Exam 2 module 3 part 5 Flashcards
Skin and Wound Healing Ch 32
What is skin integrity?
The preservation of all layers of the skin being intact.
What is a wound?
A disruption in the normal skin integrity.
How are skin integrity and wounds related?
They are opposites.
What factors affect skin integrity?
Factors include age and mobility.
What is the epidermis?
The outer portion of the skin.
How many layers does the epidermis have?
Four or five layers.
What is the stratum corneum?
The outermost layer of the epidermis composed of dead cells.
What is the function of the stratum corneum?
It restricts water loss and prevents fluids, pathogens, and chemicals from entering the body.
What is the stratum germinativum?
The innermost layer of the epidermis that produces new cells.
What are keratinocytes?
Protein-containing cells in the dermis that provide strength and elasticity to the skin.
What do melanocytes produce?
Melanin, a pigment that gives skin its color.
What is the function of Langerhans cells?
To phagocytize foreign material and trigger an immune response.
Where is the dermis located?
Below the epidermis and above the subcutaneous tissue.
What type of tissue is the dermis made of?
Irregular fibrous connective tissue.
What structures are found within the dermis?
- Sweat glands
- Sebaceous (oil) glands
- Ceruminous (wax) glands
- Hair and nail follicles
- Sensory receptors
- Elastin
- Collagen
What is the subcutaneous tissue composed of?
Connective and adipose tissue.
What are the functions of the subcutaneous layer?
- Provides insulation
- Offers protection
- Serves as a reserve of calories
What influences the distribution of subcutaneous tissue?
- Sex hormones
- Genetics
- Age
- Nutrition
True or False: Age does not affect skin integrity.
False
Fill in the blank: The _______ is the outermost layer of the epidermis.
stratum corneum
Fill in the blank: The _______ layer is composed primarily of connective and adipose tissue.
subcutaneous
What is vernix caseosa?
A creamy substance that protects an infant’s skin
Vernix caseosa varies in amount at birth
How does an infant’s skin differ from an adult’s skin?
Thinner and more permeable
This predisposes infants to skin breakdown, such as diaper rash
What developmental aspect of infants affects thermoregulation?
Underdeveloped subcutaneous layer and sweat glands
Infants must be swaddled to maintain body heat
What happens to the skin texture of children as they age?
Becomes coarser due to exposure to sun and environmental elements
Infants and young children initially have smooth skin
What hormonal changes occur during adolescence that affect skin?
Increased sex hormones lead to sebaceous and sweat gland activity
This can result in perspiration, odor, and acne
What skin changes may occur in women due to high estrogen levels?
Softening of connective tissue, striae, and darkening of the skin
Commonly seen on the face, areolae, nipples, vulva, and umbilicus
What skin condition affects up to 85% of older adults?
Xerosis
Characterized by itchy, red, dry, scaly, cracked, or fissured skin
What happens to the dermal layer of older adults’ skin?
Loses elasticity due to collagen changes
This increases the risk of skin breakdown and prolongs wound healing
How does aging affect wound healing in older adults compared to young adults?
Regeneration of healthy skin and healing is significantly slower
Chronic diseases in older adults can further interfere with healing
What are some chronic diseases that can interfere with skin healing?
- Diabetes
- Liver dysfunction
These conditions can predispose to infections and affect blood-clotting factor synthesis
What is a key risk factor for immobility-related pressure injury?
Inability to move independently or lack of sensation
Pressure from the body weight can lead to skin tissue injury
List some conditions that increase the risk for immobility-related pressure injury.
- Paralysis
- Extreme fatigue
- High-risk pregnancy
- Sedation
- Casts
- Traction
- Altered sensory perception
These conditions can prevent movement and increase pressure on the skin
What does skin condition reflect?
A person’s overall nutritional status
Nutritional intake affects the skin.
What is essential to maintaining skin integrity?
Adequate intake of protein, cholesterol, calories, fluid, vitamin C, and minerals
These nutrients contribute to skin health.
Why is protein important for the skin?
It maintains the skin, repairs minor defects, and preserves intravascular volume
Adequate protein levels are critical for skin health.
What happens when protein levels decline?
- Skin injury is slow to heal
- Minor defects cannot be repaired
- Edema develops
Fluid leaks from the vascular compartment of dependent areas.
How does edema affect the skin?
- Decreases skin elasticity
- Interferes with oxygen diffusion
- Prone to breakdown
Edema is excess fluid in the tissues.
What is the consequence of low cholesterol levels?
Predisposes patients to skin breakdown and inhibits wound healing
Low-fat tube feedings may lead to deficiencies.
What role do fats play in wound healing?
Provide fuel for wound healing and maintain a waterproof barrier in the stratum corneum
Cholesterol, fatty acids, and linoleic acid are important.
What happens with inadequate calorie intake?
The body uses proteins for energy, making them unavailable for building and maintenance functions
This leads to catabolism.
What are the effects of prolonged malnutrition?
- Weight loss
- Loss of subcutaneous tissue
- Muscle atrophy
- Decreased padding between skin and bones
This predisposes skin to pressure injuries.
Which nutrients are involved in collagen formation and maintenance?
- Vitamin C (ascorbic acid)
- Zinc
- Copper
A deficiency can delay wound healing.
What can poor skin turgor indicate?
Dehydration
Skin turgor reflects the hydration status of the skin.
What does edema result from?
Overhydration
Both dehydrated and edematous skin are prone to injury.
What conditions make skin more prone to injury?
- Pressure
- Shearing
- Friction
- Moisture
Both dry and overhydrated skin are at risk.
What condition developed on the patient’s bony prominences?
Pressure injury
What are the contributing factors for the development of pressure injury?
Immobility, friction, shear, postoperative drainage
What is the population targeted in the PICOT framework?
Malnourished adults
What is the intervention in the PICOT framework?
Nutritional supplements
What is the comparator in the PICOT framework?
Diet without supplements
What is the expected outcome of the intervention in the PICOT framework?
Improved (or faster) healing time
Fill in the blank: The PICOT framework includes Population, Intervention, Comparator, Outcome, and _______.
Time
What is diminished tactile sensation?
A reduced ability to sense touch, heat, and pressure in affected areas
Patients with conditions like peripheral vascular disease, spinal cord injury, diabetes, cerebrovascular accident, trauma, or fractures often experience diminished tactile sensation.
What are the risks associated with diminished sensation?
Increased risk of skin breakdown, burns, unnoticed cuts or wounds, and inability to feel pressure
Patients may not shift position to relieve pressure or notice constricting footwear or clothing.
How does impaired cognition affect pressure injury risk?
Increased risk due to lack of awareness of the need to reposition
Conditions such as Alzheimer disease and dementia can lead to cognitive impairment.
What is impaired arterial circulation?
Restriction of activity, production of pain, and muscle atrophy due to reduced blood flow
Impaired arterial circulation can result in thin tissue that may lead to tissue death.
What is impaired venous circulation?
Engorged tissues with high levels of metabolic waste, leading to edema, ulceration, and breakdown
This occurs when blood flow back to the heart is inadequate.
What is the main cause of chronic wounds?
Circulatory impairment
Both arterial and venous circulation issues interfere with tissue metabolism and delay wound healing.
Fill in the blank: Patients with diminished sensation are less able to sense a _______.
hot surface
True or False: Cognitive impairment can be easily recognized in patients.
False
What should caregivers do to help manage patients with impaired cognition?
Talk to families or caregivers and review the patient’s health history
This helps adjust the plan of care.
List some conditions that can lead to diminished tactile sensation.
- Peripheral vascular disease
- Spinal cord injury
- Diabetes
- Cerebrovascular accident
- Trauma
- Fractures
What happens to tissue due to impaired venous circulation?
Tissue becomes engorged, susceptible to edema, ulceration, and breakdown
What are some effects of medications on skin integrity?
Medications can cause pruritus, dermatoses, photosensitivity, alopecia, or pigmentation changes
These effects can impair skin integrity or delay healing.
How do blood pressure medications affect blood flow?
They decrease the amount of pressure required to occlude blood flow, creating a risk for ischemia
Ischemia is insufficient blood supply to tissues.
What is the impact of anti-inflammatory medications on wound healing?
They inhibit wound healing
Examples include over-the-counter NSAIDs and steroids like prednisone.
What is the effect of anticoagulants on tissue injury?
They can lead to extravasation of blood into subcutaneous tissue, causing hematomas
Anticoagulants include heparin and warfarin.
Which class of medications delays wound healing due to toxicity?
Chemotherapeutic agents
Methotrexate is an example.
What types of medications can increase sensitivity to sunlight?
Certain antibiotics, psychotherapeutic drugs, and chemotherapy agents
This increases the risk for sunburn.
What severe skin condition can be triggered by certain antibiotics and psychotherapeutic drugs?
Stevens-Johnson syndrome
This condition is characterized by severe rash and skin peeling.
Fill in the blank: Several herbal products, such as those containing lavender and tea tree oil, _______ but dry out the skin.
cleanse
These products can cleanse the skin while also leading to dryness.
What is the effect of excessive exposure to moisture on the skin?
Leads to maceration and increases the likelihood of skin breakdown
Maceration refers to the softening of the skin due to prolonged moisture exposure.
What are the most common sources of moisture that lead to skin damage?
Incontinence and fever
Bowel incontinence is particularly troublesome due to the presence of digestive enzymes and microorganisms.
What is the consequence of bowel incontinence on the skin?
Can lead to excoriation, moisture-associated skin damage, dermatitis, pressure injury, and infection
Excoriation refers to the denuding of superficial skin layers.
How does fever contribute to skin issues?
Leads to sweating and increases metabolic rate, raising tissue demand for oxygen
Increased oxygen demand is especially problematic with circulatory impairment or pressure-induced tissue compression.
What does contamination of a wound refer to?
Presence of microorganisms in the wound
All chronic wounds are considered contaminated.
What is colonization in the context of wound care?
Microorganisms increase in number but cause no harm
Colonization can occur from surrounding skin, the external environment, and internal sources like the GI system.
What is critical colonization?
When bacteria begin to overwhelm the body’s defenses
Signs include increased drainage, foul odor, color change of the wound bed, new tunneling, or absent/friable granulation tissue.
What does infection imply in wound care?
Microorganisms are causing harm by releasing toxins, invading tissues, and increasing metabolic demand
Infection makes the skin more vulnerable to breakdown and impedes healing.
True or False: Infection in the skin can allow bacteria to access systemic circulation.
True
If not controlled, bacteria can enter the bloodstream.
What risks are associated with tanning?
Increases the risk for skin cancer and drying the skin
Tanning exposes the skin to ultraviolet radiation.
How can excessive skin cleansing affect the skin?
May impair skin integrity and lead to drying
Frequent bathing and use of soap remove skin oils.
What are the consequences of insufficient skin cleansing?
Contributes to excessive oiliness, clogged sebaceous glands, and inadequate removal of microbes
This can lead to infections on wounds or lesions.
How does regular exercise benefit the skin?
Improves circulation, necessary for skin integrity and wound healing
Circulation is vital for delivering nutrients and oxygen to skin tissues.
What role does a nutritious diet play in skin health?
Provides nutrients needed to maintain skin integrity
Nutrients are essential for skin repair and health.
How does smoking affect the skin?
Compromises oxygen supply, delays wound healing, and interferes with vitamin C absorption
Vitamin C is necessary for collagen formation.
What risks do body piercings and tattoos pose?
Risk for infection and scarring
Common complications include local inflammation, allergic reactions, and skin infections.
What are the common bacterial infections associated with body piercings?
Staphylococcus and Pseudomonas strains
These bacteria are often found at or near the site of body piercings.
What systemic infection can result from unsterile tattooing conditions?
Hepatitis C
Unsterile conditions can lead to serious infections.
What complications can arise from oral piercings?
Gingivitis, damage to teeth and gums, choking, difficulty eating, and changes in speech
Oral piercings can lead to various oral health issues.
What can prolonged bleeding during tongue piercing indicate?
A punctured blood vessel
Prolonged bleeding can be a serious complication.
What should patients do before getting a tattoo or piercing?
Become informed about the procedure and aftercare, and find reputable tattoo artists/piercers
Knowledge and safety are key to minimizing risks.
What is a wound?
A disruption in the normal integrity of the skin
Wounds may be intentional (surgical) or unintentional (cuts, pressure injuries)
How are wounds classified?
According to length of time and condition of the wound
Factors include contamination and severity
What defines a closed wound?
No breaks in the skin
Examples include contusions and tissue swelling from fractures
What is an open wound?
A break in the skin or mucous membranes
Includes abrasions, lacerations, puncture wounds, and surgical incisions
What is a compound fracture?
A fracture that leads to an open wound caused by the projection of bone through the skin
This type of injury can create significant complications
What are acute wounds?
Wounds expected to be of short duration that heal spontaneously
They go through three phases: inflammation, proliferation, and maturation
What characterizes chronic wounds?
Wounds that exceed the expected length of recovery due to interrupted healing
Examples include pressure injuries and diabetic ulcers
List factors that can stall the healing of chronic wounds.
- Infection
- Continued trauma
- Ischemia
- Edema
These factors can lead to prolonged recovery times
What are clean wounds?
Uninfected wounds with minimal inflammation
They may be open or closed and do not involve certain tracts that harbor microorganisms
True or False: Clean wounds involve the gastrointestinal, respiratory, or genitourinary tracts.
False
Clean wounds do not involve these systems, which frequently harbor microorganisms
Fill in the blank: Chronic wounds may linger for _______ or even years.
months
Unless properly diagnosed and treated, chronic wounds can persist for long durations
What is an abrasion?
A scrape of the superficial layers of the skin; usually unintentional but may be performed intentionally for cosmetic purposes to smooth skin surfaces.
Also see excoriation.
Define abscess.
A localized collection of pus resulting from invasion from a pyogenic bacterium or other pathogen; must be opened and drained to heal.
What is a contusion?
A closed wound caused by blunt trauma; may be referred to as a bruise or an ecchymosis.
Describe a crushing wound.
A wound caused by force leading to compression or disruption of tissues, often associated with fracture; usually minimal or no break in the skin.
What is an excoriation?
A superficial wound, usually self-inflicted due to excessive scratching or mechanical force.
What characterizes an incision?
An open, intentional wound caused by a sharp instrument.
Define laceration.
The skin or mucous membranes are torn open, resulting in a wound with jagged margins.
What is a penetrating wound?
An open wound in which the agent causing the wound lodges in body tissue.
Describe a puncture wound.
An open wound caused by a sharp object; often there is collapse of tissue around the entry point, making this wound prone to infection.
What is a tunnel wound?
A wound with entrance and exit sites.
What are clean-contaminated wounds?
Surgical incisions that enter the GI, respiratory, or genitourinary tracts with increased risk of infection but no obvious infection.
These wounds are at risk due to their nature of entering areas that are normally not sterile.
What characterizes contaminated wounds?
Open, traumatic wounds or surgical incisions with a major break in asepsis and high risk of infection.
Contaminated wounds often involve exposure to pathogens.
Define infected wounds.
Wounds with bacteria above 100,000 organisms per gram of tissue.
Presence of beta-hemolytic streptococci in any number is also considered an infection.
List signs of wound infection.
- Erythema and swelling around the wound
- Fever
- Foul odor
- Severe or increasing pain
- Large amount of drainage
- Warmth of the surrounding soft tissue
These signs indicate potential complications in wound healing.
What is a major determinant of wound healing time?
Depth of the wound and location.
Deeper wounds take longer to heal, and wounds in areas of pressure or movement heal slower.
How does circulation affect wound healing?
Wound healing is more difficult in areas of poor circulation, such as the feet in those with diabetes or congestive heart failure.
Adequate blood flow is essential for healing.
What are superficial wounds?
Wounds that involve only the epidermal layer of the skin, usually due to friction, shearing, or burning.
These wounds typically heal faster than deeper wounds.
Describe partial-thickness wounds.
Wounds that extend through the epidermis but not through the dermis.
These wounds can be more complex than superficial wounds.
What are full-thickness wounds?
Wounds that extend into the subcutaneous tissue and beyond.
The term ‘penetrating’ may be added if internal organs are involved.
What types of cells are involved in the wound healing process?
Epithelial cells, endothelial cells, inflammatory cells, platelets, fibroblasts
Fibroblasts are cells in connective tissue that produce fibrin.
What is the primary function of fibroblasts in wound healing?
To produce fibrin
Fibrin is essential for tissue repair and regeneration.
Does the wound healing process differ based on the type of injury or tissues involved?
No, the process is essentially the same regardless of the type of injury or tissues involved.
Fill in the blank: The wound healing process involves the migration of _______ into the wound.
cells
True or False: Wound healing is a uniform process across different types of injuries.
True
What is the role of platelets in the wound healing process?
To assist in tissue repair and regeneration
List the main cell types involved in the wound healing process.
- Epithelial cells
- Endothelial cells
- Inflammatory cells
- Platelets
- Fibroblasts
What do epithelial and endothelial cells contribute to during wound healing?
Tissue repair and regeneration
What is the primary cause of pressure injuries?
Pressure, shear, and friction resulting in tissue ischemia and injury
Pressure injuries are often located over bony prominences and can lead to serious tissue damage.
What are the common characteristics of arterial ulcers?
Located over lower leg, especially ankles, toes, side of foot, and shin; appears ‘punched out’, small and round with smooth borders; wound base usually pale; shiny, thin, dry surrounding skin; cool to touch; loss of hair in surrounding area; delayed capillary refill time; very painful, especially at night and with increased activity
Arterial ulcers are caused by inadequate circulation of oxygenated blood to the tissue.
Where are venous stasis ulcers typically located?
Around the inner ankle or in the lower part of the calf
Venous stasis ulcers are caused by incompetent venous valves, deep vein obstruction, or inadequate calf.
What is a distinctive feature of the surrounding skin of arterial ulcers?
Shiny, thin, and dry; cool to touch
This characteristic is due to inadequate blood flow and oxygenation.
True or False: The appearance of pressure injuries is uniform regardless of the stage.
False
The appearance of pressure injuries varies depending on the stage or tissue layers involved.
Fill in the blank: Arterial ulcers are very painful, especially at _______ and with increased activity.
night
What are the common symptoms of venous stasis ulcers?
Reddened or brown surrounding skin; edematous
These symptoms are due to fluid accumulation and poor circulation.
What is the wound base appearance of arterial ulcers?
Usually pale with or without necrotic tissue
Necrotic tissue may be present if the ulcer is severe.
What causes arterial ulcers?
Inadequate circulation of oxygenated blood to the tissue
This leads to tissue ischemia and subsequent damage.
What type of injury is characterized by tissue ischemia and injury due to pressure, shear, and friction?
Pressure injury
What causes venous stasis ulcers?
Incompetent venous valves, deep vein obstruction, or inadequate calf muscle function
Where are venous stasis ulcers usually located?
Around the inner ankle or in the lower part of the calf
What are the characteristics of the surrounding skin of venous stasis ulcers?
Reddened or brown and edematous
Describe the wound characteristics of venous stasis ulcers.
Usually shallow, with irregular wound margins
What does the wound bed of a venous stasis ulcer appear like?
Ruddy or beefy red and granular
What is the typical drainage level of venous stasis ulcers?
Moderate to heavy depending on the amount of edema
When does pain usually occur in patients with venous stasis ulcers?
With leg dependence and dressing changes
What causes a diabetic foot ulcer?
Narrowing of the arteries leading to reduced oxygenation to the feet
This results in delayed wound healing and tissue necrosis.
What are common symptoms of a diabetic foot ulcer?
Often painless; may include drainage, swelling, redness, and ulceration
Symptoms may vary but often include visible signs of ulceration.
Where do diabetic foot ulcers mainly occur?
On the plantar surfaces and toes (balls of the foot or underside of the toes)
These areas are prone to pressure and injury.
True or False: Diabetic foot ulcers are highly susceptible to wound infection.
True
This susceptibility is due to poor sensation, circulation, and immune protection.
Fill in the blank: Diabetic foot ulcers result in _______ due to poor sensation.
[wound infection]
Poor sensation contributes to the inability to detect injuries.
What are the types of healing wounds may undergo?
Regeneration, primary intention, secondary intention, tertiary intention
What characterizes regenerative or epithelial healing?
Occurs when a wound affects only the epidermis and dermis; no scar forms; new epithelial and dermal cells form skin indistinguishable from intact skin
Partial-thickness wounds heal by regeneration
Define primary intention healing.
Healing occurs with minimal or no tissue loss and well approximated edges; little scarring expected
A clean surgical incision is an example of primary intention healing
What is the strength of a scar formed by primary intention healing compared to original tissue?
80% as strong
Fill in the blank: A clean surgical incision heals by _______.
primary intention
What is secondary intention healing?
Healing that occurs when a wound involves extensive tissue loss or should not be closed.
What prevents wound edges from approximating in secondary intention healing?
Extensive tissue loss.
When should a wound not be closed?
When there is an infection.
How does a wound heal in secondary intention?
It heals from the inner layer to the surface by filling in with granulation tissue.
What is granulation tissue?
A form of connective tissue with an abundant blood supply.
What appearance may healing epithelial tissue have in a wound?
Small pink or pearl-like areas.
True or False: Wounds that heal by secondary intention heal more quickly.
False.
What are the risks associated with wounds healing by secondary intention?
More prone to infection and develop more scar tissue.
Fill in the blank: Wounds that heal by secondary intention heal _______.
more slowly.
What is tertiary intention healing also known as?
Delayed primary closure
Tertiary intention healing is a surgical technique used in wound management.
What occurs during tertiary intention healing?
Two surfaces of granulation tissue are brought together
This technique is applied after a period of healing by secondary intention.
When is tertiary intention healing used?
When the wound is clean-contaminated or contaminated
This approach is taken after initial healing by secondary intention.
What happens to the wound initially in tertiary intention healing?
It is allowed to heal by secondary intention
This phase is crucial before assessing for closure.
What conditions must be met before closing a wound in tertiary intention healing?
No evidence of edema, infection, or foreign matter
Ensuring these conditions helps reduce the risk of complications.
What technique is required during dressing changes for wounds healing by tertiary intention?
Strict aseptic technique
This is necessary because these wounds are prone to infection.
How does scarring from tertiary intention healing compare to other healing types?
Less scarring than secondary but more than primary intention healing
Understanding scarring outcomes is important for patient expectations.
What are the three stages of wound healing?
Inflammatory, proliferative, maturation
How long does the inflammatory phase last?
1 to 5 days
What are the two major processes in the inflammatory phase?
Hemostasis, inflammation
What happens during hemostasis?
Blood and plasma leak into the wound, vessels constrict, platelets aggregate, and a blood clot forms
What characterizes the inflammatory reaction?
Edema, erythema, pain, temperature elevation, migration of white blood cells
What role do macrophages play in the inflammatory phase?
Engulf bacteria (phagocytosis) and clear debris
What forms a scab on the wound surface?
Plasma proteins, fibrin, and debris
What is the main purpose of the scab?
Seals the wound and helps prevent microbial invasion
Fill in the blank: The inflammatory phase consists of _______ and inflammation.
[Hemostasis]
What is the Proliferative Phase in wound healing?
Occurs from days 5 to 21, where cells fill the wound defect and resurface the skin.
This phase involves key processes like fibroblast migration and collagen formation.
What role do fibroblasts play in the Proliferative Phase?
Fibroblasts migrate to the wound and form collagen, adding strength to the healing wound.
Fibroblasts are a type of connective tissue cell.
What is granulation tissue?
A tissue that forms during the Proliferative Phase, characterized by its ability to bleed readily and be easily damaged.
Granulation tissue is vital for wound healing.
What process occurs as the clot or scab is dissolved?
Epithelial cells begin to grow into the wound from surrounding healthy tissue, sealing over the wound (epithelialization).
Epithelialization is crucial for restoring skin integrity.
When does the Maturation Phase of wound healing begin?
It begins in the second or third week and continues even after the wound has closed.
This phase is also known as remodeling.
What happens to collagen fibers during the Maturation Phase?
Initial collagen fibers are broken down and remodeled into an organized structure, such as scar tissue.
This remodeling increases the tensile strength of the wound.
How long does the Maturation Phase last?
It lasts for 3 to 6 months after the wound has closed.
This phase is important for the final strength of the healed tissue.
What are the two types of wound healing that may involve closure methods?
Primary and tertiary intention
Wound healing by primary intention involves direct closure, while tertiary intention involves delayed closure.
What are adhesive strips used for in wound closure?
They are used for:
* Closing superficial low-tension wounds
* Closing the skin on wounds closed subcutaneously
* Providing additional support after sutures or staples have been removed
An example of adhesive strips is Steri-Strips.
Fill in the blank: Adhesive strips are used to close _______ wounds.
superficial low-tension
True or False: Adhesive strips can only be used on wounds that have not been sutured.
False
Adhesive strips can also be used after sutures or staples have been removed.
What is one benefit of using adhesive strips on wounds that have been closed subcutaneously?
Aiding in healing and reducing scarring
What are adhesive strips used for?
Adhesive strips are often kept in place until they begin to separate from the skin on their own.
What is the traditional method for wound closure?
Sutures (stitches)
What do sutures create along the laceration or incision?
Small puncture wounds
What are the two types of sutures based on absorbency?
- Absorbent sutures
- Nonabsorbent sutures
Where are absorbent sutures typically used?
Deep in the tissues, such as to close an organ or anastomose tissue.
What is a characteristic of absorbent sutures?
They gradually dissolve and do not need to be removed.
Where are nonabsorbent sutures placed?
In superficial tissues
What is required for nonabsorbent sutures after placement?
Removal, usually by the nurse.
Fill in the blank: Suturing creates ______ along the track of the laceration or incision.
small puncture wounds
True or False: Nonabsorbent sutures are made of material that dissolves.
False
What material are surgical staples made of?
Lightweight titanium
What is one advantage of using surgical staples over sutures?
Lower risk of infection and tissue reaction
What is a downside of using surgical staples?
Some wound edges are more difficult to align
What are the most common sites for wound stapling?
- Arms
- Legs
- Abdomen
- Back
- Scalp
- Bowel
True or False: Wounds on the hands, feet, neck, or face should be stapled.
False
What type of wounds is surgical glue safe for?
Clean, low-tension wounds
What is an ideal use of surgical glue?
Wound closure method for skin tears
What are collaborative treatments necessary for?
Wounds that will not heal despite aggressive care
Name three surgical options used for complicated wounds.
- Extensive débridement
- Skin grafts
- Flap techniques
What is hyperbaric oxygen therapy (HBOT)?
Administration of 100% oxygen under pressure to a wound site
What are the effects of hyperbaric oxygen therapy (HBOT) on wound healing?
- Increases oxygen concentration in tissue
- Stimulates growth of new blood vessels
- Enhances WBC action
- Promotes development of fibroblasts
What does platelet-derived growth factor do in wound healing?
Augments the inflammatory phase and accelerates collagen formation
Fill in the blank: HBOT enhances _______ action in wound healing.
WBC
True or False: Flap techniques involve completely detaching tissue.
False
What is drainage that oozes from a wound or cavity called?
Exudate
Exudate is composed of serum, fibrin, and leukocytes.
What is serous exudate and what does it consist of?
Watery in consistency and contains very little cellular matter; consists of serum
Serum is the straw-colored fluid that separates out of blood when a clot is formed.
What type of exudate indicates damage to capillaries and is often seen with deep wounds?
Sanguineous exudate
Fresh bleeding produces bright red drainage, while older, dried blood appears darker.
What is serosanguineous drainage?
A combination of bloody and serous drainage
It is most commonly seen in new wounds.
What characterizes purulent exudate?
Thick, often malodorous drainage seen in infected wounds
It contains pus, which is a protein-rich fluid filled with WBCs, bacteria, and cellular debris.
What type of bacteria commonly causes purulent exudate?
Pyogenic bacteria
Examples include streptococci and staphylococci.
What color is pus typically, and what can change its color?
Normally yellow; can turn blue-green due to Pseudomonas aeruginosa
Presence of this bacterium can cause a change in color.
What does purosanguineous exudate indicate?
Red-tinged pus
It indicates that small vessels in the wound area have ruptured.
What are the phases of wound healing?
Inflammation, proliferation, maturation
What complications can interrupt the wound healing process?
- Hemorrhage
- Infection
- Dehiscence
- Evisceration
- Fistulas
What does hemorrhage imply?
Profuse or rapid loss of blood
What happens when a capillary network is interrupted?
Bleeding occurs
What is hemostasis?
Cessation of bleeding
How quickly does hemostasis usually occur after an injury?
Within minutes
What can delay hemostasis?
- Injury to large vessels
- Clotting disorder
- Anticoagulant therapy
What might indicate a problem if bleeding resumes after initial hemostasis?
- Slipped suture
- Erosion of a blood vessel
- Dislodged clot
- Infection
When is the risk of hemorrhage greatest following surgery or injury?
In the first 24 to 48 hours
What are the indicators of internal bleeding?
Swelling of the affected body part, pain, and changes in vital signs (decreased blood pressure, elevated pulse)
Internal bleeding refers to bleeding that cannot escape to the surface, leading to a hematoma.
What is a hematoma?
A red-blue collection of blood under the skin that forms due to bleeding that cannot escape to the surface
A large hematoma can cause pressure on surrounding tissues.
How does a large hematoma affect surrounding tissues?
It causes pressure on surrounding tissues
If located near a major artery or vein, it may impede blood flow.
What characterizes external hemorrhage?
Bloody drainage on dressings and in wound drainage devices
External hemorrhage is relatively easy to recognize.
What happens during a brisk external hemorrhage?
Blood often pools underneath the patient as dressings become saturated
It is important to look underneath the patient to assess the full extent of the bleeding.
How can microorganisms be introduced to a wound?
During an injury, during surgery, or after surgery
It is important to maintain sterile techniques during surgical procedures to minimize this risk.
What is a key indicator to suspect an infection in a wound?
A wound fails to heal
This can be a critical sign that the body is unable to recover from the injury due to infection.
List symptoms suggesting infection in a wound.
- Localized swelling
- Redness
- Heat
- Pain
- Fever (temperatures higher than 38°C [100.4°F])
- Foul-smelling or purulent drainage
- A change in the color of drainage
These symptoms can help healthcare providers assess the presence of an infection.
When do symptoms of infection typically occur in a contaminated or traumatic wound?
Within 2 to 3 days
Early detection of these symptoms is crucial for effective treatment.
When do signs and symptoms of infection usually appear in a clean surgical wound?
Usually not until the fourth or fifth postoperative day
Understanding the timeline of infection symptoms can aid in monitoring postoperative recovery.
What is dehiscence?
Rupture (separation) of one or more layers of a wound
When is wound dehiscence most likely to occur?
During the inflammatory phase of healing
What increases the risk of dehiscence after surgery?
Incisions that begin draining within 5 to 7 days
What are common causes of wound dehiscence? List at least three.
- Poor nutritional status
- Inadequate closure of the muscles
- Wound infection
- Increased tension on the suture line
- Obesity
Why are obese patients more likely to experience dehiscence?
Fatty tissue does not heal readily and increased tissue mass puts strain on the suture line
Which type of wounds are usually associated with dehiscence?
Abdominal wounds
What might patients report feeling during dehiscence?
A ‘pop’ or tear
What is a common nursing intervention for dehiscence?
Maintaining bedrest with the head of the bed elevated at 20° and the knees flexed
What should be done if dehiscence occurs?
Notify the provider of the dehiscence immediately
Fill in the blank: An immediate increase in _______ drainage often occurs with dehiscence.
serosanguineous
True or False: Wound infection is a common cause of wound dehiscence.
True
What activities can increase tension on the suture line, contributing to dehiscence?
- Coughing
- Lifting an object
- Sudden straining
What nursing intervention might be applied to prevent evisceration in cases of dehiscence?
Applying a binder, if necessary
but if evisceration occurs DO NOT put a binder on a patient.
What is evisceration?
Total separation of the layers of a wound with internal viscera protruding through the incision
Evisceration is considered a surgical emergency.
What should be done immediately in cases of evisceration?
Cover the wound with sterile towels or dressings soaked in sterile saline solution
This prevents the organs from drying out and becoming contaminated with environmental bacteria.
What is dehiscence?
Separation of one or more layers of a wound
Dehiscence is most common in the inflammatory phase of healing.
What is a fistula?
An abnormal passage connecting two body cavities or a cavity and the skin
Fistulas are most common in the gastrointestinal and genitourinary tracts.
What position should a patient be in during evisceration?
Stay in bed with knees bent to minimize strain on the incision
This positioning helps reduce pressure on the surgical site.
Should a binder be placed on a patient with evisceration?
No
A binder can increase pressure on the wound.
What should be done after an evisceration occurs?
Notify the surgeon and prepare the patient for surgery
Immediate surgical intervention is often required.
What is a fistula?
An abnormal passage connecting two body cavities or a cavity and the skin.
What often causes fistulas?
Infection or debris left in the wound.
What forms as a result of infection in the context of fistulas?
An abscess.
What happens to surrounding tissue when an abscess forms?
It breaks down, creating an abnormal passageway.
What can chronic drainage from a fistula lead to?
Skin breakdown and delayed wound healing.
What are the most common sites of fistula formation?
The GI and genitourinary tracts.
Fill in the blank: A fistula is an abnormal passage connecting two body cavities or a cavity and the _______.
skin.
True or False: Fistulas can only occur in the gastrointestinal tract.
False.
What is a chronic wound?
A chronic wound is one that has not healed within the expected time frame.
How long does it typically take for a wound to be considered chronic?
Wounds that do not heal within 2 to 4 weeks may be considered chronic.
What is a type of chronic wound?
Pressure injury is a type of chronic wound.
What factors contribute to pressure injury?
Factors include time, pressure, tissue tolerance, friction, shearing, moisture, nutrition, age, circulation, and underlying health status.
What does tissue tolerance depend on?
Tissue tolerance depends on friction, shearing, moisture, and nutrition.
What does time and pressure depend on?
Time and pressure depend on sensation and mobility.
Fill in the blank: A chronic wound is one that has not healed within the _______.
expected time frame.
True or False: All wounds that take longer than 2 weeks to heal are classified as chronic wounds.
False.
In semi fowlers position, where does pressure injry occur
over the bony prominences of Vertebrae, sacrum, pelvis, heels
lateral position, where pressure injury near
parietal and temporal bones, ear, shoulder, illium, greater trochanter, knee, malleolus
supine position, where pressure injury
back of head, scapulae, elbows, sacrum, heels
prone position, where pressure injury
cheek and ear, shoulder, breasts, genitalia, knees, toes
What is the primary focus of a physical assessment of skin integrity?
Skin inspection, mobility, and activity assessment
What areas should be routinely assessed for skin condition?
All areas of the body for skin color, integrity, temperature, texture, turgor, mobility, moisture, lesions, and hair distribution
What specific points should be checked for erythema, tenderness, or edema?
Pressure points
Why is it important to assess bony prominences in individuals ‘at risk’ for skin breakdown?
To prevent pressure injuries
Which garments should be included in the skin assessment?
Shoes, heel elevators, and antiembolism stockings
What is the risk for patients with some degree of immobility?
Higher risk for developing pressure injuries
What factors influence the frequency of wound assessments?
Condition of the wound, work setting, patient’s overall condition, underlying disease process, type of wound, and type of treatment
How often should wounds be assessed if providing wound care?
With every treatment
How should the location of a wound be described?
In anatomical terms
What is an example of describing a wound location?
A midsternal incision extending from the manubrium to the xiphoid process
What influences the rate of healing of wounds?
Location of the wound
True or False: Wounds in highly vascular regions heal slower than those in less vascular regions.
False
Fill in the blank: Wounds in highly vascular regions, such as the _______ or ________, heal more rapidly than wounds in less vascular regions.
[scalp], [hands]
Fill in the blank: Wounds in less vascular regions, such as the _______ or ________, heal more slowly.
[abdomen], [heel]
What happens to the skin when ischemia first occurs?
The skin over the area is pale and cool
What occurs when pressure is relieved from an ischemic area?
Vasodilation occurs, extra blood goes to the area, and the area flushes bright red (reactive hyperemia)
What does it indicate if the redness in an ischemic area does not disappear quickly?
Tissue damage has occurred
What are the first steps in skin care assessment?
Regular assessment of the skin for appearance, temperature, texture, and color
Why is adequate lighting important in skin assessment?
To detect subtle, early skin changes
What should be checked at pressure points?
Erythema, tenderness, or edema
What areas should be inspected for skin breakdown in patients with obesity?
Under breasts, in abdominal folds, and where there is skin-to-skin contact
What does the Braden scale assess?
Sensory perception, moisture, activity, mobility, nutrition, friction, and sheer
Used for children.
How does the score on the Braden scale relate to pressure injury risk?
The lower the score, the more likely the patient will develop a pressure injury
What is the Braden Q scale used for?
For children
What does the Norton scale assess?
Risk based on the patient’s physical condition, mental state, activity, mobility, and incontinence
How does the score on the Norton scale relate to pressure injury risk?
The lower the score, the higher the risk is for pressure injury
What does the PUSH tool measure?
The progression of a pressure injury
What factors are scored in the PUSH tool?
Surface area, exudate, and type of wound tissue
What happens to the PUSH score as the injured area heals?
The total score falls
What is the term for damage or risk associated with the outer layer of skin?
Impaired Skin Integrity
Refers to conditions where the skin is damaged or at risk of damage.
What does ‘Impaired Tissue Integrity’ refer to?
Actual or Risk for damage to body tissues
Indicates potential or existing damage to tissues in the body.
What is a potential complication that involves the invasion of pathogens?
Infection
Can be either actual or a risk factor in wound care.
What is the term for physical suffering or discomfort experienced by an individual?
Pain
A common concern in wound care management.
What psychological aspect may change due to a wound?
Altered Body Image
Refers to how an individual perceives their physical self after a wound.
Which adjunctive wound care therapy involves the surgical removal of damaged tissue?
Surgery
Includes procedures like excision, débridement, skin grafts, drains, and flaps.
What adjunctive therapy stimulates cellular growth and increases blood flow?
Electrical stimulation
Promotes healing by encouraging fibroblast development and collagen formation.
What therapy uses high oxygen under pressure to accelerate healing?
Hyperbaric oxygen therapy (HBOT)
Enhances white blood cell activity to improve healing.
What are naturally occurring proteins that promote cell growth and replication?
Tissue growth factors
Important for chronic wound healing, especially in diabetic patients.
What type of therapy uses sound waves to stimulate tissue metabolism?
Ultrasound
Aids in débridement and increases cell metabolism through vibration and heat.
What are bioengineered skin substitutes used for?
Temporary or permanent closure of partial- and full-thickness wounds
Made from human epidermis, dermis, animal cells, or synthetic materials.
What substance enhances wound healing by improving circulation?
Nitric oxide
Promotes fibroblast and collagen growth for skin and tissue repair.
What therapy uses irradiated maggots for precise débridement?
Maggot therapy
Effective as it targets and consumes only necrotic tissue.
What is the primary focus for at-risk patients regarding pressure injury?
Prevention strategies
Includes using visual cues to remind staff to implement these strategies.
How often should hospitalized patients be reassessed for pressure injuries?
Daily, at transfer or discharge, and if condition changes
At-risk patients should be assessed every 8-12 hours.
What is the reassessment schedule for nursing home residents regarding pressure injuries?
Weekly for the first 4 weeks; then quarterly; or if condition deteriorates
This schedule helps monitor ongoing risk.
How frequently should home patients be monitored for pressure injuries?
With every visit
Ensures continuous assessment of their condition.
What should be done to manage moisture in incontinence care?
Provide gentle cleansing, apply moisture barrier cream, use absorbent products
Consider pouching systems for persistent bowel incontinence.
What bathing considerations should be taken for diaphoretic patients?
They may need frequent bathing due to sweat irritation
Older adults typically do not require daily bathing.
What technique should be used when bathing fragile skin?
Gently bathe with minimum force and friction
Washcloths can be abrasive, so care is needed.
What type of soap should be used for bathing sensitive skin?
Mild, emollient cleansing soap
Rinse thoroughly and gently pat the skin dry.
What is the purpose of using a barrier cream?
To prevent skin damage in adults at risk for pressure injury
Especially for those with incontinent, edematous, or inflamed skin.
What should be avoided when massaging fragile skin?
Do not massage over bony prominences
This can irritate the area and lead to tissue injury.
What are the requirements for linens in patient care?
Keep linens soft, clean, dry, and free from wrinkles
Change them frequently to maintain skin integrity.
What is a hydrating dressing used for?
To reduce wound size using hydrocolloid or foam dressings.
Refer to Procedure 32-8 for application details.
What is the purpose of negative-pressure wound therapy?
To create a vacuum that reduces edema, promotes granulation tissue formation, removes exudate and infectious material, and stimulates blood vessel growth.
Refer to Procedure 32-6 for more information.
What is a silver dressing’s role in wound care?
Acts as a barrier to bacteria, eliminates bacterial biofilms, and can reduce prophylactic antibiotic use.
This helps in preventing antibiotic resistance.
How should a transparent dressing be applied?
Apply the clear film or drape free of wrinkles to create a seal for negative pressure.
Refer to Procedure 32-7 for application guidelines.
What is the recommended angle for the head of the bed (HOB) to minimize pressure and shear?
Limit the angle to no more than 30°.
What devices should be used to support patients in bed?
Lift devices, drawsheets, heel and elbow protectors, sleeves, and stockings.
What should never be done when moving a patient up in bed?
Never drag a patient up in bed.
What types of surfaces are included in support surfaces?
Specialty mattresses, integrated bed systems, mattress overlays consisting of air, gel, foam, and water.
What is the function of pressure-redistributing devices?
To redistribute pressure and moisture to prevent bacterial growth on the skin.
What should be used to raise the heels off the bed?
Products specifically designed for that purpose; pillows may not be effective.
What type of devices should be avoided for pressure redistribution in chairs and wheelchairs?
Avoid donut-type devices.
What is the primary reason for frequent position changes in patients at risk for pressure injury?
To prevent tissue damage from ischemia
Ischemia refers to insufficient blood supply to tissues, which can lead to tissue damage and pressure injuries.
How often should patients be turned to prevent pressure injuries?
At least every 2 hours
More frequent turning is required for patients with fragile skin or little subcutaneous tissue.
What is the recommended turning frequency for chair-bound patients?
Every hour, with weight shifts every 15 minutes
What is the ‘Rule of 30’ for positioning?
Elevate the head of bed at a 30° angle or less; side-lying at a 30° angle
This positioning helps avoid direct pressure on the trochanter.
List the key teaching points for preventing pressure injury for at-risk patients.
- Characteristics of healthy skin
- Appearance of skin with unrelieved pressure
- Skin protection and injury prevention
- Skin care and hygiene
What factors indicate a patient is at risk for pressure injury related to nutrition?
- Rapid weight loss
- Increased metabolic demands
- Limited intake
- Decreased serum albumin
What is the recommended daily caloric intake for patients at risk for pressure injury?
30-35 kcal/kg/day
What is the protein requirement for an undernourished patient with a wound?
2 g/kg
What dietary modifications may be necessary for frail patients?
Soft diet for patients who are frail or missing teeth
What supplemental nutritional methods may be used for patients with insufficient oral intake?
- Tube feeding
- Parenteral nutrition
- Dietary referral as needed
What are some techniques to optimize nutrition and hydration in at-risk patients?
- Monitor hydration status
- Offer water when repositioning
- Provide adequate calories and protein
True or False: It is essential to report skin changes to healthcare professionals.
True
Fill in the blank: It is important to use _______ devices to prevent pressure injuries.
[pressure-redistributing]
What is a key question to assess a patient’s activity level during a focused skin and wound assessment?
What is your typical activity level?
Understanding the patient’s activity level can help identify risk factors for skin issues.
What should be asked regarding mobility aids in a skin and wound assessment?
Do you ever use a wheelchair or mobile device to get around? Do you require assistance to get out of bed or a chair?
This assesses the patient’s mobility and potential risk for skin breakdown.
What dietary information is important to gather during a skin assessment?
Tell me about your usual diet.
Nutrition plays a crucial role in skin health and wound healing.
What information regarding hydration should be collected?
How much liquid do you drink each day?
Adequate hydration is essential for skin integrity.
What symptom related to sensation should be assessed?
Do you have any areas of numbness and tingling?
Numbness and tingling can indicate neurological issues that affect skin health.
What recent changes should be inquired about during a skin assessment?
Have you had any recent changes in your skin?
Identifying changes can help in early detection of potential skin problems.
What specific questions should be asked about existing wounds?
Do you have any sores or open areas? If so, how long have you had the wound?
Duration of a wound can indicate severity and need for intervention.
What question assesses the patient’s history with wound healing?
Have you ever had difficulty with wound healing?
Previous healing difficulties can indicate underlying issues.
What healthcare problems should the patient be asked about?
What kinds of healthcare problems have you been experiencing?
Understanding broader health issues can inform skin and wound care.
What medication information is relevant during the assessment?
What medications - prescribed, herbal, or over the counter - are you taking?
Some medications can affect skin integrity or wound healing.
What hygiene routine question is important in skin assessments?
What is your typical hygiene routine?
Hygiene practices can directly impact skin health.
What question assesses incontinence issues?
Do you ever lose control of your bladder or bowels?
Incontinence can lead to skin breakdown and wounds.
What lifestyle habit should be assessed during the skin assessment?
Do you smoke?
Smoking can impair circulation and affect skin health.
What question gauges outdoor activity levels?
How much time do you spend outdoors?
Sun exposure and outdoor activity can affect skin conditions.
What diabetes-related questions should be included in the assessment?
Do you have diabetes? If so, how often do you check your feet? How often do you see a podiatrist? What is your average blood sugar?
Diabetes can significantly impact skin health and wound healing.
What characterizes a Stage 1 Pressure Injury?
Localized area of intact skin with nonblanchable redness
Nonblanchable redness does not become pale under applied light pressure.
Where is a Stage 1 Pressure Injury typically located?
Usually over a bony prominence
It is important to monitor areas over bony prominences for pressure injuries.
What are the possible sensations or conditions of the area affected by a Stage 1 Pressure Injury?
Painful, firm, soft, warmer or cooler compared to adjacent tissue
These sensations may vary based on the individual and the severity of the injury.
How long does discoloration from a Stage 1 Pressure Injury remain after pressure is relieved?
More than 30 minutes
This prolonged discoloration is a key indicator of a Stage 1 Pressure Injury.
In individuals with dark skin, how might a Stage 1 Pressure Injury differ in appearance?
May not have visible blanching and color may differ from surrounding area
This makes detection of Stage 1 Pressure Injuries more challenging in dark-skinned individuals.
True or False: A Stage 1 Pressure Injury can be identified by maroon or purple discoloration.
False
Stage 1 Pressure Injuries do not present with maroon or purple discoloration.
What characterizes a Stage 2 pressure injury?
Involves partial-thickness loss of dermis and is open but shallow with a red-pink wound bed.
It does not include slough (necrotic tissue) or bruising.
What are the possible appearances of a Stage 2 pressure injury?
May be:
* An intact or open/ruptured serum-filled blister
* A shiny or dry shallow ulcer without slough or bruising
The injury remains shallow and does not involve deeper tissue.
What types of damage should not be confused with Stage 2 pressure injury?
Do not mistake for:
* Moisture-associated skin damage
* Fungal infections
These conditions can present similarly but are different from pressure injuries.
True or False: Stage 2 pressure injury can include sloughing.
False.
Stage 2 pressure injury specifically does not involve sloughing.
What is the wound bed color of a Stage 2 pressure injury?
Red-pink.
This color indicates healthy granulation tissue rather than necrotic tissue.
Fill in the blank: Stage 2 pressure injury does not involve _______.
sloughing or bruising.
This distinction is crucial for accurate diagnosis.
What characterizes a Stage 3 Pressure Injury?
A deep crater with full-thickness skin loss and damage or necrosis of subcutaneous tissue. Adipose is visible.
Full-thickness skin loss means that the injury extends through the epidermis and dermis into the subcutaneous tissue.
How deep can some Stage 3 pressure injuries be?
Extremely deep, especially in areas with significant adipose layers; may extend down to, but not through, underlying fascia.
The depth can vary based on the location and amount of adipose tissue present.
What may be present in a Stage 3 Pressure Injury besides full-thickness skin loss?
Undermining of adjacent tissue may be present.
Undermining refers to deeper-level damage under boggy superficial layers.
Is bone or tendon visible in a Stage 3 Pressure Injury?
No, bone/tendon is not visible or directly palpable.
What is a Stage 4 Pressure Injury?
Involves full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or support structures.
Exposed bone/tendon is visible or directly palpable.
What types of necrotic tissue may be present in a Stage 4 Pressure Injury?
Slough or eschar (tan, black, or brown leathery necrotic tissue) may be present.
Eschar refers to dead tissue that falls off from healthy skin.
What is the significance of the depth of a Stage 4 Pressure Injury?
The depth varies by location and can be shallow on areas like the bridge of the nose, ear, occiput, and malleolus due to lack of subcutaneous tissue.
These areas are more prone to pressure injuries due to their anatomical structure.
What are common features observed in Stage 4 Pressure Injuries?
- Ebole (rolled edges)
- Undermining
- Sinus tracts (blind tracts underneath the epidermis)
These features indicate the severity and complexity of the injury.
Can a Stage 4 Pressure Injury extend beyond the skin?
Yes, it can extend into muscle and supporting structures (e.g., fascia, tendon, or joint capsule).
This extension complicates the healing process and may require advanced treatment.
How long does it typically take for a Stage 4 Pressure Injury to heal?
Often requires a full year to heal.
Healing time can vary based on individual health factors and treatment approaches.
What is a long-term risk associated with healing from a Stage 4 Pressure Injury?
The site remains at risk for future injury because the scar tissue is not as strong as the original tissue.
This highlights the importance of ongoing care and monitoring after healing.
What is Deep Tissue Pressure Injury (DTI)?
An area of skin that is intact but persistently discolored
What colors might characterize a DTI?
Purplish or deep red
What are common symptoms associated with DTI?
Painful, boggy, or have a blister
What often precedes the symptoms of DTI?
Pain and temperature change
What causes Deep Tissue Pressure Injury?
Damage of underlying soft tissue from pressure or shear
Why might DTI go unrecognized?
Findings can be subtle enough that often DTI is not recognized until after severe tissue damage has occurred
What might happen to a DTI if not treated optimally?
May heal or evolve further and become covered by thin eschar
What is a potential risk of a DTI developing further?
Rapidly exposing additional layers of tissue
In individuals with darker pigmentation, what is a challenge regarding DTI?
Discoloration might go undetected
What characterizes an unstageable pressure injury?
Involves full-thickness skin loss
The depth cannot be determined until slough or eschar is removed.
What obscures the base of the wound in an unstageable pressure injury?
Slough or eschar
Slough can be tan, yellow, gray, green, or brown; eschar can be tan, black, or brown.
What is stable eschar?
Dry, adherent, and intact without erythema or fluctuance
It serves as the body’s natural cover.
True or False: The depth of an unstageable pressure injury can be determined without removing slough or eschar.
False
The depth cannot be assessed until the base of the wound is exposed.
Fill in the blank: An unstageable pressure injury cannot be classified until enough _______ is removed to expose the base of the wound.
slough and/or eschar
What should be assessed for all wounds?
Location, Size, Appearance, Drainage, Patient Responses
These are the key categories for wound assessment.
How should the location of a wound be described?
In anatomical terms, e.g., a midsternal incision extending from the manubrium to the xiphoid process
This helps provide clarity in communication regarding the wound’s position.
What measurements should be taken for a wound?
Length and width in centimeters, depth with a sterile cotton-tipped applicator
Use photo documentation to indicate dimensions, especially for irregular borders.
What types of wound appearance should be described?
Type of wound, color, condition of the wound bed, presence of necrosis, slough, eschar, and surrounding skin condition
Detailed descriptions help in assessing healing and potential complications.
What indicates normal healing in a wound bed?
A beefy red, moist appearance
This suggests that the wound is healing properly.
What should be observed in the surrounding skin of a wound?
Discoloration, hematoma, additional injury, maceration, tunneling, crepitus, blistering, erythema
These observations can indicate complications or the severity of the wound.
What aspects should be assessed regarding drainage?
Color, consistency, amount, and odor
Quantify drainage by weighing dressings before and after use.
What should be done if profuse bleeding occurs?
Apply direct pressure and call the physician if bleeding continues after 5 minutes
Immediate action is crucial in managing severe bleeding.
When should a tetanus immunization be given?
If last immunization was 10 years ago or longer, wound is contaminated and last shot was over 5 years ago, or if uncertain about immunization history
Tetanus shots are important for preventing infection in wounds.
What additional care might a deep bite wound require?
Additional observation and/or antibiotics
Bite wounds are prone to infection and may need special attention.
What should be assessed regarding pain in wound care?
Level of pain, with severe pain requiring comprehensive evaluation
Pain assessment is critical for appropriate management of wounds.
What chronic medical conditions could affect wound healing?
Diabetes, malnutrition, immunocompromise, bleeding disorders
Patients with these conditions require ongoing evaluation due to impaired healing.
How does the location of a wound affect healing?
Wounds that can be stabilized heal more rapidly than those affected by constant movement
Location can also indicate the wound’s etiology.
Fill in the blank: A beefy red, moist appearance of a wound indicates _______.
healing
This appearance is a positive sign in wound assessment.
What is the first step in assessing a wound?
Determine if it is an acute or chronic wound
What should be examined if the wound is sutured?
Closure, wound edges, tension, and stitch integrity
How should a wound be measured?
In a neutral position, measuring length, width, and depth in centimeters
What tool can be used to measure wound depth?
A sterile cotton-tip applicator
What is the purpose of serial photographs in wound assessment?
To document baseline and wound healing
What is undermining in wound assessment?
Separation in tissue type or plane at the wound edges
How can the location of undermining or tunneling be recorded?
Using the face of a clock as a guide
What condition may be indicated by skin discoloration surrounding a wound?
Hematoma or additional injury
What causes maceration in wound care?
Excessive moisture from pooled drainage on intact skin
What does crepitus indicate?
Gas trapped under the skin
What are signs that surrounding tissue is in jeopardy?
Erythema, swelling, or other signs of irritation
What is epiboly in wound assessment?
Closed or rolled wound edges
What does slough look like?
Soft, stringy, and pale yellow or gray moist necrotic tissue
What is eschar?
Dry necrotic tissue that appears thick, hard, and black or brown
Fill in the blank: Excessive moisture from pooled drainage can cause _______.
maceration
True or False: Epiboly indicates that epithelial cells have moved down and rolled under the wound edges.
True
What is assessed to understand the severity and treatment options of a wound?
The types of tissue and their amounts in the wound base
Assessment of tissue types can indicate healing progress and necessary interventions.
What must be distinguished in wound assessment?
Viable (living) tissue from nonviable tissue
This distinction is crucial for appropriate wound management.
How should different types of tissue in a wound bed be described?
By percentages, e.g., ‘80% granulation tissue, 20% necrotic’
This method provides a clear picture of the wound composition.
What does granulation tissue indicate?
Evidence of healing
Granulation tissue is a positive sign in wound healing.
What might a pale color or dry texture in a wound suggest?
A delay in healing
These characteristics can signify complications in the healing process.
What is the impact of necrotic tissue on wound healing?
It will delay wound healing and should be removed
The only exception is stable eschar on a heel that is not infected.
What should be determined regarding drainage in wound assessment?
Whether exudate is present and its characteristics
Key characteristics include amount, color, consistency, and odor.
How should the amount of drainage be described?
None, light, moderate, or heavy
Drainage amounts can vary by wound type.
What types of drainage color descriptions are used?
Serous, serosanguineous, sanguineous, purulent, or seropurulent
These terms help in assessing the nature of the wound fluid.
What should be done before assessing the odor of a wound?
Clean the wound of all exudate or foreign material
This ensures that the odor characteristics are accurately evaluated.
What can a change in odor indicate in wound assessment?
Fistula formation or bacterial contamination
An example includes a previously odorless abdominal wound that begins to smell of bile or feces.
Fill in the blank: Necrotic tissue of any type will ______ wound healing.
delay
This highlights the importance of addressing necrotic tissue promptly.
True or False: Venous stasis ulcers usually produce less drainage than arterial ulcers.
False
Venous stasis ulcers typically produce more drainage.
What is the key concept in improving wound care?
Wound Healing
Wound healing is a critical aspect of nursing care, particularly in managing various types of wounds.
What is essential for providing quality patient care in nursing?
Interprofessional collaboration
Collaboration among healthcare professionals leads to improved patient outcomes and a stronger healthcare system.
Name three types of wounds that require a team approach for treatment.
- Diabetic foot ulcers
- Venous stasis ulcers
- Pressure injury
These wounds often require specialized care and input from various healthcare professionals.
What characteristics are needed to create high-functioning interprofessional teams?
- Trust
- Effective communication
- Role clarity
- Mutual respect
These traits foster a collaborative environment that enhances patient care.
Who does the World Health Organization suggest as a leader of the wound care team?
Wound navigator
The wound navigator acts as an advocate for patients and coordinates care among team members.
What is the role of a wound navigator?
To advocate for patients and collaborate with healthcare professionals
The navigator focuses on patient needs and ensures a comprehensive care plan.
What does the wound navigator provide to each patient?
A list of care/service providers
This list includes names and contact information for appropriate resources, aiding patient access to care.
Fill in the blank: Effective __________ is required for high-functioning interprofessional teams.
communication
Effective communication is crucial for understanding roles and coordinating care.
True or False: The patient is central in the interprofessional team model.
True
The model emphasizes care efforts based on patient needs and desires.
What practical challenges may need to be addressed within the context of a wound care team?
Various logistical and communication challenges
Addressing these challenges is crucial for effective team functioning.
How can technology play a role in effective implementation of wound care teams?
By enhancing communication and information sharing
Technology can streamline processes and improve patient outcomes in wound care.
What is slough?
Soft, moist, devitalized (necrotic) tissue; may be white, yellow, tan; may be stringy, loose, or adherent to bed.
Débride the wound.
What characterizes eschar?
Necrotic tissue; dry, thick, leathery; may be black, brown, or gray depending on moisture level.
Débride the wound.
Describe granulation tissue.
Pink to red moist tissue; made of new blood vessels, connective tissue, and fibroblasts; surface is granular or pebble-like.
Cleanse, protect. Promote epithelialization (epithelial growth).
What does clean, nongranulating tissue indicate?
Absence of granulation tissue, but bed is pink, shiny, and smooth.
Cleanse, protect. Promote growth of healthy tissue.
What is epithelial tissue in the context of wound healing?
Regenerating epidermis; may appear pink or pearly white as it crosses the wound bed; may begin as a ring around the wound or from epithelial cells lining hair follicles.
Cleanse, protect.
What should you routinely ask your patients regarding wounds?
About pain or discomfort related to the wound or wound care.
What is a key point regarding patients’ complaints of pain?
Always take seriously the patient’s complaint of pain, especially if there is a sudden increase.
Why is pain an important symptom to monitor in wound care?
Pain is often an early symptom of infection.
In immunocompromised patients, what may be the only symptom of infection?
Pain.
What should you do to assess a patient’s nutritional status?
Screen and assess the nutritional status of each patient admitted with a pressure injury and whenever there is a change in the patient’s condition.
When may a referral to the dietitian be necessary?
If nutritional problems are present.
What is required for effective wound healing?
Sufficient calories.
What interventions may be involved in a nutritional plan for wound healing?
Adding oral supplemental meals, or even enteral or parenteral nutrition.
What assessments should be made for an untreated wound?
The same assessments as for a treated wound, plus additional assessments to determine immediate treatment needs.
What should you assess for in an untreated wound?
Bleeding, severe pain, numbness, or loss of movement below the wound.
What action should be taken if bleeding is profuse?
Apply direct pressure to the site.
What should be done if bleeding continues after applying pressure for 5 minutes?
Call the provider immediately.
What are signs that require immediate evaluation in an untreated wound?
Severe pain, numbness, or loss of movement below the wound.
What is a Tetanus-prone wound?
Wounds such as compound fractures, gunshot wounds, crush injuries, burns, punctures, foreign object injuries, and wounds contaminated with soil.
When should an immunization be given for tetanus?
If the last immunization was 10 or more years ago, if the wound is contaminated and the last immunization was over 5 years ago, or if it is uncertain when the last immunization was received.
Fill in the blank: Tetanus-prone wounds include _______.
compound fractures, gunshot wounds, crush injuries, burns, punctures, foreign object injuries, wounds contaminated with soil.
True or False: An immunization for tetanus is not needed if the last immunization was given less than 5 years ago and the wound is not contaminated.
True
What should be integrated with laboratory data?
History and physical assessment findings
What are the common laboratory assessments related to skin integrity?
- Protein levels
- Complete blood count
- Erythrocyte sedimentation rate
- Glucose
- Thyroid levels
- Iron levels
- Coagulation studies
- Wound cultures
What may indicate the need for a wound culture?
- Local or systemic signs of infection
- Suddenly elevated glucose levels
- Pain in a neuropathic extremity
- Lack of healing after 2 weeks in a clean wound
What are the methods to obtain a wound culture?
- Swab
- Aspiration
- Tissue biopsy
What is the most common method to obtain a culture?
Swab
True or False: Swab specimens are not accurate in representing bacteria counts biopsied from a wound.
False
When should swab cultures be used as an alternative to biopsy?
When antibiotic-resistant bacteria is not suspected
What does needle aspiration involve?
Insertion of a needle into the tissue to aspirate tissue fluid
What is a risk associated with needle aspiration?
Inadvertent needle damage to tissue and underlying structures
What is considered the ‘gold standard’ for culturing a chronic wound?
Tissue biopsy
What are the risks associated with tissue biopsy?
- Risk of sepsis
- Causes pain
- Disrupts the wound bed
- May cause delayed healing
Fill in the blank: The most accurate method for culturing a chronic wound is _______.
[tissue biopsy]
What does a normal leukocyte (WBC) count range from?
5,000–10,000/mm3
What may an increase in white blood cells (WBCs) indicate in relation to wounds?
Potential infection
What can a low WBC count indicate regarding wound healing?
Delayed wound healing
What are leukocytes responsible for at the wound site?
Inflammatory reaction, phagocytosis of bacteria and debris, creation of antibodies
What are the normal serum protein and serum albumin levels?
Serum protein: 6.0–8.0 g/dL; Serum albumin: 3.4–4.8 g/dL
What does low serum levels indicate regarding nutritional status?
Limited nutritional stores that delay wound healing or increase risk for pressure injury
How are serum protein and albumin levels related?
Closely related but fluctuate slowly
What is a more accurate measure of a patient’s immediate protein stores?
Prealbumin level
Fill in the blank: A low WBC count may ______ wound healing.
Delay
True or False: Serum protein levels fluctuate rapidly.
False
What is the erythrocyte sedimentation rate (ESR)?
A test that indicates whether red blood cells stick together, become heavier, and settle at the bottom of a laboratory tube when held vertically.
ESR is used to assess the presence of inflammation or necrotic processes in the body.
What is the normal ESR range for individuals less than 50 years old?
0–15 mm/hr
The ESR range varies with age.
What is the normal ESR range for individuals older than 50 years old?
0–20 mm/hr
Normal ESR values can increase with age.
True or False: An increased ESR indicates normal blood protein levels.
False
An increased ESR indicates altered blood proteins due to inflammation or necrosis.
Fill in the blank: The ESR test is influenced by the presence of an _______ and necrotic process.
inflammatory
The test reflects changes in blood proteins due to inflammation.
What does aPTT stand for?
Activated Partial Thromboplastin Time
What factors can cause variations in aPTT results?
Equipment and reagents used
What are the critical values for aPTT?
Greater than 70 seconds or less than 53 seconds
What can prolonged coagulation times result in?
Excessive blood loss or ongoing bleeding in the wound bed
What problems can shortened coagulation times increase the risk for?
- Blood clot formation problems
- Deep vein thrombosis
- Pulmonary embolus
- Stroke
What is Prothrombin time?
Clotting time
What are the critical values for Prothrombin time?
Greater than 20 seconds (uncoagulated) or three times normal control (anticoagulated)
What factors can alter coagulation?
Anticoagulant medications, concurrent illness, trauma, reaction to transfusions
What is the International normalized ratio (INR)?
A standardized test to evaluate clotting times, considered the gold standard
The INR is crucial for monitoring patients on anticoagulation therapy.
What is the INR value for patients not receiving anticoagulation therapy?
Less than 2.0
This indicates normal clotting function in patients not on anticoagulants.
What is the INR range for patients receiving coagulation therapy?
2.0–3.0
This range is generally therapeutic for patients on anticoagulants.
True or False: The INR is used to monitor blood clotting times.
True
The INR helps assess the effectiveness of anticoagulation therapy.
What is the purpose of wound cultures?
To determine the types of bacteria present in the wound
How can cultures be obtained?
By swab, aspiration, or tissue biopsy
True or False: A positive culture always indicates an infection.
False
What does a positive culture in chronic wounds indicate?
Colonization with bacteria
What does it mean if wound cultures are negative?
No growth of pathogens
What is the significance of a tissue biopsy?
It is used to examine tissue samples for the presence of pathogens or abnormalities.
Tissue biopsies are crucial in diagnosing diseases, including infections and cancers.
What does a negative biopsy result indicate?
No growth of pathogens.
A negative result suggests that there are no infectious agents present in the sampled tissue.
What is the threshold for bacteria count to consider wounds infected?
Exceeds 100,000 organisms per gram of tissue.
This threshold helps in determining whether a wound requires treatment for infection.
What is the exception to the bacteria count rule for infection?
The presence of beta-hemolytic streptococci in any number indicates infection.
This specific type of bacteria is pathogenic even in low quantities.
Who must perform the initial assessment of a wound?
The RN
Ongoing evaluation of a wound also requires the RN.
What task can be delegated to unlicensed assistive personnel (UAP) regarding wound care?
Inspection of the skin for evidence of skin breakdown
UAP should notify the RN of redness, tissue warmth, or drainage.
What instructions must be given to UAP for turning and positioning a patient?
Provide times for turning and specific positioning instructions
A turning chart at the bedside can be helpful.
What do turning and movement prevent in patients?
Tissue damage from ischemia
This is crucial for preventing pressure injury.
What nursing diagnosis is appropriate for patients at risk for skin breakdown?
Risk for Impaired Skin Integrity
This applies to patients with risk factors like immobility and incontinence.
What are some risk factors for skin breakdown?
- Immobility
- Incontinence
- Extremes of age
- Impaired circulation
- Impaired sensation
- Undernutrition
- Emaciation
Use a risk assessment tool to identify these patients.
Fill in the blank: A risk assessment tool that can be used is the _______.
[Norton or Braden scale]
These tools help assess the risk for skin breakdown.
What does sensory perception refer to in the context of the Braden Scale?
Ability to respond meaningfully to pressure-related discomfort
What does moisture refer to in the Braden Scale?
Degree to which skin is exposed to moisture
What does activity refer to in the Braden Scale?
Degree of physical activity
What does mobility refer to in the Braden Scale?
Ability to change and control body position
What does nutrition refer to in the Braden Scale?
Usual food intake pattern
What does friction and shear refer to in the Braden Scale?
Factors contributing to skin breakdown due to movement
What is the scoring for completely limited sensory perception?
Unresponsive to painful stimuli due to diminished level of consciousness or sedation
What score indicates constant moisture in the Braden Scale?
Skin is kept moist almost constantly by perspiration, urine, etc.
What does ‘bedfast’ indicate in the Braden Scale?
Confined to bed
What does ‘completely immobile’ signify in the Braden Scale?
Does not make even slight changes in body or extremity position without assistance
What does ‘very poor’ nutrition status indicate?
Never eats a complete meal and rarely eats more than ½ of any food offered
Fill in the blank: A person who requires moderate to maximum assistance in moving is considered a _______.
Problem
What is the score for ‘very limited’ sensory perception?
Responds only to painful stimuli, cannot communicate discomfort except by moaning
What does ‘very moist’ indicate in the context of the Braden Scale?
Skin is often, but not always moist, requiring linen change at least once a shift
What does ‘chairfast’ mean?
Ability to walk severely limited or non-existent, must be assisted into chair or wheelchair
What does ‘probably inadequate’ nutrition status indicate?
Rarely eats a complete meal, generally eats only about ½ of any food offered
Fill in the blank: A person who moves feebly or requires minimum assistance is considered a _______.
Potential Problem
What is the definition of ‘slightly limited’ sensory perception?
Responds to verbal commands but cannot always communicate discomfort
What does ‘occasionally moist’ mean?
Skin is occasionally moist, requiring an extra linen change approximately once a day
What does ‘walks occasionally’ indicate?
Walks occasionally during the day, but for very short distances
What does ‘adequate’ nutrition status signify?
Eats over half of most meals, takes a total of 4 servings of protein per day
True or False: A person who moves independently in bed and in a chair has no apparent problems.
True
What does ‘no impairment’ mean in the context of the Braden Scale?
Responds to verbal commands and has no sensory deficit limiting ability to feel pain
What does ‘rarely moist’ indicate?
Skin is usually dry, linen only requires changing at routine intervals
What does ‘walks frequently’ indicate?
Walks outside room at least twice a day and inside room at least once every two hours during waking hours
What does ‘no limitation’ refer to in the Braden Scale?
Makes major and frequent changes in position without assistance
What does ‘excellent’ nutrition status indicate?
Eats most of every meal, never refuses a meal, and usually eats a total of 4 or more servings of protein
What is the purpose of the Norton Scale?
To assess patients’ risk for pressure ulcers
The Norton Scale evaluates physical condition, mental condition, activity, mobility, and incontinence.
What score indicates a liability to pressure ulcers on the Norton Scale?
Scores of 14 or less
Scores below 12 indicate a very high risk for developing pressure ulcers.
List the five criteria used in the Norton Scale.
- Physical Condition
- Mental Condition
- Activity
- Mobility
- Incontinence
Each criterion is scored, and the total score determines the risk level.
What is the maximum score on the Norton Scale?
20
This score represents the best possible outcome for patient risk assessment.
True or False: A score of less than 12 on the Norton Scale indicates a very high risk for pressure ulcers.
True
Scores below 12 suggest a significant risk for patients.
Fill in the blank: The Norton Scale assesses risk for pressure ulcers based on _______.
[five criteria]
These criteria include physical condition, mental condition, activity, mobility, and incontinence.
What does a ‘Poor’ physical condition score indicate on the Norton Scale?
A score of 2
This indicates a significant concern for the patient’s overall health status.
What does the ‘Apathetic’ mental condition score represent on the Norton Scale?
A score of 3
This score reflects a patient’s reduced engagement or responsiveness.
What is the score for ‘Chair-bound’ activity level on the Norton Scale?
2
This indicates limited mobility and increased risk for pressure ulcers.
What is considered ‘Doubly incontinent’ on the Norton Scale?
A score of 1
This status significantly increases the risk for pressure ulcers.
What is the lowest possible score on the Norton Scale?
5
This score indicates a very high risk for pressure ulcers.
What is the diagnosis for patients with damage to the epidermis or dermis?
Impaired Skin Integrity
Appropriate for patients with superficial wounds or stage 1 or 2 pressure injury.
What is the appropriate diagnosis for patients with wounds extending into subcutaneous tissue, muscle, or bone?
Impaired Tissue Integrity
Used for patients with deep wounds or stage 3 or 4 pressure injury.
What diagnosis is suitable for patients with Impaired Skin Integrity who are at risk for delayed healing?
Risk for Impaired Tissue Integrity
Example: A patient with a stage 1 pressure injury at risk for progression due to age, nutritional state, and presence of another wound.
What nursing diagnosis is appropriate if the patient has a traumatic wound or is immunosuppressed?
Risk for Infection
Also consider if the patient is undernourished or immobile.
What diagnosis may be used for patients experiencing discomfort from a wound?
Pain
This includes discomfort from treatments required to heal the wound.
What nursing diagnosis should be considered if a patient is experiencing distress about a wound?
Disturbed Body Image
Important to consider even if the patient is expected to make a complete recovery or if disfigurement is expected.
What are some examples of NIC standardized interventions for skin and tissue integrity problems?
- Bedrest Care
- Infection Protection
- Pressure Injury Prevention
- Pressure Management
- Skin Surveillance
- Nutrition Management
- Positioning
- Wound Care
- Wound Irrigation
- Specific nursing activities directed at maintaining skin integrity or healing wounds.
What is the focus of specific nursing activities related to wound care?
Preventing and treating pressure injury and other chronic wounds, providing wound care, and applying heat and cold therapies.
Who is involved in the multidisciplinary team for care planning of a patient with a chronic wound?
- Dietitians
- Infection control specialists
- Wound specialists
What is essential to consider when assessing a patient with a diabetic foot ulcer?
All pressure must be taken off the area to prevent trauma to healing tissues.
What should be selected for a diabetic foot ulcer patient in addition to offloading pressure?
The appropriate dressing and a special shoe made for patients with neuropathy.
What do patients with a venous stasis ulcer typically wear?
Compression garments such as elastic hose, stockings, or multilayer compression wraps.
What is the purpose of compression garments for venous stasis ulcers?
They provide continuous pressure to the veins, improving venous return and helping the ulcer to heal.
Before applying elastic compression, what should be checked regarding the limb?
Ensure the limb is not increasing in size due to edema.
What condition must be ruled out before applying compression to the lower extremities?
Lower extremity arterial disease.
True or False: Lower extremity arterial disease can compromise arterial circulation and should be ruled out before applying compression.
True
What is the primary purpose of cleansing wounds?
To remove exudate, slough, foreign materials, and microorganisms from the wound
This promotes healthy tissue healing.
When should a wound be cleaned?
Initially and with each dressing change
This ensures ongoing cleanliness and promotes healing.
How should a wound be cleansed?
Gently pat the surface with gauze soaked with saline or other prescribed wound cleanser
Care should be taken not to disrupt granulation tissue.
What characteristics should the ideal wound cleansing solution have?
Isotonic, easy to sterilize, inexpensive, available, non-irritating, and non-damaging to tissue
It should not cause bleeding.
What are some examples of antiseptic solutions?
- Dakin solution
- Acetic acid
- Hydrogen peroxide
- Povidone-iodine
- Chlorhexidine
- Alcohol
These have been historically used to cleanse various types of wounds.
Why should some antiseptic solutions be avoided on healing tissue?
They can damage granulating tissue
This can hinder the healing process.
Under what circumstances should antiseptic solutions be reserved?
- New wounds
- Wounds that will not heal
- Wounds where bacterial burden is more harmful than the solution
This approach minimizes potential harm to healing tissue.
What is the nature of normal saline in wound cleansing?
Isotonic and safe for injured or healing tissue
It cleanses most wounds effectively if used in sufficient amounts.
What should be noted about the use of normal saline after opening the container?
It should be used within 24 hours to avoid bacterial growth
This ensures the solution remains safe for use.
What are the characteristics of sterile water and distilled water?
Clean, contain no additives, less expensive than normal saline
Both are hypotonic and can cause fluid shifts to damaged cells.
What can occur when large volumes of sterile water are used on wounds?
Water toxicity to an open wound
This is due to the hypotonic nature of sterile water.
Can potable tap water be used to cleanse wounds?
Yes, it is as effective as saline
The decision to use tap water should consider the nature of the wound and the patient’s condition.
What factors should influence the decision to use tap water for wound cleansing?
Nature and complexity of the wound, patient’s general condition, presence of comorbid conditions, immunological status
Examples of comorbid conditions include diabetes.
What type of water should be used instead of tap water for cleansing wounds?
Purified water
This reduces the risk of microbial contamination from biofilm.
What is biofilm?
A coating of bacteria that adheres to a surface
Biofilms form in hospital water delivery systems and impede wound healing.
How does biofilm affect wound healing?
Reduces the effectiveness of fibroblasts and antimicrobials
This can lead to delayed healing and increased risk of infection.
What types of skin cleansers can be used for periwound skin?
Liquid or foam skin cleansers that are pH balanced
These are not for use inside wounds.
What is the primary purpose of irrigation (lavage) in wound care?
To cleanse wounds by flushing debris and bacteria on the surface
This includes hydrating the site and improving visual inspection of the wound.
Name two benefits of wound irrigation.
- Facilitates progression from the inflammatory to the proliferative phase of healing
- Reduces infection by preventing premature surface healing
This is particularly important over an infected area of a wound.
What is the most commonly used wound irrigation solution?
Normal saline
Bacterial growth in saline may occur as soon as 24 hours after opening the saline bottle.
What types of solutions can be used for wound irrigation?
- Topical cleansers
- Antiseptics
- Antibiotics
- Antifungals
- Anesthetics
- Analgesics
These solutions serve to clean wounds, prevent or treat infection, and manage pain.
Fill in the blank: The irrigation solution should be _______ to prevent injury to healing tissue.
Isotonic
What are the characteristics an ideal irrigation solution should have? List at least three.
- Nonhemolytic
- Nontoxic to healing tissue
- Transparent
Other characteristics include being inexpensive and warmed to room temperature.
True or False: Cytotoxic solutions can enhance wound healing.
False
Cytotoxic solutions may impair wound healing.
What is a key consideration regarding the temperature of the irrigation solution?
It should be warmed to room temperature to prevent hypothermia.
Fill in the blank: An ideal irrigation solution should be _______ to allow visualization of the wound bed.
Transparent
What is the role of irrigation in improving wound healing?
Improves wound healing from the inside tissue layers to the skin surface.
What is a piston syringe used for?
Irrigation
A larger, sterile, disposable syringe designed to minimize hand slippage.
Why is a bulb syringe not advised for irrigation?
Increases the risk of aspirating drainage and disrupting healing granulation tissue
Bulb syringes can cause complications during wound care.
Name two types of commercial irrigation systems.
- Whirlpool agitators
- Pulsed lavages
These systems are used for delivering irrigation solutions effectively.
What is continuous irrigation?
An uninterrupted stream of irrigation solution to the wound’s surface
This method is used for consistent wound care.
What is pulsed irrigation?
The intermittent delivery of irrigation solution
This technique allows for more controlled irrigation.
What is the ideal irrigation pressure range?
4 psi to 15 psi
This range is effective for removing debris without causing harm.
What type of syringe and gauge should be used to deliver irrigation solution at approximately 8 psi?
35-mL syringe attached to a 19-gauge angiocatheter
This setup helps effectively manage wound care.
What risks are associated with pressures above 15 psi during irrigation?
- Driving bacteria into tissues
- Causing mechanical damage to the wound
- Dislodging healing granulation tissue
High-pressure irrigation can lead to serious complications.
What is the pressure range for high-pressure irrigation systems?
35 psi to 70 psi
These systems can cause complications in wound healing.
True or False: High-pressure irrigation systems can increase the risk of infection.
True
They can drive bacteria deeper into the wound compartment.
What is the ideal volume of irrigation solution for cleansing a wound per centimeter of laceration?
50 to 100 mL
This volume may vary based on the level of contamination and type of wound.
What additional irrigation volume consideration is necessary for highly contaminated wounds?
More irrigation volume is needed
This ensures thorough cleansing of the wound.
What is the required irrigation volume for chemical burns?
More irrigation volume is needed
Chemical burns can be particularly severe and require extensive flushing.
What personal protective equipment should be used during irrigation to prevent splattering?
Gowns, masks, and goggles
These items help protect the healthcare provider from potential exposure.
What tool can be used at the end of the irrigating syringe to reduce splashing?
A plastic shield
This is particularly useful for IV sites and other open areas.
When should sterile technique be used for wound irrigation?
For acute surgical wounds, wounds recently undergoing sharp débridement, or as prescribed by the provider
Sterile technique minimizes infection risk.
What technique is primarily used for the majority of wound irrigations?
Clean technique
This is sufficient for many types of wounds that are not severely contaminated.
What is the purpose of drains in wound care?
To allow fluid and exudate to exit and prevent excessive pressure from building up in the tissues.
During what procedure are drains usually placed?
During a surgical procedure.
What is a Penrose drain?
A flexible, flat latex tube placed in the wound bed, usually not sutured into place.
How is a Penrose drain typically secured?
With a clip or pin at the insertion site to prevent slipping.
What are Hemovac and Jackson-Pratt drains?
Drains attached to a collection device for fluid removal.
What does ‘placed to suction’ mean for a drainage device?
The device is compressed to create suction and facilitate the removal of drainage.
What should be done if a specific pressure is to be applied to a drain?
Connect the drain to wall suction as prescribed by the provider.
How should a nurse describe drain placement?
Using the drain’s position on a clock face with the patient’s head at the 12 o’clock position.
What is important to monitor regarding wound drains?
The amount and character of the drainage.
What should a nurse do if they suspect a drain is occluded?
Check the drain line for kinks and notify the provider if the problem persists.
True or False: Many drains are sutured in place.
False.
What should be done to maintain suction in a collection apparatus?
Empty the apparatus at a designated volume as it fills.
Fill in the blank: A _______ drain is a type of drain that is not typically sutured into place.
Penrose
Flowers in a vase can be moved
What is the consequence of not emptying a drainage device regularly?
Suction pressure decreases.
Why is it necessary to label drains numerically?
To ensure consistent care by each caregiver.
What information should be recorded in nursing notes regarding drains?
The amount and character of the drainage.
What is débridement?
The removal of devitalized tissue or foreign material from a wound.
It also involves removing senescent cells from the wound bed and edges.
What is the purpose of removing necrotic tissue from a wound?
To stimulate wound healing and prepare the wound bed for advanced therapies or biological agents.
This includes the removal of exudate and infective material.
What should not be removed during débridement if the wound has poor circulation?
Eschar.
This is critical to avoid further complications in the healing process.
What is a stable heel eschar?
A type of eschar that should be left alone during débridement.
It indicates a stable condition that does not require intervention.
When is débridement not beneficial for a patient?
In cases where the patient is critically unstable or has a grave prognosis.
This consideration is crucial for patient safety and care.
How many types of débridement are there?
Five types.
These types include sharp (surgical), mechanical, enzymatic, autolytic, and biotherapy (maggot) therapy.
What is sharp débridement?
A type of débridement performed surgically.
It involves the use of surgical instruments to remove tissue.
What is mechanical débridement?
A type of débridement that uses physical force to remove tissue.
This can include methods like irrigation or wet-to-dry dressings.
What is enzymatic débridement?
A type of débridement that uses enzymes to break down necrotic tissue.
This method is often applied topically.
What is autolytic débridement?
A type of débridement that relies on the body’s own mechanisms to remove dead tissue.
This process is facilitated by moisture-retentive dressings.
What is biotherapy (maggot) therapy?
A type of débridement that uses live maggots to consume necrotic tissue.
This method is effective in promoting healing in certain types of wounds.
What is sharp débridement?
The use of a sterile, sharp instrument, such as scalpel or scissors, to remove devitalized tissue.
What is the primary benefit of sharp débridement?
Provides an immediate improvement of the wound bed and preserves granulation tissue.
Who can perform sharp débridement?
A physician, nurse, or physical therapist with specialized training.
Where may sharp débridement be performed if extensive?
In the operating room.
What is often performed simultaneously with the débridement of stage 4 pressure injuries?
A bone biopsy.
What does a bone biopsy detect in the context of sharp débridement?
Osteomyelitis, extension of the infection into the bone.
Fill in the blank: Sharp débridement uses a _______ to remove devitalized tissue.
[sterile, sharp instrument]
True or False: Sharp débridement is only performed by physicians.
False
What is mechanical débridement?
Mechanical débridement may be performed via lavage, wet-to-damp dressings, or hydrotherapy.
Describe the wet-to-dry dressing method.
Coarse gauze moistened with normal saline packed into the wound, allowed to dry, and removed several times a day.
Why has the use of wet-to-dry dressings declined?
It causes pain and provides only nonselective débridement, removing both debris and healing granulation tissue.
What should be done to manage pain when using wet-to-dry dressings?
Medicate the patient beforehand with opioid analgesics.
How does rewetting the gauze affect the dressing change?
It aids in removal and decreases pain but may eliminate the débriding action.
What is hydrotherapy?
A vigorous form of nonselective débridement using a whirlpool for wounds with a large amount of nonviable tissue.
What are the general recommendations for hydrotherapy treatments?
Usually performed in the physical therapy department once or twice per day for 5 to 15 minutes.
What precautions should be taken during hydrotherapy?
Do not expose the wound directly to the water jets.
List the risks associated with hydrotherapy.
- Increased risk for periwound maceration
- Contamination by waterborne infections
- Cross-contamination
- Vasodilation, increasing edema and congestion
- Increased risk for burns in persons with diabetic neuropathies
True or False: Hydrotherapy is safe for all wound types.
False
Fill in the blank: The wet-to-dry dressing method allows the gauze to ______ before removal.
dry
What is the primary purpose of mechanical débridement?
To remove nonviable tissue from wounds.
What is enzymatic débridement?
Enzymatic débridement uses proteolytic agents to break down necrotic tissue without affecting viable tissue in the wound.
It involves cleaning the wound with normal saline, applying a thin layer of cream, and covering with a moisture-retaining dressing.
How often can enzymatic débridement be performed?
Once or twice daily, depending on the product.
It is important to apply the product only to devitalized tissue.
What is autolytic débridement?
Autolytic débridement (autolysis) is the use of an occlusive, moisture-retaining dressing and the body’s own enzymes and defense mechanisms to break down necrotic tissue.
This process is slower but better tolerated than other techniques.
How often should the dressing for autolytic débridement be changed?
Every 72 hours, or sooner if drainage breakthrough occurs.
The wound should be cleansed before applying a new dressing.
What color may the fluid collected under the dressing during autolytic débridement be?
Tan.
Observing the fluid is part of the monitoring process.
What should be regularly observed for in autolytic débridement?
Signs of infection, such as an increase in pain or a foul odor.
Regular observation is crucial for timely intervention.
Fill in the blank: Autolysis is contraindicated in the presence of _______.
infection or immunosuppression.
What is biotherapy (maggot) débridement therapy?
The use of medical-grade larvae of the greenbottle fly to dissolve dead and infected tissue from wounds
The larvae secrete enzymes that break down dead tissue while neutralizing on healthy tissue.
How do maggot larvae affect dead tissue?
They secrete enzymes that break down dead tissue
The enzymes are neutralized upon contact with normal tissue, protecting healthy areas.
What additional benefit do maggot larvae provide in wound care?
They digest bacteria from the wound
This helps reduce infection and promotes healing.
What is a potential issue when using maggot therapy?
Containing the larvae within the dressing can be problematic
Larvae are typically changed every 48 to 72 hours.
How should used maggots be disposed of?
Disposed of as biohazardous medical waste
This is important for safety and infection control.
What emotional considerations should be taken into account with maggot therapy?
It can be emotionally disturbing to both patients and nurses
Discussing this with the patient is essential.
What defines a physiological wound environment?
Maintains the right amount of moisture for cells to flourish
This is crucial for healing.
What role do wound dressings play in moisture management?
Function as a barrier to water vapor loss
They help prevent dehydration of body cells.
What factors should be considered when choosing a dressing?
Purpose, duration, change frequency, and removal ease
These factors help ensure effective treatment.
What are the goals of the dressing of choice for a wound?
- Prevent drying of the wound bed
- Absorb drainage
- Keep surrounding tissue dry and intact
- Protect from contamination and infection
- Aid in hemostasis
- Débride the wound
- Eliminate dead space
- Prevent heat loss
- Splint the wound site
- Provide comfort to the patient
- Control odor
- Minimize scarring
Each of these goals contributes to effective wound management.
What are primary dressings?
Dressings placed in the wound bed that physically touch the wound
What is a secondary dressing?
A dressing that covers or holds a primary dressing in place
Can some dressings act as both primary and secondary dressings?
Yes, many dressings can touch the wound bed and secure themselves with adhesive
What is the importance of patient history and assessment in wound treatment?
Each wound must be treated and dressed individually based on patient history and assessment
Is there a single ‘recipe’ for healing a wound?
No, each wound must be treated individually
Should the newest dressing always be chosen for a wound?
No, the newest dressing is not necessarily the best for the wound being treated
What should guide the choice of dressing for a wound?
The needs of the wound and not the manufacturer’s brand name
What should be performed every time a wound is assessed?
Ongoing reassessment of the dressing choice
What is the purpose of modifying dressings and treatments?
To adapt as the wound evolves
Fill in the blank: Gauze dressings are available in a variety of _______.
[shapes and forms]
True or False: IV sites are commonly dressed with transparent film dressings.
True
What are absorbent dressings made from?
Highly absorptive layers of fibers such as cellulose, cotton, or rayon
May or may not have an adhesive border.
What types of wounds can absorbent dressings be used for?
Partial- or full-thickness wounds
Used as a primary or secondary dressing to manage drainage.
What is the absorption capability of absorbent dressings?
Moderate to large amounts of drainage
When should absorbent dressings not be used?
To pack undermining wounds or if the wound is not draining
Can dry out the wound bed and damage tissue.
What are alginates derived from?
Brown seaweed and kelp
In what forms are alginates available?
Pad or rope form
What is the absorbency level of alginates?
Very high absorbency (20–40 times their weight)
What do alginates promote in wound management?
A moist environment and facilitate autolytic débridement
What type of wounds are alginates ideal for?
Wounds that have depth, tracts, tunneling, or undermining
What happens when alginate comes in contact with exudate?
A nonadhesive gel is created
Must irrigate this gel from the wound before placing the next dressing.
What should be considered regarding allergies when using alginates?
Allergy to antibiotic components, seaweed, or kelp
What are the two main types of antimicrobials mentioned?
Antibiotic and antifungal
In what forms are antimicrobials available?
Ointments, impregnated gauzes, pads, gels, foams, hydrocolloids, and alginates
What common elements do many antimicrobials contain?
Silver and iodine
What are the primary functions of antimicrobials in wound care?
Reduce exudate and prevent infection by reducing bacteria in the wound, promote collagen deposition
What is a potential allergy concern with antimicrobials?
Allergy to silver or iodine
What types of wounds can antimicrobials be used on?
Partial- or full-thickness wounds, malodorous wounds with little to large amounts of drainage, highly contaminated or infected wounds
What are the sources of collagens used in wound care?
Bovine (cow) or porcine (pig) sources
In what forms can collagens be made for wound care?
Sheets, pads, powders, and gels
What types of wounds can collagens be used with?
Partial- and full-thickness and contaminated or infected wounds
What is one key function of collagens in wound care?
Absorb exudate
How do collagens promote healing?
Promote a moist wound bed for healing
What do collagens stimulate in the wound bed?
Wounds to produce collagen fibers and granulation tissue
What should be checked before using porcine dressings?
Ensure the patient has no religious practices that would forbid this use
What is the range of wound exudate absorption for collagens?
Minimal to large
True or False: Collagens stick to the wound bed.
False
What is a notable feature of collagens in terms of application?
Easy to apply and remove
What are foams made from?
Semipermeable hydrophilic foam that forms an impermeable barrier over the wound
In what forms are foams available?
Wafers, rolls, and pillows
What types of coverings do foams have?
Film coverings; can be adhesive or nonadhesive
What type of wounds are foams absorbent for?
Wounds with moderate to heavy exudates
What is one thermal property of foams?
Thermal insulation
What environment do foams promote for wounds?
A moist environment
Do foams stick to the wound bed?
No, they do not stick to the wound bed
Can foams be used under compression?
Yes, they can be used under compression
What type of skin do foams protect?
Friable periwound skin
How can foams be shaped?
They can be shaped around body contours
With which other dressings may foams be used in combination?
Alginates or films
Should foams be used with wounds that have tunneling or tracts?
No, do not use with wounds that have tunneling or tracts
Are foams recommended for dry, desiccated wounds?
No, not recommended
What can happen if the dressing becomes oversaturated?
May macerate periwound skin
What is a visual limitation of foams?
Opaque, with inability to see wound bed for assessment
What is a risk associated with foams regarding bacterial invasion?
High probability of bacterial invasion
Foams are suitable for wounds with _______ exudates.
moderate to heavy
What is the simplest and most widely used type of dressing?
Gauze
Gauze is a common choice for various wound care needs.
What are the primary functions of gauze dressings?
Cleansing and Protection
Gauze dressings help to clean wounds and protect them from external contaminants.
What is a disadvantage of using gauze dressings?
Labor intensive
Gauze dressings require careful management and frequent changes.
Gauze dressings are made of which types of fibers?
Woven and nonwoven fibers of cotton, rayon, polyester, or a combination
These materials contribute to the absorbency and flexibility of the dressing.
What types of wounds are gauze dressings used for?
Packing large wounds, cavities, or tracts, deep or dirty wounds, or heavily draining wounds
Their versatility makes them suitable for various wound types.
Gauze may be used in combination with which of the following?
Amorphous hydrogels, saline, or medications
Combining gauze with these substances can enhance wound healing.
What are the two forms in which gauze can be packed?
Sterile or nonsterile
This allows for flexibility based on the clinical situation.
What is a potential drawback of gauze dressings regarding moisture?
Does not ensure a moist wound environment
Gauze can allow for fluid evaporation, which is not ideal for healing.
What can happen if gauze sticks to wound tissue?
It can damage new, regenerated cells with gauze removal
This can impede the healing process.
What is required to avoid pressure or overpacking of a wound with gauze?
Gauze must be fluffed
Proper application is crucial to prevent complications.
What factors determine the dressing change interval for gauze?
Amount of fluid saturation of the gauze
Monitoring saturation helps maintain effective wound care.
Frequent dressing changes can disrupt the wound bed and cause what physiological condition?
Hypothermic (cold) wound
This condition can impair cell growth for healing.
What are hydrocolloids?
Wafers, pastes, or powders that contain hydrophilic particles
How do hydrophilic particles in hydrocolloids interact with water?
They form a gel that keeps the wound moist
What protective benefits do hydrocolloids provide?
They provide a protective layer against friction, caustic agents, and bacteria and reduce pain
Are hydrocolloids the dressing of choice for wounds requiring frequent changes?
No
What is a characteristic appearance of hydrocolloids?
Opaque
What type of wounds are hydrocolloids ideal for?
Wounds with minimal exudates, such as partial-thickness wounds and stage 2 pressure injuries
What process do hydrocolloids promote in wound healing?
Autolysis
How do hydrocolloids adapt to the body?
They mold to the shape of the body, making them useful for difficult areas
What is a specific application of hydrocolloids around stomas?
To create an even surface on which to place the ostomy appliance
Do hydrocolloids require a secondary dressing?
No
When are hydrocolloids not recommended?
For wounds surrounded by friable or sensitive skin and for infected wounds
What can happen when exudate comes in contact with hydrocolloid material?
It can produce an odor that might be confused with a malodorous wound
What should be done before determining if a wound is malodorous?
Clean the wound bed first
Why should hydrocolloids not be used on wounds with tunneling or tracts?
These wounds must be packed and allowed to drain
Fill in the blank: Hydrocolloids should not be used on infected wounds because they are impermeable to ______, moisture, and bacteria.
oxygen
What is a potential risk of using hydrocolloids on wounds?
May facilitate the growth of anaerobic bacteria
What are hydrogels?
Sheets, granules, or gels with a high water content, creating a jelly-like consistency that does not adhere to the wound bed.
What is one of the main benefits of hydrogels in wound care?
Enhance epithelialization to promote a moist environment.
How do hydrogels affect the wound bed?
Rehydrate the wound bed.
What is another function of hydrogels in wound management?
Promote autolysis.
What texture do hydrogels have that contributes to patient comfort?
Soft, cooling texture.
What is a limitation of hydrogels?
Have limited absorptive capabilities (not practical for wounds with significant exudate).
What type of dressing is required when using hydrogels?
Require a secondary dressing.
What is one of the uses of hydrogels in necrotic wounds?
Soften slough or eschar.
What risk do hydrogels pose to periwound skin?
Easily macerate periwound skin due to high moisture content.
What are skin sealants made from?
Liquid transparent copolymer
Skin sealants are specifically designed to provide a protective barrier on the skin.
What are the components of moisture barrier ointments?
Petrolatum, dimethicone, zinc-based products
These components help protect the skin from exudate, moisture, urine, and feces.
How should skin sealants be applied?
Wiped or sprayed on skin
They can be applied to protect the skin from wound exudate and moisture.
What is the primary purpose of moisture barrier ointments?
To protect skin from exudate, moisture, urine, and feces
They serve as a protective layer for vulnerable skin.
When should skin sealants be used?
With each dressing change
They are simple and fast to use, ensuring ongoing protection.
What do skin sealants protect the skin from?
Moisture, friction, skin stripping from adhesives
They provide a barrier against various forms of skin injury.
True or False: Ointments improve the adhesion of wound dressings or tapes.
False
Ointments can impair the adhesion of wound dressings or tapes.
Fill in the blank: Skin sealants provide a barrier of protection over vulnerable skin from the effects of _______.
moisture and mechanical and chemical skin injury
This protective barrier is essential for maintaining skin integrity.
What are transparent films?
Clear and semipermeable materials
Used in wound dressing to provide a moist environment.
What environment do transparent films promote?
A moist environment
This helps in the healing process of wounds.
What happens to tissues if transparent films are used over draining wounds?
Tissues will become macerated
This is due to excessive moisture retention.
What is a key characteristic of transparent films regarding oxygen?
Occlusive with oxygen permeability
This allows for gas exchange while protecting the wound.
What process do transparent films promote?
Autolysis
This is the body’s own process of breaking down dead tissue.
Where are transparent films often used?
To dress IV sites
They help prevent contamination and maintain a sterile environment.
What do transparent films prevent?
External bacterial contamination
This is crucial for maintaining the integrity of the wound.
What advantage do transparent films offer in wound assessment?
Allow wound assessment without removing or disturbing the dressing
This minimizes trauma to the wound during evaluations.
Can transparent films be placed over joints?
Yes, without inhibiting movement
This makes them versatile for various body areas.
What should be avoided when using transparent films?
Do not use them on friable skin
They adhere strongly and can cause further damage.
What factors influence the choice of securing a dressing?
Wound size, location, amount of drainage, frequency of dressing changes, patient’s activity level, type of dressings used
What is the most commonly used method to secure dressings?
Tape
What are the characteristics of adhesive tape?
Provides stability, tough, durable, leaves residue, can cause trauma to skin upon removal
What should be used to remove residue left by adhesive tape?
Commercial adhesive removers
What type of reactions can adhesives in tape cause?
Allergic skin reactions
Which tape is ideal for dressings over joints?
Foam tape
What types of tape are best for sensitive skin?
Nonallergenic tape, paper tape
What should be done before using tape on a patient?
Ask about history of tape allergies or irritation
How should tape be applied to a dressing?
Place strips of tape at the ends and space them evenly over the dressing
What types of tape should be used for fragile skin of older adults or infants?
Porous tapes, thin hydrocolloids, low-adhesion foam dressings, skin sealants
What is the purpose of Montgomery straps?
Decrease pulling and irritation of skin around a wound
How should Montgomery straps be applied?
Adhesive part to skin at ends and spaced intervals, lace cloth ties to secure dressing
When should the ties of Montgomery straps be changed?
Whenever they become soiled
What should be done with Montgomery straps after application?
Keep in place until they begin to loosen
What are Standard Precautions?
Infection control measures recommended by the CDC for all patients
What additional precautions should be followed for patients with open or draining wounds?
CDC Tier Two: Contact Level Precautions in addition to Standard Precautions
What is the purpose of Montgomery straps?
To secure a dressing that requires frequent changing
What should be done if a patient has an infection?
Place them in a private room or with a patient with the same organism
What is the most important aseptic measure?
Wash your hands frequently and thoroughly with soap and warm water
When should clean gloves be used in wound care?
When caring for the patient with a wound
What should be done after removing a soiled dressing?
Change gloves and wash hands before applying a clean dressing
Which wound should be treated first when a patient has multiple wounds?
The least contaminated wound
What technique should be used for sharp débridement?
Sterile technique with sterile instruments
What signs and symptoms should be monitored after sharp débridement?
Signs of sepsis (e.g., fever, tachycardia, hypotension, altered consciousness)
Who can perform sharp débridement?
Only specially trained providers
What type of dressings do acute wounds require?
Sterile dressings
What type of dressings do chronic wounds require?
Clean dressings, unless the patient is immunocompromised
How should contaminated dressings be disposed of?
In biohazard waste receptacles
What should be done with unused dressings if they become contaminated?
Discard them
Where should patient dressing supplies be stored?
In a clean and dry area
What should not be done with dressing supplies among patients?
Do not share supplies
What is the recommended practice for accessing dressing supplies?
Access only the number needed for the dressing change
What should be avoided when handling dressing supplies?
Touching the supply with gloves that have come in contact with the wound
What is the primary purpose of binders and bandages?
To hold a dressing in place, apply pressure to a wound, and support and immobilize an injured area
This promotes healing and comfort.
What should be assessed before applying a bandage or binder?
The purpose of the application and the part being bandaged
This ensures appropriate use and effectiveness.
What are binders typically used for?
To keep a wound closed or to immobilize a body part
This aids in the healing process.
What materials are binders commonly made from?
Cloth or elasticized material
They may fasten with straps, pins, or Velcro.
What is a triangular arm binder or sling used for?
To support the upper extremities
Commercial slings are commonly available.
What is the function of a T-binder?
To secure dressings or pads in the perineal area
It helps maintain cleanliness and protection.
What is an abdominal binder used for?
To provide support to the abdomen, especially after an incision or open wound
It decreases the risk of dehiscence.
Fill in the blank: Binders may be used to keep a wound closed when there is danger of _______.
dehiscence
True or False: Binders are only used on small areas of the body.
False
Binders are typically used on large areas of the body.
What is a bandage?
A cloth, gauze, or elastic covering that is wrapped in place
What are the common widths for bandages?
1.5 to 7.5 cm (0.5 to 3 in.)
When should a narrow bandage be used?
On small body parts, such as a finger
What are cloth bandages commonly used for?
As slings to immobilize an upper extremity or to hold large abdominal dressings in place
What is the most frequently used type of bandage?
Gauze
How does gauze conform to the body?
It readily conforms to the shape of the body
What can gauze be impregnated with?
Medications or plaster of Paris
What is the purpose of elastic bandages?
To apply pressure and give support
What is the most common form of elasticized bandage?
Ace bandages
What is a rolled bandage?
A continuous strip of material that you unroll as you apply it to a body part
What temperature range do temperature-sensitive nerve endings respond to?
15°C to 45°C (59°F to 113°F)
What factors affect the response to heat or cold therapy?
Area being treated, nature of the injury, duration of treatment, patient age, physical condition, and condition of the skin
What happens to thermal receptors after about 15 minutes of heat or cold application?
They adapt to the new temperature and the person notices it less
What should patients be cautioned against during heat or cold therapy?
Changing the temperature after adaptation occurs
Who are the least tolerant of heat and cold therapies?
The very young and the very old
What is a risk for patients with sensory impairment during heat or cold therapy?
Increased risk for injury due to inability to perceive temperature changes
Which body areas are very sensitive to temperature changes?
Highly vascular areas such as fingers, hand, face, and perineum
How does application to a large body surface area affect tolerance?
Decreases the patient’s tolerance of the treatment
How does intact skin compare to injured skin in tolerating heat and cold therapy?
Intact skin tolerates heat and cold therapy better
What is the purpose of local heat therapy?
To relieve stiffness and discomfort associated with musculoskeletal problems and for patients with wounds.
What physiological effect may occur when heat is applied to a large area of the body?
Vasodilatation may cause a drop in blood pressure and a feeling of faintness.
What are the mechanisms by which heat therapy increases blood flow?
Through vasodilatation, increased capillary permeability, and reduced blood viscosity.
How does increased blood flow benefit a wound?
It brings oxygen and white blood cells (WBCs) to the wound and aids in the healing process.
What are the two types of heat that may be used in heat therapy?
Moist heat and dry heat.
Fill in the blank: Moist heat can be applied in several forms, including _______.
washcloths, gauze compresses, soaks, and baths.
What should you avoid when warming moistened towels for heat therapy?
Do not microwave moistened towels to warm them.
Why should moistened towels not be microwaved?
It causes unequal heat distribution and may cause burns to the patient.
What is a gauze compress used for in heat therapy?
To apply moist heat when there are open areas on the skin.
What is the purpose of a soak in heat therapy?
To immerse the affected area, cleanse a wound, and remove encrusted material.
What is a sitz bath?
A type of bath that soaks the patient’s perineal area.
What type of heat applications can be used for dry heat therapy?
Electric heating pads, disposable hot packs, or hot water bags.
What caution should be taken when using heating pads?
Patients should place the heating pad over the body area and never lie on it.
What is an aquathermia pad?
A device that circulates water in the interior of the pad to create a constant temperature.
True or False: Moist heat therapy is less effective than dry heat therapy.
False.
What is a major advantage of electric heating pads?
Providing a constant temperature
However, there is a high risk of burns associated with their use.
What are aquathermia pads used for?
Dry heat application
Aquapads circulate water in the interior to create a constant temperature.
What are some alternatives to electric heating pads for heat application?
Disposable hot packs and hot water bags or bottles
Hot water bags are common for home use but pose a burn risk in healthcare settings.
What are the effects of applying cold therapy?
Vasoconstriction and decreased capillary permeability
Additional effects include local anesthesia, reduced cell metabolism, increased blood viscosity, and decreased muscle tension.
List some applications of cold therapy.
- Prevent or limit edema
- Reduce inflammation and pain
- Reduce oxygen requirements
- Help control bleeding
- Treat fevers
- Treat musculoskeletal injuries
- Prevent swelling after surgery
Examples include using an ice bag on the perineum after childbirth or an ice collar after tonsillectomy.
What are some side effects of cold therapy?
- Elevated blood pressure
- Shivering
- Tissue damage
Elevated blood pressure occurs due to vasoconstriction; shivering is a normal response to prolonged cold; tissue damage can result from impaired circulation.
Fill in the blank: Cold therapy can produce _______ that helps control bleeding.
Vasoconstriction
True or False: Hot water bags are widely used in healthcare agencies.
False
Hot water bags are common for in-home use but are not recommended in healthcare settings due to burn risks.
