Infection Control & Skin and Wound

Question 1

What are the risk factors for impaired tissue integrity??

Answer 1

1. Young
2. Old
3. Sun exposure
4. Congenital conditions & chronic disease

(Obesity – risk for pressure ulcers from skin folds)

Question 2

What are the two types of wounds??

Answer 2

1. Acute (intentional vs unintentional)
   - Traumatic (lacerations & skin tears, burns, punctures, gun shot wound)
   - Surgical (clean, clean-contaminated, contaminated, dirty)
   - Moisture-associated skin damage (dermatitis due to exposure to urine, feces, & wound exudate)
2. Chronic (disruption of healing process vs. chronic condition origin)
   - Risk factors: SMOKING, MALNOURISHED, IMMUNOSUPPRESSED, IMMOBILIZED, INFECTION
   - Venous, arterial & neuropathic wound (diabetics usually can’t feel since they have a decreased sensation)

Question 3

What are the risk factors of chronic wounds??

Answer 3

Smoking, malnourished, immunosuppressed, immobilized, and infection

Question 4

What are wound assessment??

Answer 4

Monitor exudate for changes in color, amount, & odor of exudate (bc it indicate healing or infection)
- Exudate: serous (clear & watery), serosanguineous (watery blood), sanguineous, or purulent (pus = infection!!!!)
- Size & shape: tracing vs. length (head to toe) and Width (Right to Left)
- Depth & tunneling
* Use a clock format to describe the location for undermining and tunneling*

Question 5

What are the risk factors contributing to pressure injury development?

Answer 5

1. Immobility
2. Malnutrition
3. Reduced perfusion
4. Altered sensation
5. Decreased level of consciousness
6. Exposure to moisture, tearing, cuts, bruises, & friction

Question 6

What are the common locations of pressure injury formation??

Answer 6

Boney prominences!!!

Question 7

What does a low/ high score in Broaden Scale mean?

Answer 7

Minimum score: 6 (HIGH risk)
Maximum score: 23 (LOW score)

The higher the number = The lower the Risk

Question 8

How do you interpret the scores of Braden scale?

Answer 8

19-23 = Low risk
15-18 = AT Risk!!!
13-14 = Moderate Risk
10-12 = HIGH Risk
<9 = VERY HIGH Risk

Question 9

What are the stages of pressure injuries?

Answer 9

1. Stage 1- un-blanchable erythema
2. Stage 2 - Partial-thickness skin loss –> like a skin tear where the first layer of skin is disruptured
3. Stage 3 - Full-thickness skin loss –> you can see the adipose
4. Stage 4 –> Full-Thickness skin and tissue loss –> you can see muscles, bones, et..
5. Unstageable –> can’t determine the stage because of sloughs (yellow) and eschar (black) that covers it

• Deep Tissue pressure injury –> skin is intact and has deep red/purple color!!

Question 10

What are the types of wound dressing?

Answer 10

1. Clean versus sterile dressings –> sterile dressings are applied AFTER surgery; then, after 1-2 days, it can be changed to clean technique
2. Dry versus wet dressings:
   1) Open Dressings –> after moistened w/ sodium chloride, gauze dressings are applied. As the gauze dries, it clings to tissue inside the wound. When gauze is removed, the tissues that clung will also be removed along w/ the gauze.
   2) Semi-Open dressings –> Have 3 layers
   3) Semi-occlusive dressings:
   
   1. Films – Wound is dry, superficial, & has MINIMAL exudates
   2. Hydrocolloid – Abrasions, superficial burns, pressure injuries, & post-op wounds
   3. Alginate – Moderate to HIGH exudate and less dressing change since it’s HIGH ABSORBENT!!
   4. Hydrofiber – MODERATE to HIGH exudate and HIGH ABSORBENT & less dressing change
   5. Foams – MILD to MODERATE exudate w/ frequent dressing changes
   6. Polymeric membranes – MILD exudate and don’t stick to wound beds
   7. HYDROGELS – Wound is DRY, Debridement of wounds w/ necrotized & eschar, and provide moisture to or draw it away from wound

Question 11

Drains are removed when you have less than how many mLs?

Answer 11

LESS THAN 100mL (30mL-100mL) in 24 hrs!!

Question 12

What are the types of wound drains???

Answer 12

• PASSIVE (rely on gravity) VS. ACTIVE (use suctioning to drain the wounds) drains!!
• Open vs. Closed = Open (removes fluid to the air, collected in gauze pad) and Closed (closed containment like a bag/bottle)

1. Penrose = Passive, Open
2. JP Drain = Active
3. Large bottle drainage = Active
4. Circular portable wound suction device/ Hemovac = ACTIVE

Question 13

What are the factors that influence wound healing????!!!!*****

Answer 13

1. Diabetes (decreases peripheral prefusion/slower circulation)
2. Infection
3. Foreign body in wound (increases risk of infection & delays healing)
4. Medications
5. Malnutrition (since u don’t have enough protein, it slows down healing process)
   6 Tissue necrosis
6. Hypoxia
7. Multiple wound present!

Question 14

What are 2 types of Asepsis?

Answer 14

1. Medical Asepsis:
   - REDUCES number of pathogens
   - “Clean technique”!!!
   - Used in administration of:
   - Meds
   - Enemas
   - Tube feedings
   - Daily hygiene
2. Surgical Asepsis:
   - ELIMINATES all pathogen
   - “Sterile technique”
   - Used in:
   - Dressing changes
   - Catheterizations
   - Surgical procedures