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Mental Health Nursing > Lecture 10 - Wound Care > Flashcards

Lecture 10 - Wound Care Flashcards

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1
Q

What are the three layers of the skin?

A

Epidermis - Outer protective
Dermis/Corneum - Nourishing Layer
Subcutaneous/Hypodermis - Fatty base layer

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2
Q

What are the six function of skin?

A

slide 7

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3
Q

Which individuals are at higher risk for skin breakdown

A

Older adults + very young population, immunosuppressed, oncology patients, those with diabetes

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4
Q

What are important things to note when document changes in skin?

A
  • New onset or existing
  • Location
  • Colour, shape, size
  • Borders, texture, arrangement, elevation or depressed
  • Temperature/altered sensation
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5
Q

make slides on configuration - slide 15

A
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6
Q

What products are best for cleansing skin?

A

A gentle/balance pH product and moisturizer or barrier products as needed

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7
Q

What do we need to avoid to protect skin integrity? Which areas should we pay extra attention to

A

Very hot water, rubbing & fraction.

Frequently check bony prominences, folds, creases, contact points.

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8
Q

What is the decision algorithm for skin tears?

A

–> Stop and control bleeding
–> Cleanse
–> Approximate edges
–> Assess and classify (measure, photograph and document)
–> Select product for dressing

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9
Q

Kinds of skin tears

A

Slide 27

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10
Q

What differentiates a chronic or acute wound?

A

Acute: Healing as expected
Chronic/Persistent: Doesn’t match expected trajectory for the type of wound

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11
Q

What are the steps in the cycle of woundcare?

A
  1. Assess
  2. Set goals
  3. Assemble the team
  4. Establish and Implement a Plan of Care
  5. Evaluate outcomes
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12
Q

When assessing a wound, what should you assess other than the wound itself?

A

Risk and causative factors that may impact skin integrity for wound healing
–> Pt, environment, systems

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13
Q

What is the MEASURE tool for wound assessment?

A

slide 13

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14
Q

What unit should you measure a wound size in?

A

Cm

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15
Q

What is fibrous exudate?

A

Cloudy, thin, watery.

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16
Q

What is haemopurulent exudate?

A

Dark red, viscous, sticky

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17
Q

What is granulation tissue?

A

Granulation tissue: red or bright pink, healthy tissue.

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18
Q

What is hypergranulation tissue?

A

Hypergranulation: excessive growth of granulation tissue “proud flesh”, raised red.
–> Can occur with high moisture

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19
Q

What is slough?

A

Slough: yellow stringy tissue – none or loosely adherent.

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20
Q

What is fibrin?

A

Fibrin: yellow stringy tissue – firmly adherent. May be confused with slough.

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21
Q

What is eschar?

A

Eschar: soft or firm, black or tan necrotic (devitalized) tissue.

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22
Q

What is epithelialization?

A

Epithelization: hypopigmented, ie pearly white
–> Often seen on wounds that are contracting and decreasing in width

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23
Q

What can cause odour in a wound?

A

Infection, dead tissue (necrotic, slough), certain dressing products.

Odour might be present before cleansing wound, but should not be after wound care. Perform wound care before complete odour assessment

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24
Q

distinct/indestinct

A

slide 22

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25
Q

attached

A

slide 22 (part 2)

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26
Q

What is epibole with wound edges?

A

When the edge is rolled or curved under, downward and into the wound

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27
Q

What is the VINDICATE tool for identifying risk factors for wounds/healing?

A

Vascular
Infection/Inflammation
Neoplasm
Drug/Degenerative
Idiopathic/Iatrogenic
Congenital
Autoimmune/anatomic/allergies
Traumatic/Toxic
Endocrine/Environmental/Exposure

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28
Q

part 2 slide 28 notes

A
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29
Q

What are the goals of wound care?

A

Prevention & Healing

For non-healing - maintenance

Palliation - First focus of QoL + symptom management

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30
Q

How often are measurements redone for wounds?

A

Usually weekly

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31
Q

Stages of wound healing 32

A

“If I were writing an exam question”

32
Q

What are the stages of wound healing?

A

Hemostasis - seconds to hours
Inflammatory phase - hours to days
Proliferative phase - days to week
Remodeling - Week to months (could be up to 2 years)

33
Q

Who would we want to contact to assemble the team for wound care?

A

NSWOCC - A nurse specialized in wounds, ostomies, and _____
Physio - mobility
OT - Equipment & positioning
Dietician - Optimizing nutrition
Speech Language Pathology - swallowing
Physicians
Pt & Family

Nurse coordinates and provides care

34
Q

What are the different kinds of wound closure techniques?

A

Primary Intention- closing wound from top edges (skin)

Secondary Intention- closing wound from bottom and letting it heal upwards (bottom up)

Tertiary Intention - SLIDE 4 PART 3

35
Q

incision healing trajectory

A

slide 6

36
Q

Uncontrolled pre-op

A

8

37
Q

controlled pre-op

A

8

38
Q

What is an important question to ask cardiac surgery patients before the operation?

A

Up to date dental work - prevent infection following surgery

39
Q

Intra-op controllable

A

slide 9

40
Q

Intra-op non controllable

A

9

41
Q

What are some important priorities in the immediate post-operative period?

A

slide 10

42
Q

What are the top three kinds of nosocomial infections?

A

UTI, Pneumonia, wound

43
Q

What products would we use for primary intention cover dressings?

A

slide 12

44
Q

Telfa slide 13 part 3

A
45
Q

combo 13

A
46
Q

NWPT slide 13

A
47
Q

How often do you change a primary intention wound covering?

A

As long as possible to promote healing -

It takes 4-8 hours for the wound to heal form removing the dressing.

48
Q

Are mucosal membrane pressure injuries staged?

A
49
Q

What does a stage 1 pressure injury look like?

A

Non-Blanchable erythema of intact skin

Brown or Black skin may present with changes in temperature, be very shiny, changes in sensation, itching.

50
Q

What change in skin temp will indicate perfusion related injury?

A

3° C

51
Q

A serum filled blister is what stage pressure injury?

A

Stage 2.

52
Q

What is a stage 2 pressure injury?

A

Partial thickness loss with exposed epidermis
–> Viable wound bed, may be serum filled blister

53
Q

What does not count as a stage 2 pressure injury?

A

Slide 29

54
Q

Stage 3 slide 30

A
55
Q

Stage 4 slide 32

A
56
Q

What kind of injury is a blood filled blister

A

Deep Tissue Pressure Injury (DTPI)

57
Q

If you can touch the bone of a stage 4 pressure injury, what are the chances they also have osteomyelitis?

A

80%

58
Q

What is a deep tissue pressure injury?

A

slide 33

59
Q

What is a medical device pressure injury? Should they be staged?

A

Pressure injury from use of diagnostic or therapeutic devices - clues can be found in the shape or pattern.

Should not be staged

60
Q

slide 40

A
61
Q
A
62
Q
A
63
Q

Different kidns of ulcers - part 4, slide 6

A
64
Q

What is the VIPS tool for diabetic foot ulcer management?

A

Vascularity - Pulses, doppler

Infection/Inflammation - Rule out bc they will stall healing

Pressure - Relieve pressure

Sharps/Surgical Debridement

65
Q

What test can be used to test sensation of the feet in those with diabetic neuropathy?

A

Monofilament test

66
Q

What are Marjolin’s Ulcers?

A
67
Q

What are possible risk factors for arterial leg ulcers?

A
67
Q

What does an arterial leg ulcer look like?

A

Punches hole, small and deep, well defined borders
May see pallor, coolness, faint pulses

Intermittent claudication - pain with walking

68
Q

How can severe arterial leg ulcers be treated?

A

Surgical reperfusion is necessary is circulation is interrupted.

69
Q

What are the 6Ps are arterial insufficiency?

A

Pain, pulselessness, pallor, paresthesia, paralysis, poikilothermia

70
Q

ABPI

A
71
Q

What kind of solution should you irrigate with?

A

A sterile non-cytotoxic solution

72
Q

When should you not irrigate a wound?

A

When there is an unknown point of tunnels, sinuses, or undermining/fistulas

73
Q

When is debridement contraindicated?

A

With stable a dry eschar when:
–> Perfusion is not adequate and
–> Very close to bone or cartilage, for examples on the heels or scalp.

Instead, paint with iodine solution

74
Q

Surgical debridement can only be performed by…

What should you be aware of before?

A

A physician or trained nurse

Ensure hemostatic agents readily available if bleeding occurs

Mental Health Nursing (15 decks)

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