Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

NRS 128 Kaley > Fundamentals Study Guide- Ch. 48 Skin Integrity And Wound Care > Flashcards

Fundamentals Study Guide- Ch. 48 Skin Integrity And Wound Care Flashcards

0
Q

Identify the risk factors that predispose a patient to pressure ulcer formation.

A 
A. Impaired sensory perception
B. impaired mobility
C. Alteration in level of consciousness
D. Shear
E. friction
F. Moisture
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
1
Q

Identify the pressure factors that contribute to pressure ulcer development.

A

A. Pressure intensity
B. pressure duration
C. Tissue tolerance

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Staging systems for pressure ulcers are based on the depth of tissue destroyed. Describe the stages.

A

One: intact skin with nonblanchable redness of a localized area over a bony prominence.
Two: partial-thickness skin loss involving epidermis, dermis, or both.
Three: full thickness with tissue loss.
Four: full thickness tissue loss with exposed bone, tendon, or muscle.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Define granulation tissue.

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Define slough.

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Define eschar.

A

Black or brown necrotic tissue.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Define exudate.

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Describe this physiological process: primary intention.

A

Wound that is closed by epithelialization with minimal scar formation.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Describe the physiological process: secondary intention.

A

Wound is left open util it becomes filled by scar tissue; chance of infection is greater.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Identify the three components involved in the healing process of a partial thickness wound.

A

A. Inflammatory response
B. epithelial proliferation
C. Migration with reestablishment of the epidermal layers

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Explain the four phases involved in the healing process of a full thickness wound.

A

Hemostasis: injured blood vessels constrict, and platelets gather to stop bleeding; clots form a fibrin matrix for cellular repair.
Inflammatory phase: damaged tissues and mast cells secrete histamine with exudation of serum and WBC into damaged tissues.
Proliferative phase: with the appearance f new blood vessels as reconstructive progresses, begins and lasts from 3-24 days. Filling of wound with granulation tissue, contraction of the wound, and resurfacing of the wound by epithelialization.
Remodeling: maturation, the final stage, may take up to one year; the collagen scar continues to reorganize and gain strength for several months.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Define 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.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Define hematoma.

A

Localized collection of blood underneath the tissue.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Define healthcare associated infection.

A

Second most common nosocomial infection; purulent material drain from the wound.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Define dehiscence.

A

A partial or total separation of wound layers; risks are poor nutritional status, infection, or obesity.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Define evisceration.

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

What are the subscales of the Braden scale.

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

List the factors that influence pressure ulcer formation.

A

Nutrition, tissue perfusion, infection, age, and psychosocial impact of wounds.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Explain how mobility places a patient at risk for pressure ulcer.

A

Potential effects of impaired mobility; muscle tone and strength.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

How does body fluids place a patient at risk for pressure ulcer?

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

How does pain put a patient at risk for pressure ulcer?

A

Adequate pain control and patient comfort will increase mobility, which in turn reduces risk.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Which type of emergency setting wound is this: is superficial with little bleeding and is considered a partial thickness wound.

A

Abrasion

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

Name the emergency setting wound: sometimes bleeds more profusely depending on depth and location.

A

Laceration

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

Name the emergency setting wound: bleeds in relation to the depth and size, with a high risk of internal bleeding and infection.

A

Puncture

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

How would you assess a wound appearance?

A

Whether the wound edges are closed, the condition of tissue at the wound base; look for complications and skin coloration.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

How would you assess character of wound drainage?

A

Amount, color, odor, and consistency of drainage, which depends on the location and the extent of the wound.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

Name the wound drainage described: clear, watery plasma.

A

Serous

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

Name the wound drainage described: thick, yellow, green, tan, or brown.

A

Purulent

28
Q

Name the wound drainage described: pale, pink, watery; mixture of clear and red fluid.

A

Serosanguineous

29
Q

Name the wound drainage described: bright red; indicates active bleeding.

A

Sanguineous

30
Q

Drains:

A

Observe the security of the drain and its location with respect o the wound and the character of the drainage; measure the amount.

31
Q

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.

32
Q

List the potential or actual nursing diagnosis relate to impaired skin integrity.

A 
A. Risk for infection
B. Imbalanced nutrition: less than body requirements
C. Acute or chronic pain
D. Impaired skin integrity
E. Impaired physical mobility
F. Risk for impaired skin integrity
G. Ineffective tissue perfusion
H. Impaired tissue integrity
33
Q

List possible goals to achieve wound improvement.

A

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

34
Q

Identify the three major areas of nursing interventions for preventing pressure ulcers.

A
  1. Skin care
  2. . Mechanical loading and support devices
  3. Education
35
Q

List the principles to address to maintain a healthy wound environment.

A 
A. Manage infection
B. Cleanse the wound
C. Remove nonviable tissue
D. Manage exudates
E. Maintain the wound in moist environment
F. Protect the wound
36
Q

Explain the rationale for debriding a wound.

A

Removal of nonviable necrotic tissue to rid the ulcer of a source of infection, enable visualization of the wound bed, and provide a clean base necessary for healing.

37
Q

Identify the four methods of debridement.

A
  1. Mechanical
  2. Autolytic
  3. Chemical
  4. Sharp or surgical
38
Q

Describe how to hemostasis a wound.

A

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

39
Q

Describe how to cleanse a wound.

A

Gentle cleansing rather than vigorous cleansing with NS.

40
Q

Describe how to protect a wound.

A

Applying sterile or clean dressing and immobilizing the body part.

41
Q

List the purposes of dressings.

A

A. Protects a wound from microorganism contamination
B. Aids in hemostasis
C. Promotes healing by absorving drainage and debriding a wound
D. Supports or splints the wound site
E. Protects the patient from seeing the wound
F. Promotes thermal insulation of the wound surface
G. Provides a moist environment

42
Q

List the clinical guidelines to use when selecting the appropriate dressing.

A

A. Use a dressing that will continuously provide a moist environment.
B. Perform wound care using topical dressings as determined by assessment.
C. Choose a dressing that keeps the surrounding skin dry.
D. Choose a dressing that controls exudates.
E. Consider caregiver time, availability, and cost.
F. Eliminate wound dead space by loosely filling all cavities with dressing material.

43
Q

List the advantages of a transparent film dressing.

A

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

44
Q

What are the functions of hydrocolloid dressings.

A

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

45
Q

List the advantages of the hydrogel dressing.

A

A. Soothing and reduces pain
B. Provides a moist environment
C. Debrides the wound
D. Does not adhere to the wound base and is easy to remove

46
Q

List the guidelines to follow during a dressing change procedure.

A

A. Assessment of the skin beneath the tape
B. Performing thorough hand hygiene before and after wound care
C. Wear sterile gloves
D. Removing or changing dressings over close wounds when they become wet or if the patient has signs and symptoms of infection

47
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 (over packing causes pressure); do not overlap the wound edges (maceration of the tissue).

48
Q

Briefly describe how the wound vacuum-assisted closure (wound VAC) device works.

A

Applies localized negative pressure to draw the edhes of a wound together by evacuating wound fluids and stimulating granulation tissue formation and reduces the bacterial burden of a wound and maintains a moist environment.

49
Q

Identify three principles that are important when cleaning an incision.

A

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

50
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.

51
Q

Explain the purpose for drainage evacuation.

A

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

52
Q

Explain the benefits of binders and bandages.

A 
A. Creating pressure over a body part
B. Immobilizing a body part
C. Supporting a wound
D. Reducing or preventing edema
E. Securing a splint
F. Securing dressings
53
Q

List the nursing responsibilities when applying a bandage or binder.

A

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

54
Q

Describe the physiological responses 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.

55
Q

Describe the physiological responses to cold applications.

A

Diminishes swilling and pain, prolonged results in reflex vasodilation.

56
Q

List the factors that influence heat and cold tolerance.

A

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

57
Q

Whats the rationale for warm, moist compresses?

A

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

58
Q

Whats the rationale for warm soaks?

A

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

59
Q

Whats the rationale for sitz baths?

A

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

60
Q

Whats the rationale for commercial hot packs?

A

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

61
Q

Whats the rationale for cold, moist, and dry compresses?

A

Relieves inflammation and swelling.

62
Q

Whats the rationale for cold soaks?

A

Immersing a body part for 20 minutes.

63
Q

Whats the rationale for ice bags or collar?

A

Used for muscle sprain, localized hemorrhage, or hematoma.

64
Q

Mr. Post is in a Fowler position to improve his oxygenation status. The nurse notes that he frequently slides down in the 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. Imparied peripheral circulation
A
  1. The force exerted parallel to the skin resulting from both gravity pushing downon the body and resistance between the patient and the surface.
65
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 is not a subscale. Perception, moisture, activity, mobility, nutrition, friction, and shear are subscales.
66
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 0.5g/kg/day.
  4. Patient D has a body weight that is 5% greater than his ideal weight.
A
  1. The recommend protein intake for adults is 0.8g/kg; a higher intake of up to 1.8g/kg/day is necessary for healing.
67
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

2.

NRS 128 Kaley (4 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions