to a home care agency or outpatient care clinic helps to improve not only wound healing but also the patient’s level of independence.
What is the first step of implementation for pressure ulcer?
First is to assess the patient’s risk factors for pressure ulcer development. The plan on reducing or eliminating the identified risk factors.
What are the 3 majors areas of nursing interventions for prevention of pressure ulcer?
1) skin care and management of incontinence.
2) mechanical loading and support devices, which include proper positioning and the use of therapeutic surfaces.
3) education.
Nursing diagnostic process box 48-8
Obtain patient’s temperature, heart adage, WBC, and serum albumin level.
Patient’s febrile, heart rate 125 beats/min, leukocyte (WBC) count 12,000/mm3, serum albumin less than 3.5 g/100 mL.
Inspect wounds for signs of healing- brown-red or beige drainage 5 days after surgery and edges of wouldn’t not approximated.
When cleaning the patient’s skin avoid using _____ and _____
Soap and hot water. Use cleaner with nonionic surfactants that are gentle to the skin instead.
Position patient’s every how many hours?
1 to 2 hours as indicated
To avoid friction and shear
Reposition patient using draw sheet and lifting off surface. Provide trapeze to facilitate movement.
Position patient at a 30-degree lateral turn and limit head elevation to 30 degrees.
What are the risk factors of pressure ulcer?
Decreased sensory perception Moisture Friction and shear Decreased and shear Decreased activity mobility Poor nutrition
True or false: Rigid and donut shaped cushions are contraindicated because they reduce blood supply to the area, resulting in wider areas of ischemia.
True page 1197
Have the patient sit on of lam or gel or an air cushion to redistribute weight away from the ischial areas.
True or false: treatment of patients with pressure ulcer requires a holistic approach that uses the expertise of several multidisciplinary health care professionals
True
Acute wounds requires close monitoring every ___ hours.
8
Evaluate the wound with every dressing change, usually not more than 1 time per day.
Is the removal of nonviable, necrotic tissue.
Debrinement
True or false: a wound does not move through the phases of healing if it is infected. How do you prevent infection?
True
Preventing a wound infection includes cleaning and removing nonviable tissue with noncytotoxic with normal saline
Cytotoxic solutions are Dakin’s solution (sodium hypochlorite solution), acetic acid, povidone-iodine, and hydrogen peroxide are not used in clean, granulating wounds.
True
Give an example of mechanical debrinement
Wet to dry saline gauze dressing. Place moistened gauze into the wound and allow the dressing to dry thoroughly before “pulling” the gauze that has adhered to the tissue out of the pressure ulcer.
NEver use this method in a clean, granulating wound.
Other examples of mechanical wound debrinement
High pressure irrigation and pulsating high pressure
Uses synthetic dressings over a wound to allow the Escher to be self digested by the action of enzymes that are present in wound fluids.
Autolytic debrinement
Use of topical enzyme preparation, dakin’s solution or sterile maggots.
Chemical debrinement
These preparation require a health care provider’s order. Because Dakin’s solution breaks down and loosens the wound. Sterile maggots are used in a wound because it is through that they ingest the dead tissue.
True or false: moist environment supports the movement of epithelial cells and facilitates wound closure.
True
