Essentials Flashcards
Ischemia
Obstructed blood flow to to skin tissue or organ
Hyperemia
Blood vessel expansion (vasodilation). Pressure is relieved and blood flow is returned, skin turns red.
Blanchable Hyperemia
Hyperemia does not last long after applying pressure
Nonblanchable Erythema
Skin does not turn light in color after applying pressure. Deep tissue damage occurs.
Edema
Abnormal accumulation of fluid or swelling
Tissue Slough
Dead tissue separates from living tissue
Shear force
Sliding movement of skin over bony protrusions
Example:
Elevated head on the bed. Sliding skeleton but skin intact.
Friction
Skin is dragged across coarse surface. Affects epidermis of skin.
Example: bed linen (sheet burn)
Moisture Associated Skin Damage (MASD)
Inflammation and erosion to skin from various sources of moisture.
Example: Wound drainage, urine, stool, wound exudate, mucus, or saliva
Stage 1 pressure injury
Intact skin, nonblanchable erythema
Stage 2 pressure injury
Partial-thickness skin loss with exposed dermis.
Wound bed is viable, pink, red, and moist. No tissue visualization, slough, or eschar.
Example: adverse microclimate and shear in skin over PELVIS and HEELS
Stage 3 pressure injury
Full skin thickness loss. Adipose tissue is visible along with rolled wound edges. Slough and eschar may be visible.
Stage 4 pressure injury
Full thickness skin and tissue loss with exposed or directly palpable fascia, musicale, tendon, ligament, cartilage, and bone.
Unstageable pressure injury
Obscured by slough or eschar. Tissue loss extent cannot be confirmed.
Deep-tissue pressure injury
Intact or non intact skin with persistent nonblanchable deep red, maroon, purple discoloration and epidermal separation revealing dark wound bed or blood filled blister.
Epibole
Rolled edges of skin around wound or ulcers
MDRPI
Medical Device Related Pressure Injury.
Example: occurs at face, head region, and ears. O2 masks, nasal cannulas, cervical collars, medical adhesives.
MARSI
Medical adhesive related skin injury persist after 30 mins or more after removal of device or adhesive securing the device
Example: IV sites
Closed Wounds
Skin is intact but underlying tissue is damaged
Example: contusions, hematomas, or Stage 1 pressure injuries
Closed Wounds
Skin is open and tissue is exposed. Increased risk for infection
Acute Wound
Caused by trauma or surgical incision, short duration, functional integrity can be restored. Wound edges are clean and intact
Chronic Wound
Caused by vascular compromise, chronic inflammation, or repetitive insults to tissue. Does not heal in timely process.
Primary Intention
Closed wound by epithelialization with minimal scarring. Forms natural fibrin seal.
Example: sutures or staples
Secondary Intention
Wound edges are not closed. Needs support of moist wound environment.
Example: surgical wounds that have tissue loss
Tertiary Intention
Wound is left open for several days for edges to be approximated
Example: for contaminated/infection wounds that require observation until resolved
Partial Thickness Wound
Shallow in depth, moist, and painful, generally appears to be red. Heals by regeneration
Full thickness wound
Extends to subcutaneous layer and is painful. Depth varies. Healing is new tissue formation.
Epithelialization
Filling wound with granulation tissue, wound contraction and resurfacing
SSI
Surgical Site Infection. Common in acute care settings. Occurs within 30 days of surgery.
Local Clinical Signs of Wound Infections
Erythema (redness or inflammation of skin, ex sunburn), increased wound drainage, change in appearance of wound drainage (color, odor, consistency), periwound warmth, pain, or edema.
Serous Wound Drainage
Clear Watery Plasma
Purulent Wound Drainage
Thick, yellow, green, tan, or brown
Serosanguineous Wound Drainage
Pale, pink, watery; mixture of clear and red fluid
Sanguineous Wound Drainage
Bright red; indicates active bleeding
Dehiscence
Partial or total separation of wound layers. Occurs 5-12 days after wound repair peak or suturing. Could see increase in serosanguineous fluid
Can happen when sudden strain such as coughing, vomiting, or sitting up. Pt report “given way.”
Evisceration
Total separation of wound layers and require emergency surgical repair.
Place sterile gauze soaked in saline over tissue to prevent bacteria and drying of tissue. Do not allow anything by mouth, observe signs of shock. Gather team.
Pressure Risk Injury Assessment: Acute Care
Within 8 hours of admission. Every 24-48 hours or change in pt condition
Pressure Risk Injury Assessment: Critical Care
On admission. Every 24 hours
Pressure Risk Injury Assessment: Long term care
On admission. Weekly for the first 4 weeks after admission. Routinely on quarterly basis, or change in pt condition
Pressure Risk Injury: Home Care
On admission. Every RN visit.
Braden Scale Components
Used in long term care and hospitals for pressure injury assessment. Max score 23 little to no risk. <16 is at risk. <9 is very high risk.
Sensory, Perception, Moisture, Nutrition, & Friction/Shear
Sensory Perception
Respond to pressure related discomfort
Moisture Perception
Degree to which skin is exposed to moisture
Activity Perception
Degree of patients physical activity
Mobility Perception
Ability to change and control body position
Nutrition Perception
Usual food intake
Friction and Shear Perception
Ability to adjust self to avoid discomfort
Calories
Cell energy (whole milk, nuts, beans, salmon)
Protein
Collagen formation and wound remodeling (poultry, eggs, fish, beef, milk)
Vitamin C
Collagen synthesis (citrus fruit, tomatoes, potatoes)
Vitamin A
Epithelialization, wound closure, inflammatory response, collagen formation (green vegetables, carrots, sweet potato, liver)
Zinc
Protein synthesis (vegetables, meats, legumes)
Wound infection indication
Purulent drainage, change in odor, volume, redness, fever, or pain.
Wound assessment factors
Amount (%) and color of viable and non-viable tissue, length, width, and depth
Granulation Tissue
Red moist tissue. Presence may indicate progress towards slow healing.
Slough
Soft yellow or white tissue (stringy substance attached to wound bed) must be removed in order for wound to heal
Eschar
Black, brown, tan tissue is necrotic (dead). Removal is needed.
Assessment of wound exudate (drainage)
Amount, color, consistency, odor
Induration
Hardening of tissue (skin) due to edema or inflammation
Maceration
Break down or softening of skin due to prolonged exposure moisture
Abrasion
Superficial wound with little bleeding and is considered a partial thickness wound.
Laceration
May bleed more profusely (esp if pt is on anticoagulants or blood thinners)
Puncture Wounds
Bleed in relation to depth, size, and location of wound. These wounds could cause internal bleeding and infection.
Assessment of Abnormal Healing (Primary)
Incision line poorly approx, drainage present >3 days after closure, inflammation increase in first 3-5 days after injury, no healing ridge by day 9
Assessment of Abnormal Wound Healing (Secondary)
Pale/fragile granulation tissue, wound exudate is Purulent, nonviable tissue (necrotic or slough) found in wound base, odor present after cleaning, presence of fistulas, tunneling, or undermining
Surgical Wound Drain
Remove excess wound fluid and promote wound healing in wound bed. Healing is done from the inside out.
Example) Penrose Drain: lies under dressing and is pinned or clipped.
Hemovac
Drain is connected to a suction. Exerts low pressure to suction drainage.
Hemostasis
Termination of bleeding by mechanical or chemical mean or coagulation
Debridement
Removal of nonviable necrotic tissue. Note increase or decrease in wound exudate, odor, and size
Autolytic debridement
Removal of dead tissue via lysis. Achieved by using dressing what support moisture in wound surface
Chemical debridement
Use of topical enzyme. Either Dakin (breaks down and loose a dead tissue in a wound) or sterile maggots (ingest dead tissue)
Surgical debridement
Removal of dead tissue with a scalpel, scissors, or sharp instrument. (Quickest removal)
Pressure dressings
Promote hemostasis for bleeding wounds. Applied elastic bandages and exerts local downward pressure. Eliminates dead space.
Hydrocolloid Dressing
Forms gel over wound exudate and is absorbed while maintaining a moist healing environment . Autolytically debride necrotic wounds. Used for shallow to moderately deep dermal injuries.
Hydrogel Dressing
Gauze or sheet soaked with water or glycerin based amorphous gel. Hydrates wounds and absorbs small amount of exudate. Used for partial or full thickness wounds, deep with some exudate, necrotic wounds, burns, and radiation damaged skin.
Foam Dressing
Used for wounds with large amount of exudate and that need pack. Used around drainage tubes for absorption.
Alginate Dressing
Manufactured from seaweed and form soft gel when in contact with wound fluid. Highly absorbent. NEVER use for dry wounds.
Negative Pressure Wound Pressure Therapy (NPWT)
Application or subatomic (-) pressure to wound through suction to facilitate healing an collect fluid. Used for chronic, a cure, traumatic, and dehiscence wounds. Common for diabetic patients. Wear time is 24 hours to 5 days.
Vacuum Assisted Closure (V.A.C)
Liquifies infection material and wound debris. Implements (-) pressure to dear edges of wound together.
MARSI
Medical Adhesive Related Skin Injury
Montgomery Ties
Multiple ties that fasten across dressings to avoid repeated removal. Common for demented, kids, or elderly patients
Irrigation
Used for open or deep wounds. Common for inaccessible body parts such as ear canal or sensitive body parts such as eyes. Fluid must flow directly over wound and not over a contaminated area.
Heat Therapy
Causes vasodilation and improves blood flow to injury. Increases muscle and ligament flexibility, relaxation and healing, spasm relief, joint pain and stiffness
Cold Therapy
Causes vasoconstriction. Treat inflammation of injury that presents as edema, hemorrhage, muscle & joint spasm or pain.
Sits baths
After redraw surgery, episiotomy during child birth, painful hemorrhoids, or vaginal inflammation. Pt sits in tub excludes leg and feet for 20 mins
Hypoxia
Insufficient oxygen reaching cells
Anoxia
Total lack of oxygen in body tissue
Hypoxemia
Reduced oxygenation of arterial blood
Capnography
End-tidal Co2 monitoring, provides information about patient ventilation, perfusion, and production of Co2. Measured near end of exhalation.
Dyspnea
Difficult or uncomfortable breathing. Observed labored breathing or SOB. Associated with hypoxia. Occurs with pregnant women in final months of pregnancy.
Orthopnea
Abnormal condition in which patient uses multiple pillows when reclining to breathe or sits leaning forward with arms elevated.
PND
Paroxysmal nocturnal dyspnea occurs when patient is asleep. Panic and suffocation.
Hemoptysis
Bloody Sputum associated with coughing and bleeding from upper RT and sinus drainage. Note if pt is on anticoagulants.
Hematemesis
Blood sputum from GI tract
Huff Cough
Natural cough reflex. Help move secretions to larger airways
Cascade Cough
Series of coughs through exhalation. Large amount of sputum. Common in cystic fibrosis patients.
Quad or Manually Assisted Cough
For patients without abdominal muscle control. Common in spinal cord injuries. Pt breathes out with maximal effort while nurse pushes inward and upward on abdominal muscles toward diaphragm
Diaphragmatic Breathing
Encourages deep nasal inspiration to increase airflow to lower lungs. Common for COPD pt to increase tidal volume and O2 saturation. Reduces dyspnea.
CPT
Chest Physiotherapy, helps mobilize pulmonary secretions through external chest wall manipulation using percussion, vibration, or high frequency chest wall compression.
HFCWC
High frequency chest wall compression is an inflatable vest attached to an air pulse generator that loosens and removes secretions. Send pulses to chest wall
PEP
Positive expiratory pressure allows air to be inhaled easily but forces patients to exhale against resistance. Helps expectorate mucus with CF or other lung diseases.
Incentive Spirometry
Encourages voluntary deep breathing that could prevent atelectasis. Should be used on pt that have undergone thoracic or abdominal surgery, prolonged bed rest, neuromuscular disease or spinal injuries. Measures volume of air moving in and out and calculates lung capacity.
ET
Endotracheal Tube. Invasive mechanical ventilation, relives upper airway obstruction, protections against aspiration or clear secretions. Remove within 14 days.
TT
Tracheostomy tube, made for prolonged mechanical ventilation, upper airway obstruction, trauma, difficulty with airway clearance. Pt with spinal or neuromuscular diseases
Open Suctioning
Through nose into trachea and pharynx. Catheter and port where endotracheal tubes connect to ventilator.
Closed Suctioning
Introducing suction catheter into airways without disconnecting a patient from ventilator
CPAP
Continuous (+) airway pressure maintains steady stream of pressure through pt breathing cycle. For pt with sleep apnea
BiPAP
Bilevel (+) airway pressure prevents alveolar closure
Ventilation
Movement of air in and out of lungs and is controlled by neurologic and musculoskeletal systems
Respiration
O2 and CO2 exchange in lungs and is controlled by pulmonary and cardiovascular system
ABG
Arterial Blood Gas measure pH, O2, CO2, bicarbonate concentrations in arterial blood. Used to to detect respiratory acidosis and alkalosis
Respiratory alkalosis
Develops during hyperventilation when excessive CO2 is exhaled. Example) hysteria & anxiety
CBC
Complete blood count reveals RBC (O2 carrying capacity of blood) Hb (O2 and CO2 transport capability) Hct (% of blood volume) and WBC (% of leukocytes)
Nasal Cannulas
Low flow. Most common, low flow delivery (1 to 15 L). Ideal for patients with stable respiratory patterns and require low levels of O2. (0.5 to 6.0 L) humidifier starts at 4
Face Masks (Simple)
For patients who require short term higher O2 concentrations. Can be set at rate no more than 6-10 L/min 40-60% of O2
NRB
Low flow. Have a reservoir bag (600 to 1,000 mL capacity) allows for higher concentration of O2 delivery. Used for pt that have smoke inhalation, carbon monoxide poisoning, and chronic airway disease, and hypoxia 100% O2
Ventimask
3-6 L of O2 35%-50% .9L/min
