Fundamentals 48- Skin and wound care

Question 1

Bed Bound Patients

Answer 1

Reposition Q 2 hours, more often if at high risk Place pillow between bony prominences, avoid positioning directly on trochanter, and 30 degree turn recommended dependent upon patient tolerance.

Question 2

Bed bound Patients and heel protection:

Answer 2

Hell suspension/ suspend heels off bed with pillow.

Question 3

Correct cause of incontinence if possible:

Answer 3

Offer frequent or timed toileting, keep toilet aids within easy reach, answer call lights promptly, rule out possible UTI, check for fecal impaction(frequent cause of fecal/urinary incontinence), discuss plan of care with physician and nutritionist to correct diet, and initiate measures to normalize stool frequency/consistency.

Question 4

Incontinent associated dermatitis:

Answer 4

Urine: water saturates skin, increases risk of friction and erosion. Ammonia raises pH, promotes pathogenic growth, disrupts acid mantle, activates fecal enzymes.

Question 5

Stool incontinent:

Answer 5

Fecal enzymes damage skin, promote erosion, worse in high volume diarrhea. GI bacteria may be pathogenic. Water overhydrates the skin.

Question 6

Principles of dermatitis prevention:

Answer 6

Cleanse-routine daily cleansing for everyone; Moisturize-cleanse and moisturize after each major incontinent episode; Protect-apply moisture barrier for significant urine/stool/double incontinence.

Question 7

Skin with too much moisture:

Answer 7

Is 5 times more likely to ulcerate than dry skin.

Question 8

Skin with too little moisture:

Answer 8

Is 2.5 times more likely to ulcerate than healthy skin.

Question 9

Manage nutrition:

Answer 9

Protein, and calories, multivitamin, vitamin C, zinc, hydration, dietician consult of course!

Question 10

Factors that affect skin breakdown:

Answer 10

Mechanical, friction, shearing abrasion, pressure, cytotoxic, chemical incontinence, urine, bowel, and thermal.

Question 11

Shearing and friction that cause skin breakdown:

Answer 11

Shearing from tape, and skins tears from drag/pulling across the bed sheets, etc., especially if patient is being moved incorrectly.

Question 12

What is the impact that pressure ulcers have?

Answer 12

Pain, loss of dignity and quality of life, infection, chronic non-healing wound;, surgical procedures(debridement, fecal diversions, and amputation), loss of tissue strength, death-3 times increased mortality.

Question 13

Financial impact of pressure ulcers:

Answer 13

Increased healthcare costs, prolonged length of stay(3.5 to 5 times), average cost to treat is $2,000 to 50,000 per ulcer, estimated 6.4 billion dollars spent each year to treat pressure ulcers. and treatment costs are 2.5 time the cost of preventive measures.

Question 14

Impact of pressure ulcers on staff:

Answer 14

Increased staff workload, dressing changes, and antibiotic therapy and management, litigation due to neglect- awards can be as high as $60-$80 million, and considered elder abuse- monetary awards in addition to malpractice claim, up to $250,000.

Question 15

How often must risk assessment be done?

Answer 15

It must be done on admission and at regular intervals. Use Braden scale risk assessment tool

Question 16

What does the Braden Scale assess?

Answer 16

Sensory perception, moisture, activity, mobility nutrition, friction and shear.

Question 17

How is the Braden scale used?

Answer 17

A risk number is given- the lower the number, the higher the risk. Interventions must be started on admission and re-assessed throughout hospital stay.

Question 18

What is the cutoff score for onset of pressure ulcer risk with the braden scale?

Answer 18

The score ranges from 6 to 23 and the cutoff for the general adult population is 18.

Question 19

What is a pressure ulcer?

Answer 19

Localized area of tissue breakdown resulting from compression of soft tissue between a bony prominence and an external surface.

Question 20

What is the Iceberg effect?

Answer 20

Its when pressure is highest between the soft tissue and the bony prominence. Tissue injury starts at the bone/tissue interface and extends outwards. This accounts for the undermining commonly seen in pressure ulcers.

Question 21

Pressure ulcer staging:

Answer 21

Staging is for pressure ulcers only. Staging describes only the level of tissue damage or loss and does not describe levels of progression or healing. Pressure ulcers stages cannot revers- a healing stage 3 does not become a stage 2.

Question 22

Stage 1 pressure ulcer:

Answer 22

Non-blanchable erythema of intact skin. May include: discoloration, warmth/coolness, edema, or change in tissue consistency.

Question 23

Stage II pressure ulcer:

Answer 23

Partial thickness loss of dermis: shallow open crater with red, pink wound bed that presents as: abrasion, open blister or shallow crater. May be painful.

Question 24

One way blisters can develop:

Answer 24

Improperly fitted brace for foot drop.

Question 25

Stage III pressure ulcer:

Answer 25

Full-thickness skin loss - subcutaneous fat may be visible, may extend down to but not through underlying fascia, may be shallow or deep, with/without undermining or tunneling, and eschar and/or slough may be present.

Question 26

Stage IV pressure ulcer:

Answer 26

Full-thickness skin loss-Extensive destruction of tissue, with visible or palpable muscle, bone, tendon, may include undermining/sinus tracts and may be shallow or deep.

Question 27

Unstageable ulcer:

Answer 27

ulcer bed is covered with eschar or slough so that full extent of injury cannot be assessed.

Question 28

Suspected deep tissue injury:

Answer 28

Purple or maroon area of intact skin, or blood-filled blister due to damage of underlying tissue. May evolve into ulcer.

Question 29

What are the four cardinal signs of inflammation, as described by the Roman physician and science writer Celsus?

Answer 29

Rubor(redness), tumor(swelling), calor(heat), and dolor (pain).

Question 30

Proliferation :

Answer 30

To grow by rapid production of new parts, cells, buds, or offspring. This lasts 4-21 days-pink granulation tissue or epithelialization, contraction.

Question 31

Remodeling of wound healing:

Answer 31

Can last up to 2 years

Question 32

Basic repair of a wound:

Answer 32

Regeneration:
Age 18-25=21 days
Age 35>=42 days

Question 33

Factors that affect wound healing:

Answer 33

Perfusion/oxygenation, nutrition, infection, corticosteroids, aging, diabetes, smoking.

Question 34

Nursing measures to optimize wound repair /Pre-op:

Answer 34

Nutrition, reduce steroids, eliminate aspirin, patient education to reduce anxiety.

Question 35

Post-op for wounds:

Answer 35

Pain control, warmth, hydration, supplemental oxygen, provide support binders.

Question 36

Acute wounds:

Answer 36

Wounds with sudden onset includes superficial, penetrating, perforating, laceration, abrasion, contusion, skin tears, surgical wounds.

Question 37

Chronic wounds;

Answer 37

Any acute wound that fails to heal, or pressure, venous, arterial, diabetic, and neuropathic wounds.

Question 38

Surgical wounds healings occurs by:

Answer 38

Primary intention, secondary intention, and tertiary intention.

Question 39

Different types of surgical wounds:

Answer 39

JP, Hemovac, autotranfusion device, penrose, suction catheter.

Question 40

Remove dressing & assess:

Answer 40

Incision, drainage, signs of inflammation, replace dressing-sterile vs clean technique, and staple/suture removal.

Question 41

Wound documentation:

Answer 41

Location, measurements in centimeters - length X width X depth, any tunneling/undermining, color of wound bed, condition of surrounding tissue/skin, drainage, odor, and pain.

Question 42

Some nursing diagnosis for wounds:

Answer 42

Alteration in comfort
Impaired skin/tissue integrity
Risk for infection

Question 43

Basic documentation of wounds:

Answer 43

What was observed, what interventions were performed, patient response to interventions.

Question 44

What does undermining mean?

Answer 44

Tissue destruction to underlying intact skin along wound edges. Measure by using cotton tip applicator, mark distance between tip and wound edge, indicate the extent of undermining and location by using clock face.

Question 45

What is tunneling/tracts:

Answer 45

A measurable tract extending from the wound bed. Measure by using cotton tip applicator, mark length between tip and wound edge, indicate location by using clock face.

Question 46

Serous wound:

Answer 46

Is clear, water plasma.

Question 47

Sanguineous wound

Answer 47

indicates fresh bleeding.

Question 48

Serosanguineous wound

Answer 48

Is a pale, more watery drainage than sanguineous drainage.

Question 49

Purulent wound

Answer 49

Is a thick, yellow, green, or brown drainage.

Question 50

Exudate odor:

Answer 50

Foul smelling-expected in the presence of eschar or slough, and/ or infected wounds. Mild exudate may be associated with wound care products.

Question 51

Wound bed appearance:

Answer 51

Red- usually indicated granulation tissue.
Yellow-slough-soft necrotic tissue
Black-Eschar-firm/hard necrotic tissue.

Question 52

Universal principles of wound care:

Answer 52

Remove necrotic tissue(slough, eschar)
Treat infection
Fill dead space
Maintain most wound envrionment

Question 53

Stool consistency varies with location;

Answer 53

Transverse=loose

Signmoid=formed

Question 54

Location of Loop colostomy:

Answer 54

Location is usually in the transverse colon
Proximal opening = stool
Distal opening = mucus

Question 55

Patient with an lleostomy:

Answer 55

Stool always loose
High enzyme & alkaline content
Permanent or temporary
May be loop

Question 56

Urostomy(ileal conduit)

Answer 56

Ileum used to form reservoir
urine flow nearly constant
Mucus in urine normal
Always permanent

Question 57

Care for a colostomy:

Answer 57

Measure stoma with measuring guide. Cut wafer to fit, allowing a little “wiggle room” no more than 1/8th inch. Opening may need to be oval. If measuring guide not available, cut small, try on for size, then enlarge opening as needed. Re-measure stoma at least weekly for 4-6 weeks post-op or until size has not changed in 2 weeks. Clean skin with water only( may use soap & water if takin a shower). When showering, leave appliance on or remove completely-do not remove pouch only. Do not use baby wipes or wipes of any kind to clean the skin!!

Question 58

How to empty colostomy bag:

Answer 58

Empty at no more than 1/2 full
Replace immediately if leakage occurs
No need to rinse pouches
lleostomy and urostomy will fill quickly-2 hours or less
Empty gas as needed

Question 59

Care for urostomy pouch at night:

Answer 59

Urostomy pouch should be attaché to drainage bag. Spout must be in open position when attached to drainage bag.

Question 60

Wear time for pouch;

Answer 60

should GET 3-5 DAYS wear time. Instruct patient to change appliance 2 X week.
Contact WOCN nurse if changing more often.