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NRS 130 Test #8 > Fund SG CH 48 skin integrity & wound care > Flashcards

Fund SG CH 48 skin integrity & wound care Flashcards

1
Q

What is the epidermis?

A

-the top layer of skin.

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2
Q

What is the dermis?

A

-inner layer of skin that provides tensile strength and mechanical support.

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3
Q

What is collagen?

A

-tough, fibrous protein

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4
Q

What is a pressure ulcer?

A

-localized injury to the skin and underlying tissue over a body cavity.

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5
Q

What is blanching?

A

-normal red tone of light-skinned patients are absent

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6
Q

What is different about darkly pigmented skin?

A

-does not blanch.

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7
Q

What pressure factors contribute to pressure ulcer development?

A
  • pressure intensity
  • pressure duration
  • tissue tolerance
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8
Q

What are the risk factors that predispose a patient to pressure ulcer formation?

A
  • impaired sensory perception
  • impaired mobility
  • alteration in level of consciousness
  • shear
  • friction
  • moisture
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9
Q

Describe a stage I pressure ulcer:

A

Intact skin with non- blanchable redness of a localized area over a bony prominence.

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10
Q

Describe a stage II pressure ulcer:

A

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

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11
Q

Describe a stage III pressure ulcer:

A

Full-thickness with tissue loss.

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12
Q

Describe a stage IV pressure ulcer:

A

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

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13
Q

What is granulation tissue?

A

Red, moist tissue composed of new blood vessels which indicate wound healing.

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14
Q

What is slough?

A

Stringy substance attached to wound bed that is soft, yellow, or white tissue.

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15
Q

What is eschar?

A

Black or brown necrotic tissue.

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16
Q

What is exudate?

A

Describes the amount, color, consistency, and odor of wound drainage.

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17
Q

What is primary intention?

A

A wound that is closed by epithelialization.

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18
Q

What is secondary intention?

A
  • A wound that is left open until it becomes filled with scar tissue.
  • Chance of infection is greater.
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19
Q

What three components are involved in the healing process of a partial–thickness wound?

A
  • inflammation response
  • epithelial proliferation (reproduction)
  • migration with reestablishment of the epidermal layers
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20
Q

What are the four phases involved in the healing process of a full-thickness wound?

A

1-hemostasis
2-inflammatory phase
3-proliferative phase
4-remodeling

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21
Q

What is hemostasis?

A
  • First phase involved in the healing process of a full thickness wound.
  • Injured blood vessels constrict, and platelets gather to stop bleeding.
  • Clots form fibrin matrix for cellular repair.
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22
Q

What is the inflammatory phase?

A
  • Second phase involved in the healing process of a full thickness wound.
  • Damaged tissue and mast cells secrete histamine (vasodilate) with exudation of serum and WBC into damaged tissue.
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23
Q

What is the proliferative phase?

A
  • Third phase involved in the healing process of a full thickness wound.
  • With the appearance of new blood vessels as reconstruction progresses, the proliferative phase begins and lasts from 3 to 24 days.
  • The main activities during this phase are the filling of the wound with granulation tissue, contraction of the wound, and resurfacing of the wound by epithelialization.
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24
Q

What is remodeling?

A
  • Fourth phase involved in the healing process of a full thickness wound.
  • Maturation, the final stage, may take up to one year.
  • The collagen scar continues to reorganize and gain strength for several months.
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25
Q

What is hemorrhage?

A
  • Bleeding from a wound site
  • Occurs after hemostasis
  • Indicates a slipped surgical suture, a dislodged clot, infection, , or erosion of a blood vessel by a foreign object (internal or external)
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26
Q

What is a hematoma?

A

-Localized collection of blood underneath the tissue.

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27
Q

What is an HAI (Health care-associated infection)?

A
  • The second most common nosocomial infection

- Purulent material drains from the wound (yellow, green, or brown, depending on the organism)

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28
Q

What is dehiscence?

A
  • A partial or total separation of wound layers

- Risks are poor nutritional status, infection, or obesity

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29
Q

What is evisceration?

A

-Total separation of wound layers with protrusion of visceral organs through a wound opening requiring surgical repair.

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30
Q

What are the sub scales of the Braden Scale?

A
  • sensory perception
  • moisture
  • activity
  • mobility
  • nutrition
  • friction or shear
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31
Q

What factors influence pressure ulcer formation?

A
  • nutrition
  • tissue perfusion
  • infection
  • age
  • psychosocial impact of wounds
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32
Q

How does mobility place a pt at risk for a pressure ulcer?

A
  • potential effects of impaired mobility

- muscle tone and strength

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33
Q

How does nutritional status place a pt at risk for a pressure ulcer?

A
  • malnutrition is a major risk factor

- A loss of 5% of usual weight, weight less than 90% of IDW, or a decrease of 10 pounds in a brief period

34
Q

How do body fluids place a pt at risk for a pressure ulcer?

A

-continuous exposure of the skin to body fluids, especially gastric and pancreatic drainage, increases the risk for breakdown

35
Q

How does pain place a pt at risk for a pressure ulcer?

A

-adequate pain control and patient comfort will increase mobility, which in turn reduces risk

36
Q

What is an abrasion?

A
  • Superficial with little bleeding

- Considered a partial-thickness wound

37
Q

What is a laceration?

A

-Sometimes bleeds more profusely depending on death and location (>5 cm or 2.5 cm in depth)

38
Q

What is a puncture wound?

A

-Bleeds in relation to the depth and size, with a high risk of internal bleeding and infection

39
Q

How does a nurse assess wound appearance?

A
  • Whether the wound edges are closed
  • The condition of tissue at the wound base
  • Look for complications and skin coloration
40
Q

How does a nurse assess the character of wound drainage?

A
  • Amount, color, odor, and consistency of drainage

- Depends on the location and the extent of the wound.

41
Q

How does a nurse assess drains?

A
  • Observe the security of the drain and its location with respect to the wound and the character of the drainage
  • Measure the amount of drainage
42
Q

How does a nurse assess wound closures?

A
  • Surgical wounds are closed with staples, sutures, or wound closures
  • Look for irritation around staple or suture sites and note whether the closures are intact
43
Q

What are potential or actual nursing diagnoses related to impaired skin integrity?

A
  • Risk for Infection
  • Imbalanced Nutrition: Less than Body Requirements
  • Acute or Chronic Pain
  • Impaired Skin Integrity
  • Risk for Impaired Skin Integrity
  • Impaired Physical Mobility
  • Ineffective Tissue Perfusion
  • Impaired Tissue Integrity
44
Q

What are possible goals to achieve wound improvement?

A
  • Higher percentage of the granulation tissue in the wound base
  • No further skin breakdown in any body location
  • An increase in the caloric intake by 10%
45
Q

Identify three major areas of nursing interventions for preventing pressure ulcers:

A
  • Skin care
  • Mechanical loading and support devices
  • Education
46
Q

List the principles to address to maintain a healthy environment:

A
  • managed infection
  • cleanse the wound
  • remove non-viable tissue
  • manage exudates
  • maintain the wound in moist environment
  • protect the wound
47
Q

Explain the rationale for debriding a wound:

A

Removal of non-viable necrotic tissue to read the ulcer of a source of infection, enable visualization of the wound bed, and provide a clean base necessary for healing.

48
Q

What are the four methods of debridement?

A
  • Mechanical
  • Autolytic
  • Chemical
  • Sharp or surgical
49
Q

First aid for wounds includes the following:

A
  • hemostasis
  • cleansing
  • protection
50
Q

First aid for wounds includes hemostasis. Explain.

A

Control bleeding by applying direct pressure in the wound site with a sterile or clean dressing, usually after trauma, for 24 to 48 hours.

51
Q

First aid for wounds includes cleansing. Explain.

A

Gentle cleansing rather than vigorous cleansing with NS (physiological and will not harm tissue)

52
Q

First aid for wounds includes protection. Explain.

A

Applying sterile or clean dressings and immobilizing the body part.

53
Q

What are the purposes of dressings?

A
  • Protects a wound from microorganism contamination
  • Aids in hemostasis
  • Promotes healing by absorbing drainage and debriding a wound
  • Supports or splints the wound site
  • Protects the patient from seeing the wound
  • Promotes thermal insulation of the wound surface
  • Provides a moist environment
54
Q

What are the clinical guidelines used when selecting an appropriate dressing?

A
  • Choose a dressing that will continuously provide a moist environment.
  • Perform wound care using topical dressings as determined by assessment.
  • Choose a dressing that keeps the surrounding skin dry.
  • Choose a dressing that controls exudates.
  • Eliminate wound dead space by loosely filling all cavities with dressing material.
55
Q

What are the advantages of a transparent film dressing?

A
  • Adheres to undamaged skin
  • Serves as a barrier to external fluids and bacteria but allows the wound surface to breathe.
  • Promotes a moist environment.
  • Can be removed without damaging underlying tissues.
  • Permits viewing.
  • Does not require a secondary dressing.
56
Q

What are the functions of hydrocolloid dressings?

A
  • Absorbs drainage through the use of exudate absorbers
  • Maintains wound moisture
  • Slowly liquefies necrotic debris
  • Impermeable to bacteria
  • Self–adhesive and molds well
  • Acts as a preventative dressing for high-risk friction areas
  • May be left in place for 3 to 5 days, minimizing skin trauma and disruption of healing
57
Q

What are the advantages of hydrogel dressings?

A
  • Soothing and reduces pain
  • Provides a moist environment
  • Debrides the wound
  • Does not adhere to the wound base and is easy to remove
58
Q

What guidelines are followed during a dressing change procedure?

A
  • Assessment of the skin beneath the tape
  • Performing thorough hand hygiene before and after wound care
  • Wear sterile gloves
  • Removing or changing dressings over closed wounds when they become wet or if the patient has s/s of infection
59
Q

Summarize the principles of packing a wound:

A
  • Assess the size, depth, and shape of the wound
  • Dressing (moist) needs to be flexible and in contact with all of the wound surface
  • Do not pack tightly (overpacking causes pressure)
  • Do not overlap the wound edges (maceration of the tissue)
60
Q

How does a wound vacuum assisted (wound VAC) closure device work?

A
  • Applies localized negative pressure to draw the edges of a wound together by evacuating wound fluids and stimulating granulation tissue formation
  • Reduces the bacterial burden of a wound and maintains a moist environment
61
Q

What three principles are important when cleaning an incision?

A
  • Cleanse in a direction from the least contaminated area to the surrounding skin.
  • Use gentle friction when applying solutions locally to the skin.
  • When irrigating, allow the solution flow from the least to the most contaminated area.
62
Q

Summarize the principles of wound irrigation:

A
  • Use of an irrigating syringe to flush the area with a constant low-pressure flow of solution of exudates and debris.
  • Never occlude a wound opening with a syringe.
63
Q

Explain the purpose for drainage evacuation:

A

Portable units that connect tubular drains lying within a wound bed and exert a a safe, constant low-pressure vacuum to a remove and collect drainage.

64
Q

What are the benefits of binders and bandages?

A
  • Creating pressure over a body part
  • Immobilizing a body part
  • Supporting a wound
  • Reducing or preventing edema
  • Securing a splint
  • Securing dressings
65
Q

List the nursing responsibilities when applying a bandage or binder:

A
  • Inspecting the skin for abrasions, edema, discoloration, or exposed wound edges.
  • Covering exposed wounds or open abrasions with a sterile dressing.
  • Assessing the condition of underlying dressings and changing if soiled.
  • Assessing the skin for underlying areas that will be distal to the bandage for signs of circulatory impairment.
66
Q

What is the physiological response to heat applications?

A
  • Improves blood flow to an injured part
  • If applied for more than one hour, the body reduces blood flow by reflex vasoconstriction to control heat loss from the area
67
Q

What is the physiological response to cold applications?

A

Diminishes swelling pain, prolonged application results in reflex vasodilation.

68
Q

What factors influence heat and cold tolerance?

A
  • A person is better able to tolerate short exposure to temperature extremes.
  • More sensitive to temperature variation: neck, inner aspect of the wrist and forearm, and perineal region.
  • The body responds best to minor temperature adjustments.
  • A person has less tolerance to temperature changes to which a large area of the body is exposed.
  • Tolerance to temperature variations changes with age.
  • Physical conditions that reduce the reception or perception of sensory stimuli.
  • Uneven temperature distribution suggests that the equipment is functioning improperly.
69
Q

What is the rationale for warm, moist compresses?

A

Improve circulation, relieve edema, and promote consolidation of pus and drainage.

70
Q

What is the rationale for warm soaks?

A

Promote circulation, lessens edema, increases muscle relaxation, and provides a means to deride wounds and apply medicated solutions.

71
Q

What is the rationale for sitz baths?

A

The pelvic area is immersed in warm fluid, causing wide vasodilation.

72
Q

What is the rationale for commercial hot packs?

A

Disposable hot packs that apply warm, dry heat to an area.

73
Q

What is the rationale for cold, moist, and dry compresses?

A

Relieves inflammation and swelling.

74
Q

What is the rationale for cold soaks?

A

Immersing a body part for 20 minutes.

75
Q

What is the rationale for ice bags or collars?

A

Used for muscle sprain, localized hemorrhage, or hematoma.

76
Q

What questions need to be asked if the identified outcomes were not met?

A
  • Was the etiology of the skin impairment addressed?
  • Was wound healing supported by providing the wound base with a moist, protected environment?
  • Were issues such as nutrition assessed and a plan of care developed?
77
Q

Mr. Post is in a Fowler position to improve his oxygenation status. The nurse notes that he frequently slides down in bed and needs to be repositioned. Mr. Post is at risk for developing a pressure ulcer on his coccyx because of:

  1. Friction
  2. Maceration
  3. Shearing force
  4. Impaired peripheral circulation
A
  1. Shearing force

The force exerted parallel to the skin resulting from both gravity pushing down on the body and resistance between the pt and the surface.

78
Q

Which of the following is NOT a subscale on the Braden scale for predicting pressure ulcer risk?

  1. Age
  2. Activity
  3. Moisture
  4. Sensory perception
A
  1. Age

Age is not a subscale. Perception, moisture, activity, mobility, nutrition, friction, and shear are the subscales.

79
Q

Which of these patients has a nutritional risk for pressure ulcer development?

  1. Patient A has an albumin level of 3.5
  2. Patient B has a hemoglobin level within normal limits
  3. Patient C has a protein intake of 0.5 g/kg/day
  4. Patient D has a body weight that is 5% greater than his ideal weight
A
  1. Patient C has a protein intake of 0.5 g/kg/day

The recommended protein intake for adults is 0.8 g/kg; a higher intake of up to 1.8 g/kg/day is necessary for healing.

80
Q

Mr. Perkins has a stage II ulcer of his right heel. What would be the most appropriate treatment for this ulcer?

  1. Apply a heat lamp to the area for 20 minutes twice daily.
  2. Apply a hydrocolloid dressing and change it as necessary.
  3. Apply a calcium alginate dressing and change when strikethrough is noted.
  4. Apply a thick layer of enzymatic ointment to the ulcer and the surrounding skin.
A
  1. Apply a hydrocolloid dressing and change it as necessary.

See Table 48-8, p. 1203 for choice and rationale for dressings for ulcer stages.

NRS 130 Test #8 (7 decks)

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