Exam 4; fundamentals of nursing Flashcards
What are some factors that affect skin integrity
impaired mobility, nutrition and hydration, impaired circulation, medications, fever, contamination or infection, lifestyle
Of the following factors, which would put a client at greatest risk for impaired skin integrity?
A. medication
B. moisture
C. Decreased sensation
D. dehydration
C
What is an open/ closed wound
open: a break in the skin or mucous membranes
closed: no breaks in the skin, tissue swelling
What is acute/ chronic wound
Acute: new fresh wound
Chronic: ongoing
What is clean/ contaminated/ infected wound
Clean: minimal infection, low risk for infection
Contaminated: increased risk for infection (surgical wounds)
Infected: open traumatic wounds, aspepsis, high risk of infection/ already occurring
What is superficial/ partial or full thickness wounds
superficial: epidermal layer caused by friction and shear
Partial: epidermis layer but not dermal layer
Full thickness: subq layer and beyond
What is penetrating wounds
penetrating: indicated that wound involves internal layers
What are some complications of wound healing
hemorrhage (24-48 hours, swelling and pain. internal bleeding), infection, dehiscence (rapture of separation of one or more layer), evisceration (total separation of the wound were internal viscera), fistula formation (abnormal passage -> through 2 body cavities. abscess usually forms, breaks down tissue)
What is the difference between dehiscence and evisveration
Dehiscence: bursting open of a wound
Evisceration: removal of the contents of a cavity or protrusion of the viscera.
What are some nursing interventions related to wound care?
cleaning/ irrigating
caring for a drainage device (jackson- pratt & hemovac)
debriding a wound (mechanical, enzymatic, autolysis, biotherapy, sharp)
applying negative pressure wound therapy
dressing a wound
supporting/ immobilizing a wound
applying heat and cold
What are some intrinsic risk factors of pressure injury developing
immobility
impaired sensation
aging
fever
infection
edema
dehydration
What are some extrinsic risk factors of pressure injury developing
friction
pressure
shearing
moisture
What are some nursing assessments of pressure injuries
determine the state: stages 1-4 (classified by tissue involvement) stages 3-4 (involve tissue necrosis, tissue death)
suspected deep tissue injury
unstageable pressure injury
What are some defining characteristics of stage one pressure injuries
area may be painful, firm, soft, or warmer or cooler than adjacent tissue.
discoloration will remain for 30 minutes after pressure is released.
redness discoloration
What are some defining characteristics of stage two pressure injuries
pressure injury is open and shallow and with a red pink wound bed.
no slough
may be intact or shallow opening
What are some defining characteristics of stage three pressure injuries
full thickness skin loss with damage or necrosis of subq tissue.
adipose visible
bone tendon is not visible
What are some defining characteristics of stage four pressure injuries
full thickness skin loss with extensive destruction of tissue
exposed bone and tendon
eschor and slough visible
ebole (rolled edges)
What are some defining characteristics of stage deep tissue injury pressure injuries
intact or non intact skin
pain and temperature change and color changes
What are some defining characteristics of stage unstageable pressure injuries
full thickness skin loss. base of wound is obscured by slough or eschar
when do risk assessments start for patients? What patients do you do risk assessments on?
ALL patients require a risk assessment at time of admission
When are reassessments done for risk assessments?
Every 24 hours= minimum
Every 12 hours= best practice
pressure ulcers can develop within 24 hours of insult or take as longa s 5 days to be present
Change in condition: surgery, nutrition, level of mobility, ect.)
when do skin inspections assessments start for patients? What patients do you do skin assessments on?
All patients require full skin inspection upon admission: inspect and palpate skin from head to toe
What are some ways to integrate skin inspection with your assessment of the patient?
when applying O2: look behind hears
for immobile patients: coccyx, back of head, bony prominent areas
when listening to lung sounds or repositioning: check the back/ sacrum
when checking bowel sounds: between skin folds and hips
when placing pillows under calves: heels and feet
when checking iv sites: elbows and arms
if patient is here for surgery: know areas prone to breakdown
when getting patient up or doing cares: back, sacrum, genital, heels, full body
What is the braden scale
a test to measure risk for skin breakdown
how is the braden scale scored
the lower the number, the more you’re at risk
6-23 is range
what are some interventions for friction and shear
use transfer devices
use minimum of 2 people
don’t drag the patient
keep HOB at or below 30 degrees
use trapeze
pad skin surfaces as needed
apply moisturizer to skin at least daily and prn
The nurse is caring for a patient on the medical- surgical unit with a wound that has a drain and a dressing that needs changing. which of these actions should the nurse take first?
A. don sterile gloves
B. provide analgesic medications as ordered
C. avoid accidentally removing the drain
D. gather supplies
B
A client has been lying on her back for two hours. When the nurse turns her, the nurse notices the skin over her sacrum is very white. By the time the nurse finishes repositioning her, the spot has turned bright red. The nurse should:
A. massage the spot with lotion
B. apply a warm compress for 30 minutes
C. return in 30-45 minutes to see if the redness has disappeared
D. wash the area with soap and water and notify the physician
C
During evening cares, the student nurse assesses the mepilex dressing on his client’s sacrum. The dressing was dated and initialed for earlier that day. the dressing was attached on all edges with no visible drainage present. Which of the following is most appropriate for the student nurse to document regarding the assessment.
A. base. site assessment clean, dry, intact
B. peri wound clean, dry, intact
C. wound healing ridge clean, dry, intact
D. dressing clean, dry, intact
D
What do you assess when assessing a wound
location- anatomical area
size- length and width in centimeters
appearance- peri wound (skin surrounding wound itself)
drainage- amount, color, any drains, odor
redness
swelling
What are the colors of wound base
pale pink, pink, red (granulating tissue, tissue that is starting to heal)
yellow (slough?), green, (infection?)
black (necrotic tissue?)
What does eschar look like
may be tan, brown or black in the wound bed
What does slough look like
may be yellow, tan, gray, green, or brown in the wound bed
What does granulation tissue look like
deep pink or red, moist, shiny, with irregular granular surface
What to look for when assessing periwound skin and wound edges?
periwound pain
edema (swelling)
induration (hardness)
erythema (redness)
maceration (white-wet)
What is an abrasion
a wearing away of the upper layer of skin as a result of applied friction
what is a laceration
a deep cut or tear into the skin
What is ecchymosis/ some characteristics of it
characterized by reddish to bluish (sometimes purple) discoloration of the skin; which results from the rupture of small capillaries beneath the skin and accumulation of blood in the surrounding tissue
What is a hematoma
a localized swelling filled with blood, resulting from a break in a blood vessel
The client calls the nurse to the room and states, “look, my incision is popping open where they did my hip surgery!” the nurse notes that the wound edges have separated 1 cm at the center and there is straw colored fluid leaking from one end. The nurse’s best action is to:
A. notify the surgeon stat
B. place a clean, sterile 4x4 over the incision and monitor the drainage
C. wrap an ace bandage firmly around the area dn have the client maintain bedrest
D. immediately cover the wound with sterile towels soaked in normal saline and call the surgeon
B
What are some characteristics of wound dimensions
measure length, width, and depth of wound
tunneling/ undermining?
describe the wound as a clock with patient’s head at 12:)) and feet at 6:)) to promote consistency in description
what are ways to close wounds
adhesive strips
sutures
surgical staples
surgical glue
What is the mnemonic to remember when assessing wound drainage
T= type
A= amount
C= consistency
O= odor
What is serous exudate
thin, clear, watery plasma
What is sanguineous
bloody drainage
What is serosanguineous
thin, watery, pale red to pink plasma cells with red blood cells
What is purulent
thick, opaque drainage that is tan, yellow, green, or brown
What is purosanguineous exudate
contains blood and pus
What are the variations of amount of drainage
none- wound tissues are dry
scant- wound tissues are moist, but there is no measurable drainage
small (minimal)- wound tissues are very moist or wet; the drainage covers less than 25% of the dressing
Moderate- wound tissues are wet; the drainage involves more than 25 to 75% of the dressing
Large (copious)- wound tissues are filled with fluid that involves more than 75% of the dressing
What are the two types of consistency with drainage
low viscosity- thin and runny
high viscosity- thick or sticky, doesn’t flow easily
