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NURS 2532 > Lab 6 - Wound Care > Flashcards

Lab 6 - Wound Care Flashcards

1
Q

list what you should assess during assessment of pressure ulcer development (6)

A
  • sensory perception (ability to respond to pressure related discomfort)
  • moisture (degree to which skin is exposed to moisture)
  • activity lvl (degree of physical activity)
  • mobility (ability to change & control body position)
  • food & fluid intake (nutrition and hydration)
  • friction & shear
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2
Q

what is an assessment tool that can be used to assess pressure ulcer risk

A
  • braden scale
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3
Q

how often should you assess the risk of pressure ulcer development

A
  • on admission
  • if any change in status occurs
  • on a regular basis according to instutional policy
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4
Q

what does a high braden score mean? low?

A
  • low = high risk

- high = low risk

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5
Q

describe what a stage 1 pressure ulcer looks like

A
  • intact skin
  • nonblanchable redness of a localized area over a bony prominence
  • presence of blanchable erythema or changes in sensation, temp, or firmness may preced visual changes
  • does NOT include purple or maroon discolorations
  • may be painful, warm, soft, firm, or cooler when compared to adjacent tissue
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6
Q

describe a stage 2 pressure ulcer

A
  • partial thickness loss of dermis
  • shallow, open ulcer
  • red, pink, moist wound bed
  • no granulation tissue, eschar, or slough
  • adipose & deeper tissues not visible
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7
Q

describe a stage 3 pressure ulcer

A
  • full thickness tissue loss
  • subcut fat may be visible but bone, tendon, and muscle are not exposed
  • may have undermining or tunnelling
  • slough, granulation tissue, and epibole (rolled edges) may be present
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8
Q

describe a stage 4 pressure ulcer

A
  • full thickness tissue loss
  • exposed bone, muscle, tendon
  • often includes undermining, tunneling, and epibole
  • slough, eschar, or both may be present
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9
Q

describe an unstageable pressure ulcer

A
  • full thickness tissue loss
  • base of ulcer is covered by slough, eschar, or both in the wound bed
  • once slough or eschar is removed, will see stage 3 or 4
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10
Q

describe what a suspected deep tissue injury looks like

A
  • nonblanchable purple or maroon localized area of discolored, intact skin
  • intact or not intact
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11
Q

what is serous drainage

A
  • clear, watery plasma
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12
Q

what is purulent drainage

A
  • thick, yellow, green, tan, or brown drainage
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13
Q

what is serosanguinous fluid

A
  • pale, red, watery

- mix of clear & red fluid

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14
Q

what is sangeinous fluid? what does it indiciate

A
  • bright red

- indicates active bleeding

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15
Q

describe what you should assess prior to treating a pressure ulcer

A
  • assess lvl of comfort and need for pain med
  • check allergies
  • review order for dressing
  • close door/curtain
  • position pt appropriately for location of wound
  • assess pressure ulcer
  • assess periwound skin
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16
Q

what should you note when assessing the pressure ulcer

A
  • color, type. and % of tissue in wound base
  • measure width and length
  • measure depth of ulcer and any undermining using a sterile cotton tip
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17
Q

what should you assess regarding the periwound skin

A
  • maceration
  • redness
  • denuded areas
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18
Q

describe how to clean/treat a pressure ulcer

A
  • hand hygeine
  • put on gloves
  • cleanse ulcer w NS or cleansing agent
  • apply topical agents as prescribed
  • remove gloves, dispose of soil supplied
  • hand hygeine
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19
Q

list 3 types of topical agents that may be applied to pressure ulcer

A
  • enzymes
  • hydrogel
  • calcium alginate or hydrofibre
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20
Q

describe how to apply enzymes to a pressure ulcer

A
  • apply thin, even layer over necrotic areas only
  • protect periwound skin
  • apply secondary nonadherent gauze dressing directly over ulcer
  • tape in place
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21
Q

describe how to apply hydrogel to a pressure ulcer

A
  • cover surface of ulcer with thin layer of hydrogel using applicator or gloves hand
  • apply secondary nonadherent gauze dressing or transparent dressing over wound & adhere to intact skin
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22
Q

describe how to apply calcium alginate or hydrofiber to a pressure ulcer

A
  • lightly pack wound with alginate or hydrofibre using applicator or gloved hands
  • apply secondary dressing of nonadherent gauze, absorbent pad, or foam over alginate
  • tape in place
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23
Q

what age-related changes occur in an older adult’s skin (6)

A
  • reduced skin elasticity
  • decreased collagen
  • thinning of underlying muscle & tissues
  • flattening of the attachment between the demris & epidermis
  • diminished inflammatory response
  • hypodermis decreased in size
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24
Q

what do the age-related changes of skin in an older adult cause? (5)

A
  • skin can be easily torn
  • decreased wound healing
  • slowed epithelialization
  • more prone to skin breakdown
  • increased risk of pressure ulcer development
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25
Q

what is an acute wound

A
  • a wound that proceeds thru an orderly and timely reparative process
  • results in sustained restoration of anatomical and functional integrity
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26
Q

what are 2 common causes of acute wounds

A
  • trauma

- surgical incision

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27
Q

what do acute wounds often look like; what implication does it have on healing

A
  • wound edges clean & intact

- easily cleaned & repaired

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28
Q

what is a chronic wound

A
  • would that fails to proceed thru an orderly and timely process to produce anatomical & functional integrity
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29
Q

what are 3 causes of chronic wounds

A
  • vascular compromise
  • chronic inflammation
  • repetitive insults to the tissue
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30
Q

what implication do chronic wounds have on healing

A
  • continued exposure to insult impedes wound healing
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31
Q

what are the 3 types of healing

A
  • primary intention
  • secondary intetion
  • tertiary intention
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32
Q

what is healing by primary intetion

A
  • healing occurs by epithelialization, when a wound is closed or the edges are well approximated
  • heals quickly w minimal scarring
  • wound edges are pulled together and approximated
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33
Q

what are two types of wounds that heal via primary intention

A
  • surgical incision

- stapled or sutured wound

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34
Q

what is healing by secondary intention

A
  • healing that occurs in wounds where edges are not well aproximated
  • would heals by granulation tissue formation, wound contraction, and epithelialization
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35
Q

what are 2 types of wounds that heal via secondary intention

A
  • pressure ulcers

- surgical wounds that have tissue loss

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36
Q

what is healing by tertiary intention

A
  • healing where the wound is left open for several days, then wound edges are approximated
  • closure of wound is delayed until risk of infection is involved
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37
Q

what type of wounds are healed via tertiary intention

A
  • wounds that are contaminated & require observations for signs of inflammation
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38
Q

what is the goal of effective wound management

A
  • maintenance of a physiological local wound enviro
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39
Q

how can we maintain a healthy wound enviro

A
  • prevent and manage infection
  • cleanse the wound
  • remove nonviable tissue
  • manage exudate
  • maintain the wound in a moist enviro
  • protect the wound
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40
Q

why is it important to prevent and manage infection of a wound

A
  • a wound will not move thru the stages of healing if it is infected
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41
Q

prevention of wound infection includes.. (3)

A
  • irrigation
  • cleansing
  • removal of nonviable tissue
42
Q

what is used to clean wounds

A

noncytotoxic wound cleansers:

  • NS
  • commercial wound cleansers
43
Q

why must we use noncytotoxic wound cleansers to clean wounds

A
  • will not damage or kill fibroblasts & healing tissue
44
Q

what are 4 cytotoxic solutions to absolutely avoid for granulating wounds

A
  • sodium hypochlorite dolution
  • acetic acid
  • povidone-iodine
  • hydrogen peroxide
45
Q

what is irrigation

A
  • common method of delivering the wound cleansing solution to the wound
  • uses a syringe to apply the cleansing solution
46
Q

what is used to ensure an irrigation pressure within the correct range

A
  • use a 35 mL syringe with a 19-gauge angiocatheter or a single 100 mL saline squeeze bottle
47
Q

what pressure should be applied to wounds during irrigiation to provide adequate removal of bacteria while avoiding trauma to the bed

A
  • 4-15 psi
48
Q

what is debridement? why do we do it?

A
  • removal of nonviable, necrotic tissue
  • is necessary to rid the ulcer of source of infection, enable visualization of the wound bed, and provide a clean base for healing
49
Q

what is an excpetion to debridement

A
  • dry necrotic heel

- only debride if infected

50
Q

what are 6 methods of debridement

A
  • mechanical
  • biological
  • autolytic
  • chemical
  • sharp
  • surgical
51
Q

what is important to manage during debridement

A
  • pain
52
Q

what is mechanical debridement

A
  • “wet-to-dry” saline gauze dressing
53
Q

why is mechanical debridement not considered appropriate for pressure ulcers

A
  • nonselective in its removal of devitalized vs viable tissue
54
Q

what is biological debridement

A
  • use of maggot therapy

- sterile maggots used in the wound bed to ingest the dead tissue while not impairing granulation

55
Q

what is chemical debridement

A
  • involves the use of enzymes which breakdown necrotic tissue
  • depending the type, it either digests or dissolves tissue
56
Q

what is an important consideration for chemical debridement

A
  • only apply to the wound bed, avoid the periwound skin
57
Q

what is the current best practice treatment option for debridement of pressure ulcers

A
  • autolytic

- sharp /surgical debridement

58
Q

what is autolytic debridement

A
  • debridement which uses synthetic dressings over a wound to maintain a moist enviro
  • allows the eschar and fibrinous slough within the wound to be self digested thru the action of enzymes that are present in wound fluids
59
Q

what are 2 types of dressing that support moisture at the wound surface ? why is this important

A
  • hydrogel & hydrocolloid

- allows the movement of epithelial cells & facilitates wound closure

60
Q

what is the consequence of excessive exudate

A
  • supports bacterial growth
  • macerates the periwound skin
  • slows the healing process
61
Q

which type of dressing should be used if there is an excessive amt of exudate

A

absorptive dressing:

  • calcium alginate
  • hydrofibre
  • foam
62
Q

what is sharp/surgical debridement

A
  • debridement that uses a scalpel, scissors, or other sharp instruments
63
Q

why/when is surgical debridement used

A
  • most efficient way to reach vitalized tissue at the base of a wound
  • when sepsis is localized or excised
64
Q

who is allowed to do surgical/sharp debridement

A

only HCP with knowledge, skill, and competence to perform the skill:

  • physicians
  • advanced practice nurses (NP)
65
Q

the wound will not heal, regardless of the use of topical therapy, unless….

A

you control or eliminate the causative factors

  • malnourishment
  • friction
  • shear
  • pressure
  • moisture
66
Q

why is continued reassessment of wounds important

A
  • as the wound goes thru the steps of healing, the treatment plan must be altered
  • key to supporting the wound thru the phases of wound healing
67
Q

what is another important factor regarding wound healing

A
  • must explain the process of wound healing to the pt and family
68
Q

when should you administer pain meds for irrigation

A

30-45 min before starting the irrigation

69
Q

describe the steps of wound irrigation prior to actual treatment

A
  • assess pain & give meds if appropriate
  • review orders
  • assess recent S+S r/t to the wound to get a baseline
  • explain procedure to pt
70
Q

what recent S+S of wound should you assess prior to irrigation

A
  • conditon of the skin & wound
  • elevation of body temp
  • drainage from wound (amt, color)
  • odour
  • consistency of drainage
71
Q

describe how to irrigate a wound

A
  • perform hand hygeine
  • position pt
  • set up garbage bag
  • put on appropriate PPE
  • irrigate wound
  • obtain any needed cultures
  • dry wound edges w gauze
  • apply appropriate dressing
  • remove gloves & dispose of equipment
72
Q

how should you position a pt for irrigation

A
  • so it permits gravitational flow of the irrigating solution thru the wound and into the collecting receptacle
73
Q

describe how to irrigate a wound with a wide opening

A
  • fill 35mL syringe with irrigation solution
  • attach 19-gauge needle or angiocatheter
  • hold syringe tip 2.5 cm above upper end of wound and over area being cleansed
  • use continuous pressure and repeated until solution draining into the basin is clear
74
Q

describe how to irrigate a deep wound with a very small opening

A
  • attach soft angiocatheter to filled irrigating syringe
  • lubricate tip of catheter with irrigating solution, then gently insert tip of catheter and pull out about 1cm
  • use slow, continuous pressure to flush the wound
  • pinch off catheter just below syringe while keeping catheter in place
  • remove & refill syringe
  • reconnect to catheter & repeat until solution draining into basin is clear
75
Q

what should you immediately report to the physician regarding irrigation

A

any evidence of:

  • fresh bleeding
  • sharp increase in pain
  • retention or irrigant
  • signs of shock
76
Q

what are the recommendations for standardized techniques for wound cultures

A
  • clean wound surface with a nonantiseptic solution (NS, or sterile water)
  • use a sterile swab for the culturette tube
  • rotate the swab in 1cm of clean tissue in the open wound
  • apply pressure to the swab to elicit tissue fluid
  • insert the tip of the swab into the appropriate sterile container & transport to the lab
77
Q

describe the use of tap water for cleaning a wound

A
  • no particular risk if from safe municpal water sources
  • however, tap water from rural areas or unknown sources can cause potential contamination
  • therefore, should err on the side of caution & use sterile water or NS
78
Q

define fistula

A
  • abnormal connection between 2 body parts
79
Q

what is purulent drainage associated with?

A
  • infection or high bacteria lvls
80
Q

define hemostasis

A
  • process of the body stops bleeding from a cut or injury
81
Q

define ischemia

A
  • condition in which blood flow (and thus O2) is restricted or reduced in part of the body
82
Q

define slough

A
  • necrotic tissue that needs to be removed from the wound for healing to take place
  • yellow or tan in appearance
83
Q

define necrotic

A
  • death of cells in living tissue caused by external factors
84
Q

define maceration

A
  • softening of tissues by soaking and enzymatic digestion
85
Q

define evisceration

A
  • extrusion of viscera outside of the body

- specifically thru surgical incision

86
Q

define debridement

A
  • medical removal of dead, damaged, or infected tissue to improve healing in the remainging healthy tissue
87
Q

define approximated edges

A
  • wounds that fit neatly together
88
Q

define granulation

A
  • part of the healing process in which lumpy, pink tissue containing new CT and capillaries forms around the edges of a wound
89
Q

define erythema

A
  • reddening of the skin that is common but nonspecific sign of skin irritation, inflammation, or injury
  • caused by dilation of superficial blood vessels in the skin
90
Q

define dehiscence

A
  • wound dehiscence is the separation of the edges of a surgical wound
91
Q

define eschar

A
  • dead tissue found in a full thickness wound
92
Q

when might we see eschar tissue (6)

A
  • burn injury
  • gangrenous ulcer
  • fungal infection
  • necrotizing fascitis
  • spotted fevers
  • exposure to cutaneous anthrax
93
Q

define epitheliazation

A
  • restoration of epithelium over a denuded area by natural growth or plastic surgery
94
Q

define laceration

A
  • wound that is produced by the tearing of soft body tissue
  • irregular & jagged
  • often contaminated with bacteria & debris from whatever caused it
95
Q

define incision

A
  • cut made into the body during surgery
96
Q

define hypergranulation

A
  • over-granulation or proud flesh
  • excess granulation tissue that fills the wound bed to a greater extent than what is required
  • goes beyond the height of the surface of the wound = raised tissue mass
97
Q

define dermatitis

A
  • inflammation of the skin
98
Q

define exudate

A
  • fluid that leaks out of blood vessels into nearby tissues

- made of cells, proteins, and solid materials

99
Q

define undermining

A
  • occurs when the tissue under the wound edges becomes eroded = pocket beneath the skin at the wound’s edge
100
Q

define tunneling

A
  • channels that extend from a wound into & thru subcutaneous tissue or muscle
  • often difficult to manage
  • may persist for long period of time
101
Q

define nonviable

A
  • aka necrotic or devitalized

- avascular tissue that has lost normal cellular structure & physical properties required of living tissue

NURS 2532 (5 decks)

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