Brainscape's Knowledge GenomeTM

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


See full index

NURS 220 > LEC 2: Wound Care Continued > Flashcards

LEC 2: Wound Care Continued Flashcards

1
Q

What are the four steps to treating a chronic wound?

A
  • Identify and control the underlying causes
  • Support patient centred concerns
  • Optimize local wound care; providing an environment to heal
  • Provide organizational support
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

What is the function of the Braden Scale?

A

Helps to identifie patients that are at risk for pressure ulcers

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

What are the six characteristics used to predicting pressure ulcers?

A
  1. Sensory perception
  2. Moisture
  3. Activity
  4. Mobility
  5. Nutrition
  6. Friction/ shear
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Braden Scale: Sensory Perception

A

Ability to respond meaningfully to pressure-related discomfort

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

Braden Scale: Moisture

A

Degree to which skin is exposed to moisture

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

Braden Scale: Activity

A

Degree of physical activity

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

Breden Scale: Mobility

A

Ability to change and control body position

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

Braden Scale: Nutrition

A

Usual food intake pattern

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

When should a Braden Scale assessment be done on a patient in acute care?

A

Every 24 hours in acute care

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

How does the Braden Scale work?

A

The total score ranges from 6 to 23, and a lower total score indicates a higher risk of pressure ulcer development

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

What are the three pressure-related factors that contribute to pressure ulcer development?

A
  • Pressure intensity
  • Pressure duration
  • Tissue tolerance
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Suspected Deep Tissue Injury

A

Purple or maroon localized area of discoloured intact skin or blood-filled blister due to damage of underlying soft tissue from pressure or shear or both. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue

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

What are the five guidlines for staging pressure ulcers?

A
  • Stage I
  • Stage II
  • Stage III
  • Stave IV
  • Unstageable
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Pressure Injury: Stage I

A
  • Intact skin with nonblanchable redness of a localized area usually over a bony prominence
  • Epidermis and dermis are still in-tacked
  • When you put pressure on pressure injury, it does not turn white
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Pressure Injury: Stage II

A
  • Partial thickness loss of dermis
  • Looks like shallow ulcer
  • Has a red/pink wound bed
  • Could be intact or open blister
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Pressure Injury: Stage III

A
  • Full thickness tissue loss
  • Subcutaneous fat may be visible
  • Bone, tendon, muscle not visible
  • May include undermining and tunnelling
  • Possible odour and drainage
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Pressure Injury: Stage IV

A
  • Fill thickness tissue loss
  • Exposed bone , tendon, or muscle
  • Slough or eschar may be present
  • Often undermining and tunnelling
  • Possible odour and drainage
18
Q

Pressure Injury: Unstageable

A
  • Full thickness loss
  • Base of ulcer covered by slough or eschar
  • Extent of tissue damage can’t be confirmed
19
Q

Slough

A

Decaying tissue/ collagen, looks yellow

20
Q

Eschar

A

Dead tissue, looks black/dark

21
Q

Best Practice Guidelines for Interdisciplinary Management

A
  • Wound cleansing
  • Debridement of healable wound
  • Moisture balance
  • Elimination of dead space; packing
  • Thermal insulation; good circulation
  • Protection of periwound skin
22
Q

Why do we pack a wound?

A

To eliminate dead space, which allows the wound to heal from bottom up

23
Q

What acronym is used for complex wound assessment?

A

MEASURE

24
Q

What dose MEASURE stand for?

A
  • Measure
  • Exudate
  • Appearance of wound base
  • Suffering
  • Undermining
  • Re-evaluate
  • Edge
25
Q

MEASURE: Measure

A
  • Length
  • Width
  • Depth
26
Q

How do you measure the length of the wound?

A

The longest dimension of the wound bed (regardless of direction)

27
Q

How do you measure the width of the wound?

A

Measured at the widest portion of the wound, perpendicular to the length

28
Q

How do you measure the depth of the wound?

A

With a sterile wet, cotton-tip applicator, measure the greatest distance 90 degrees from the skin surface to the base of the wound

29
Q

MEASURE: Exudate

A
  • Amount and type
  • Is there an odour
30
Q

MEASURE: Appearance of Wound Base

A

Estimate percentage of each tissue type

  • Black wound
  • Yellow wound
  • Pink wound
31
Q

Black Wound Base

A

Devitalized tissue May be grey, brown or black Necrosis can by moist or dry

32
Q

Yellow Wound Base

A

Decaying collagen (slough) of fibrin

33
Q

Pink Wound Base

A
  • Moist granulation tissue and indicates profiling wounds
  • May be shades of pink or red
  • Pink indicated new epithelialization

*What we want the wound to look like

34
Q

MEASURE: Suffering

A

What is the patient’s pain level

35
Q

MEASUR: Undermining

A

Evaluate the undermining and tunneling of the wound

36
Q

Undermining

A

Tissue destruction extending under intact skin along the wound margin

37
Q

Tunneling

A

(sinus tract) course or path of tissue destruction occurring in any direction from the wound bed

38
Q

MEASURE: Re-Evaluate

A

All wound should be reassessed regularly

  • Done every time you change the dressing
39
Q

MEASURE: Edge

A

Appearance of wound edge and surrounding (periwound) skin

40
Q

When talking about wounds, how do we indicate the direction of tunneling and undermining?

A

When talking about wound use a clockwise direction

NURS 220 (41 decks)

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