Chpt.5 Wound Care

Question 1

What is the largest organ of the body?

Answer 1

The skin

Question 2

What purpose does the skin serve?

Answer 2

• Protection for underlying organs and structures

* Excretion of wastes and regulation of body temperature

Question 3

Layers of the skin:

Answer 3

Outer, protective layer: Epidermis
Middle layer: Dermis, which contains nerves, hair follicles, sweat glands, oil glands
Last layer: Subcutaneous tissue or fat.

Question 4

Infection Alert

Answer 4

• Scabies and body lice are microscopic parasites that appear to be numerous, tiny scabs on the skin surface.
• Head lice do not hop, jump, or fly.

Question 5

Characteristic of Stage I

Answer 5

• Nonblanchable erythema of intact skin.

* Redness, warm, hard

Question 6

Care for Stage 1

Answer 6

• Risk of further breakdown
• Pressure Reduction
• Assess daily
• No dressing required
• Protect skin: sprays, gels, films, powders
• Cover and Protect

Question 7

Characteristic of Stage II

Answer 7

• Partial thickness; skin loss
• Skin broken/ open
• shallow ulcer, blister, abrasion

Question 8

Care for Stage II

Answer 8

• Stage 1 care plus
• Protect from infection
• Provide moist environment
• Polyurethane foam
• Moistened gauze dressing
• pressure reduction
• assess daily
• Cover, protect, hydrate, insulate, absorb

Question 9

Characteristic of Stage III

Answer 9

• Full thickness tissue loss
• Fat may visible
• Bone, tendon, muscles are not exposed but may include tunneling.

Question 10

Care for Stage III

Answer 10

• Stage 1 & 2 Care Plus
• May need to debride’
• May need absored dressing to absorb large amount of drainage
• Keep wound bed moist
• Pressure relief
• Assess daily
• Cover, protect, insulate, absorb, prevent infection,

Question 11

Characteristic of Stage IV

Answer 11

• Full thickness skin loss,
• Exposed bone, tendons, muscle
• Dead tissue, eschar, ( dry, dark scab)
• Includes tunneling
• Extreme necrosis

Question 12

Care for Stage IV

Answer 12

• Stage 1,2,3 Care Plus
• Consults experts
• WOCN- wound, Ostomy, and Continence Nurse
• Cover, protect, hydrate, insulate, absorb, cleanse, obliterate dead space, promote healing

Question 13

Systemic Factors that affect wound healing

Answer 13

• age
• nutritional status
• body build
• presence or absence of chronic disease
• circulatory problems
• weakened immune system
• radiation therapy

Question 14

Local factors that affect wound healing

Answer 14

• moist wound environment
• infection
• necrotic tissue (dead tissue)
• foreign objects in the wound
• trauma
• edema
• pressure on the wound
• incontinence and presence of excretions contaminating the wound

Question 15

Wound Observations to Report

Answer 15

• Redness
• Drainage ( pus-like and foul-smelling)
• Heat
• Edema
• Fever
• Increased pain or tenderness
• Edema of tissue surrounding the wound
• Separation of wound edges
• Trauma or injury
• Maceration ( waterlogged appearance of the wound edges)
• Bruising
• Frank bleeding

Question 16

Multiple dressings

Answer 16

• Care for each wound separately
• New gloves for each wound
• Wash hands in between wounds
• Always work from cleanest to least clean wound

Question 17

Products harmful to wounds

Answer 17

• Peroxide and povidone iodine are not recommended for open wounds because they destroy granulation tissue.
• May antiseptic cleansing products are cytotoxic, they harm healing tissue and should not be used.

Question 18

Health Alert

Answer 18

Make sure you pick the right type of gauze, some are soft and absorbent and other are rough and irritating and can be traumatic to the healing skin.

Question 19

Cleansing wound

Answer 19

• Cleanse linear wound surgical incision from to top to bottom
• Work from clean to less clean areas
• Use new gauze pad for each stroke
• Work outward from the wound in parallel lines.
• Avoid rubbing back and forth
• Rinse, if necessary using the same technique
• Cleanse open wound, work in half circles or full circles
• Begin in center of wound and work outward
• Clean at least one inch beyond the edge of dressing
• If no will be applied, then clean at least two inches beyond the wound margin.

Question 20

Guidelines for wound Irrigation

Answer 20

• Wash hands or use alcohol- based hand cleaner
• Obtain the necessary sterile equipment and sterile irrigation solution
• Check for exp. date on each sterile item and inspect for tears, cracks, or other packaging problems. If irrigation solution has been opened, check the date. Discard if it has been open longer then 24 hours.
• If irrigation solution is cold, let it stand until it reaches room temp, or use warm water to heat it to 90 to 95 degrees F or according to RN instructions.
• Open trash and keep it at the foot of the bed. Make sure you will not have to reach across sterile field to discard trash
• Clean overbed table with disinfectant and let dry. Cover with disposable underpad
• Position additional underpads under the patient to contain spills.