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Nur 333 Fun 2 > Integumentary System Pt. 2 (Exam 3) > Flashcards

Integumentary System Pt. 2 (Exam 3) Flashcards

1
Q

PROF COURTNEY WOUND CONTENT

A

TESTABLE MATERIAL

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2
Q

Factors that Affect wound Healing

A

-Age

-Loss of turgor

-Skin fragility

-Decreased circulation and oxygenation

-Slower tissue regeneration

-Decreased absorption of nutrients

-Decrease in collagen

-Impaired immune functions

-Dehydration

-Decrease WBC count

-Infection

-Medications (Chemo/ Steriods)

-Low hemoglobin levels

-Obesity, smoking, and chronic disease

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3
Q

Principles of wound management

A

-Wounds impair skin integrity

-Inflammation is localized protective response to injury or destruction of tissue

-Wounds heal by various processes and stages

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4
Q

Three key components of wound management

A
  1. Assessment
  2. Cleansing
  3. Protection
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5
Q

Wound Assessment: Appearance

A

Red: Good (want beefy)

Yellow: (Slough- dead cells accumulate in wound exudate) (Could mean we are staying in inflammatory stage)

Black: Eschar (Dead tissue) (needs to be removed)

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6
Q

Wound Assessment: Length, Width, and Depth

A

-Track progression (pictures)

-Can tell if it is worsening

-Use sterile q-tip to see if it tunneling

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7
Q

Wound Assessment: Closed Wounds

A

-Skin edges should be well approximated (Back together)

-Note drains tubes

-Note pain

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8
Q

Wound Measurement

A

-Made in CM

-First measurement: Head to toe

-Second measurement: side to side

-Third measurement: Depth

Note: tunneling and undermining on clock position

12 O-clock is at patients head.

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9
Q

Wound Drainage

A

-Results of the healing process: can be normal or abnormal

-Accumulates during the inflammatory and proliferative phases of healing

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10
Q

Wound Drainage: Document/note

A

-Amount of drainage, oder, consistency, and color of drainage from drain or on the dressing

-Note integrity of the surrounding skin

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11
Q

For accurate Measurement

A

Weigh the dressing

-1g = 1 ml of drainage

-Often just say : scant, moderate, large, copious

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12
Q

Wound Drainage: Exudate

A

-Serous: Portion of blood (serum) that is watery and clean or slightly yellow

-Sanguineous: Serum and red blood cells. Thick and appears reddish. Brighter indicates active bleeding. Darker indicates older bleeding.

-Serousanguinous- contains serum and blood. watery, looks pale/pink

-Purulent: Result of infection; thick, contains, WBC’s, tissue debris, and bacteria (foul smelling)

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13
Q

Nursing interventions: Patients with wounds

A

-Adequate hydration and nutrition

-High protein, carbohydrates and vitamins

-Monitor albumin and pre-albumin levels

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14
Q

Nursing interventions for Patients with wounds

A

-Remove sutures and staples as ordered (7x-10 days)

-Administer analgesics and monitor for pain

-Administer antimicrobials as order and monitor effectiveness

-Document well

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15
Q

Wound Dressings: Woven Gauze (Sponges)

A

-Absorb and pull exudate from wound

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16
Q

Wound Dressing: Non-adherent material

A

-Doesn’t stick

-Use if changing frequently

-Good because doesnt hurt skin around wound

17
Q

Wound dressings: Wet-to-dry

A

-Used to mechanically debride a wound until granulation tissue starts to form

-4x4’s

-Moist wound bed is a good thing (If clean)

18
Q

Wound dressing: Self adhesive / transparent

A

-Tegaderm

-Be weary: Can cause more damage than good

19
Q

Wound dressing: Hydrocolloid

A

-Occlusive dressing that swells in presence of exudate (Duoderm)

-Maintain moist environment and pull off to much drainage

-Stay in place for 3 days and do need to be changed if there is to much exudate

20
Q

Wound Dressings: Hydrogel

A

Mostly water, gels after contact with exudate, promotes autolytic debridement, rehydrates and fells dead space

-May need a secondary occlusive dressing

-For infected, deep wounds or necrotic tissue

-Not for wounds that are draining a lot

-Provides moist wound bed and can reduce pain and prevent skin breakdown in high pressure areas

21
Q

Wound Dressing: Alginate

A

Non adherent dressing that conform to wound shape and absorb exudate

22
Q

Wound dressing: Collagen

A

-Powder, pastes, granules, gels, and pastes

-Stop bleeding and promote healing

23
Q

Vacuum-Assisted Closure System: Wound Vacs

A

-Use of foam strips into the wound bed with occlusive dressing – Creates negative pressure to occur once the tubing is connected

-Helps with tissue generation, decrease swelling, and enhance healing in moist, protective environment

24
Q

Complications of wound healing

A

-Hemorrhage

-Dehiscence

-Eviscreation

Infection

25
Q

Surgical Wound Problem: Hemorrhage

A

-Greatest risk 24-48

-Can be caused by dislodgment, slipped culture, or blood vessel damage

-Internal bleeding may present with swelling, distention in area and may cause sanguineous drainage (subtle change in VS)

-Hematoma is a local area of blood collection that appears as red or blue bruise

-Wound hemorrhage can be an emergency –> apply pressure dressing, notify provider and monitor vital signs

26
Q

Surgical Wound Problems: Dehiscence

A

-Partial or total rupture of a sutured wound, usually with a separation of underlying skin layers

-3-11 days after surgery

-Small wet-to-dry dressing

27
Q

Surgical Wound Problem: Eviscertaion

A

A dehiscence that involves the protrusion of visceral organs through wound opening

28
Q

Evisceration Manifestations

A

-Significant increase in flow of serosanguionus fluid on the wound dressing

-Immediate history of sudden straining

-Patient reports of a sudden change or popping or giving way in wound area

-Visualization of viscera

29
Q

Risk factors for Dehiscence and Evisceration

A

-Chronic disease

-Advanced age

-Obesity

-Invasive cancer

-Vomiiting

-Dehydration

-Ineffective suturing

-Abdominal surgery

-Infection

30
Q

Dehiscence/Eviisceration: Nursing Management

A

-Notify provider immediately due to need for surgical intervention

-Stay with the patient

-Cover wound and any protruding organ with sterile towels or sterile dressing (gauze) soaked with sterile normal saline. (Do not reinsert organs)

-Postion patient supine with hips and knees bent

-Maintain calm environment

-Keep patient NPO in prep for returning to surgery

31
Q

Infection and Surgical Wounds

A

-Always monitor

-Age extremes, immune suppression, impaired circulation/oxygenation. wound condition and nature, malnutrition, chronic disease, poor wound care.

32
Q

Infection and Surgical Wounds: Manifestation

A

-2-11 days after injury or surgery

-Pain

-Redness, edema, and purulent drainage

-Fever and chills

-Odor

-Increased pulse and respiratory rate

-Increase WBC

33
Q
A

Nur 333 Fun 2 (12 decks)

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