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Nursing 314: Assessing and Promoting Wellness > Exam 3: Skin assessment and wound care > Flashcards

Exam 3: Skin assessment and wound care Flashcards

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1
Q

Skin and Aging

A 
Decreased elasticity and collagen
Thinning of underlying tissue
Easily torn
Co-morbidities and poly-pharmacy
Decreased inflammatory response
Decreased subcutaneous layer over bony prominences
Malnutrition
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2
Q

Wounds heal from

A

the bottom up and the sides in

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3
Q

Last place to heal is the

A

Center of the wound

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4
Q

Healing times vary

A

On circulation and ease of blood movement

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5
Q

Final remodeling of wounds occurs

A

6-12 months

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6
Q

Sun exposure of wounds

A

Hyperpigmentation

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7
Q

When to clean wound?

A

If it is

  • Dirty
  • Deep
  • Open
  • Dry
  • Wet
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8
Q

Wound

A

Disruption in integrity and function of tissues in the body

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9
Q

acute wound

A

Trauma/surgical

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10
Q

Chronic wound care

A

Prolonged healing r/t vascular compromise, inflammation, repetitive insults to issue

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11
Q

primary intention

A

sutured/staples, quick healing, minimal scarring

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12
Q

Secondary intention

A

Tissue loss/contamination, slower, moderate, scarring

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13
Q

Tertiary intention

A

Contaminated wound allowed to remain open until risk of infection resolved

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14
Q

Wounds are classified by

A

Onset
Process
Depth
Color

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15
Q

Partial thickness wound repair

A

Inflammatory response
Epithelial proliferation and migration
Reestablishment of the epidermal layers

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16
Q

Full-thickness wound repair

A

Hemostasis
Inflammatory
Proliferative
Maturation

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17
Q

Hemorrhage

A
  • Externally or internally
  • Surgical drain to remove fluid in underlying tissue
  • Risk is greatest first 24-48 hours after surgery/injury
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18
Q

Infection

A
  • Contaminated vs infected # bacteria present
  • Chronic wounds are colonized with bacteria
  • Bacteria inhibits wound healing
  • 4-5 days post surgery
  • —-Fever, tenderness and pain at wound site, elevated WBC
  • —-Purulent drainage
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19
Q

Dehiscence

A
  • Partial or total separation of wound layers
  • Coughing, vomiting, sitting up
  • Splint/bandage wounds to prevent
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20
Q

Evisceration

A
  • -Protrusion of visceral organs
  • -Emergency
  • -Use sterile towels soaked in saline
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21
Q

Pressure ulcer

A

Pressure sore, decubitus ulcer, or bed sore

22
Q

Pathogenesis of pressure ulcers

A
  • Pressure intensity
  • Tissue ischemia
  • Pressure duration
  • Tissue tolerance
23
Q

Stage 1 pressure ulcer

A

Intact skin with non-blanchable redness

24
Q

Stage 2 pressure ulcers

A

Partial-thickness skin loss involving epidermis, dermis, or both

25
Q

Stage 3 pressure ulcers

A

Full-thickness skin tissue loss with visible fat

26
Q

stage 4 pressure ulcers

A

Full-thickness tissue loss with exposed bone, muscle, or tendon

27
Q

Beyond stage 4 pressure ulcer

A

Deep tissue pressure injury

Unstageable pressure injury

28
Q

Deep tissue pressure injury (DTPI)

A
  • Persistent non-blanchable deep red, maroon, or purple
  • Skin may be intact or nonintact
  • Intense and/or prolonged pressure and shear forces down deep.
  • May/may not open up.
29
Q

Unstageable pressure injury

A
  • Obscured full-thickness skin and tissue los

- Obscured because of slough or eschar are present

30
Q

What do you want to avoid with wound healing

A

Hemorrhage

Infection

31
Q

Risk assessment for pressure ulcers

A

Braden scale

— sensory, moisture, activity, mobility, nutrition, friction/shearing

32
Q

Prevention of pressure ulcers

A
  • Beds, mattresses, good hygiene, good nutrition (check labs), adequate hydration, impeccable nursing care.
  • Time and amount of pressure = key variables
  • Increases hospital Length of Stay (LOS) = $$$
  • Pain/suffering
33
Q

Factors influencing pressure ulcer formation and wound healing

A 
Nutrition 
Tissue perfusion 
Infection 
Underlying heath status 
Age 
Use of steroids 
Site of wound 
Mechanism of injury
34
Q

Infection prolongs

A

Inflammatory phase and delays healing

35
Q

Aging dermis tends to

A

not support sutures well

36
Q

Wound prevention

A
  • Skin care
  • Continence Management
  • Positioning
  • Support surfaces
  • –Low-air-loss mattress/overlay
  • –Non-powered: cushions, foam
  • –Air-fluidized beds: change load distribution/pressure
  • –Lateral rotations: passive turning
37
Q

Assessment of skin/wounds

A

Through the patient’s eyes: impact, OLDCART
Assess skin at intake into facility/care
Appearance
Drainage:
—Amount
—Color
——Serous/Sanguinous/Serosanguinous/Purulent
—Odor
—Consistency
—Cultures
Peri-wound: tissue surrounding actual wound

38
Q

Risk factors for pressure ulcers

A 
Impaires sensory perception 
Alterations in LOC 
Impaired mobility 
Shear 
Friction 
Moisture 
Nutrition 
Hydration
39
Q

Wound cultures

A 
Clean wound surface with a non-antiseptic solution
Use sterile swab from culturette  tube
Moisten swab with normal saline
Rotate swab in open wound
Reinsert into transport tube.
40
Q

Wound management

A 
Debridement 
Closures 
Protection 
Education 
Nutritional status
41
Q

Debridement (removal of nonviable, necrotic tissue)

A

Mechanical, autolytic, chemical, or sharp/surgical
Sharp/surgical only w/NP or CWN, not general nurses
Wet to dry dressing

42
Q

Closures

A

Sutures, staples, steri strips, derma bond adhesive

43
Q

Protection

A

dressings and wraps

44
Q

Nutritional status

A
  • Caloric needs
  • Albumin/pre-albumin
  • Can lose up to 50 G of protein /day from weeping ulcer
  • Hemoglobin maintain> 12 if possible
45
Q

First aid for wounds

A

Hemostasis
Cleaning
Protection

46
Q

Ways to control bleeding

A

Allow puncture wounds to bleed

Do not remove a penetrating object!

47
Q

Purposes of dressing

A
  • Protect from microorganism contamination
  • Aid in hemostasis
  • Absorb drainage and debriding a wound
  • Support or splint the wound site
  • Protect from seeing the wound (if distressing)
  • Promote thermal insulation of the wound.
48
Q

Types of dressing

A 
Gauze
Self-adhesive/transparent film
Hydrocolloid dressings
Hydrogel
Foam
Alginate
Composite dressings
49
Q

Wound devices

A

Penrose drain
Jackson-Pratt drainage
V.A.C (vacuum assisted closure)

50
Q

VAC: Vacuum assisted closure

A
  • Reduces edema/swelling
  • Improves circulation to the wound
  • Facilitates wound healing and decreases duration of wounds.
  • Drawback: Risk for bleeding

Nursing 314: Assessing and Promoting Wellness (26 decks)

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