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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

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
Stage 3 pressure ulcers
Full-thickness skin tissue loss with visible fat
26
stage 4 pressure ulcers
Full-thickness tissue loss with exposed bone, muscle, or tendon
27
Beyond stage 4 pressure ulcer
Deep tissue pressure injury | Unstageable pressure injury
28
Deep tissue pressure injury (DTPI)
- 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
Unstageable pressure injury
- Obscured full-thickness skin and tissue los | - Obscured because of slough or eschar are present
30
What do you want to avoid with wound healing
Hemorrhage | Infection
31
Risk assessment for pressure ulcers
Braden scale | --- sensory, moisture, activity, mobility, nutrition, friction/shearing
32
Prevention of pressure ulcers
- 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
Factors influencing pressure ulcer formation and wound healing
``` Nutrition Tissue perfusion Infection Underlying heath status Age Use of steroids Site of wound Mechanism of injury ```
34
Infection prolongs
Inflammatory phase and delays healing
35
Aging dermis tends to
not support sutures well
36
Wound prevention
- 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
Assessment of skin/wounds
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
Risk factors for pressure ulcers
``` Impaires sensory perception Alterations in LOC Impaired mobility Shear Friction Moisture Nutrition Hydration ```
39
Wound cultures
``` 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
Wound management
``` Debridement Closures Protection Education Nutritional status ```
41
Debridement (removal of nonviable, necrotic tissue)
Mechanical, autolytic, chemical, or sharp/surgical Sharp/surgical only w/NP or CWN, not general nurses Wet to dry dressing
42
Closures
Sutures, staples, steri strips, derma bond adhesive
43
Protection
dressings and wraps
44
Nutritional status
- Caloric needs - Albumin/pre-albumin - Can lose up to 50 G of protein /day from weeping ulcer - Hemoglobin maintain> 12 if possible
45
First aid for wounds
Hemostasis Cleaning Protection
46
Ways to control bleeding
Allow puncture wounds to bleed | Do not remove a penetrating object!
47
Purposes of dressing
- 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
Types of dressing
``` Gauze Self-adhesive/transparent film Hydrocolloid dressings Hydrogel Foam Alginate Composite dressings ```
49
Wound devices
Penrose drain Jackson-Pratt drainage V.A.C (vacuum assisted closure)
50
VAC: Vacuum assisted closure
- 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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