NURS 255 Exam 7 Flashcards
What 13 factors affect skin integrity?
- Age
- Impaired mobility
- Nutrition and hydration
- Diminished sensation
- Diminished cognition
- Impaired circulation
- Medication
- Lifestyle
- Moisture
- Contamination
- Colonization
- Critical colonization
- Infection
What are the 5 classifications of wounds?
- Open/Closed wounds
- Acute/Chronic wounds
- Clean/Clean-contaminated/Infected
- Superficial wounds
- Partial/Full/Penetrating-thickness wounds
What does the Inflammatory (1st) phase of wound healing consist of?
- Lasts 1-5 days
- Hemostasis (the blood clotting mechanism)
- Inflammation occurs (Phagocytosis occurs)
What does the Proliferative (2nd) phase of wound healing consist of?
- 5-21 days
- Granulation stage
- Fibroblasts come to form collagen in the area
- Epithelialization begins
What does the Maturation (3rd) phase of wound healing consist of?
- Remodelling of the skin
- Week 2-3
- Scaring may occur when Keratinocytes are in the epidermis
- Collagen fibres are broken down and remodelled
What are the differences between Primary, Secondary and Tertiary indentation healing?
Primary:
- Clean surgical incision/edges approximated
- Minimal scaring
- Occurs when there is hardly any skin damage
Secondary:
- Wound edges not approximated
- Tissue loss
- Heals from inner layer to surface
- Fills with Beefy red granulation tissue
- MOST PRONE TO INFECTION
Tertiary:
- Granulating tissue brought together
- Delayed closure of wound edges
- Used when secondary is taking to long by bringing tissue together
Serous Exudate (What does it look like?)
Straw coloured
Sanguineous Exudate (What does it look like)
Bloody drainage
Serosanguineous Exudate (What does it look like?)
A mix of bloody and straw coloured fluid
Purulent Exudate (What does it look like?)
Yellow, contains pus
Purosanguineous Exudate (What does it look like?)
Contains blood and pus
What are the 3 complications of wound healing?
- Hemorrhage: internal or external
- Infection
- Fistula formation (when one part of the body heals to another that it isn’t supposed to)
What TWO surgical complications of wound healing can occur?
- Dehiscence: Most common with poor nutritional status, obesity, wound infection, tension at the suture line or inadequate closure of muscle with sutures (This should be monitored but does not require physician)
- Evisceration: When a portion of an organ pops out of the incision (THIS MEANS YOU SHOULD CALL THE SURGEON)
What INTRINSIC factors influence pressure injury development?
- Immobility
- Impaired sensation
- Poor Nutrition
- Dehydration
- Aging
- Fever, infection
- Edema
What EXTRINSIC factors influence pressure injury development?
- Friction
- Pressure
- Shearing
- Moisture
What classifies a STAGE 1 pressure injury?
- Redness
- Not broken through skin
- Non-Blanchable (no cap refill)
What classifies a STAGE 2 pressure injury?
- Reddened
- Reached dermis (Partial thickness)
- Usually blisters
What classifies a STAGE 3 pressure injury?
- Through the epidermis and dermis into sub-Q
- Adipose tissue may be visible
- Undermining may begin
What classifies a STAGE 4 pressure injury?
- Down to the bones/tendons
- Slough or Eschar
What classifies a DEEP TISSUE pressure injury?
- Area of skin that is intact but discoloured
- May be purplish or deep red, boggy, painful
- Muscle or other tissue under the skin is dying
What classifies a UNSTAGEABLE PRESSURE INJURY?
- Involves full thickness skin loss
- The base of the wound is Eschar or slough
What (9 things) should be documented in a WOUND ASSESSMENT?
- Location
- Type of wound
- Size
- Undermining or tunnelling
- Periwound (Skin surrounding the wound)
- Wound base
- Drainage
- Wound and tissue pain
- Nutritional status
What 5 Nursing practices can help to PREVENT pressure injury?
- Skin care
- Moisture control
- Adequate nutrition and hydration
- Minimize pressure (Move often)
- Therapeutic mattresses
What are the 5 types of WOUND DEBRIDEMENT?
- Sharp
- Mechanical
- Enzymatic
- Autolysis
- Biotherapy or maggot therapy
What is SHARP debridement?
The use of sterile sharp instruments to remove debris from a wound (May sometimes be performed in the operating room)
What is MECHANICAL debridement?
- The use of mechanical action to remove debris in the form of
- Wet to dry dressings
- Nonselective debridement
- Hydrotherapy or whirlpool treatment
What is ENZYMATIC debridement?
- The use of proteolytic agents to break down necrotic tissue without affecting viable tissue in the wound.
- Can be used for the removal of eschar
What is AUTOLYSIS debridement
- The use of a moisture retaining dressing and the body own enzymes to break down necrotic tissue.
- Takes more time than other techniques but is better tolerated.
- IT IS CONTRADICTED IN THE PRESENCE OF INFECTION
What is BIOTHERAPY OR MAGGOT debridement?
- The use of the greenbottle fly to dissolve dead and infected tissue from wounds
- Larvae secrete enzymes and digest bacteria in the wound
- Changed every 48-72 hours
Obtaining a wound culture (Step 1-5)
- Position the patient
- Put on a gown, gloves and face shield
- Remove old dressing
- Change gloves
- Fill a 35mL syringe
Obtaining a wound culture (Step 6-10)
- Irrigate the wound from 2-5 cm away (IRRIGATE THE MOST CONTAMINATED FIRST)
- Dispose of irrigation supplies
- Obtain an aerobic culturette tube
- Put on gloves
- Swab granular tissue
Obtaining a wound culture (Step 11-15)
- Use Levines technique (roll swab in 1cm area of granular tissue for 5 seconds)
- Put swab back in the tube (Break the tube)
- Label the tube
- Apply a new dressing
- Transport specimen to the lab
Changing dressings (Step 1-5)
- Position to where it is comfortable and accessible
- Wash hands
- Remove edges of tape with push-pull method
- Lift the edges until only centre remains and if it sticks moisten it
- Assess type and amount of drainage from wound
Changing dressing (Step 6-10)
- Dispose of gloves in biohazard bin
- Open 4x4 gauze and moisten it
- Put on gloves
- Pick up cause (ANGELA TECHNIQUE)
- Cleanse the wound with the gauze
Changing dressing (Steps 11-15)
- Discard gloves
- Reassess wound for size, colour, amount of and type of exudate, and odour
- Wash hands
- Open 4x4 packs
- Don non sterile gloves
Changing dressing (Steps 16-19)
- Apply a layer of dry dressings
- Tape dressing
- Remove gloves
- reposition patient to comfortable position
How long before a dressing change should pain be assessed?
30 minutes
Can dressing changes be delegated?
No, it should never be delegated
What should you do if infection is noted in wound assessment?
Notify the provider
What should be cleaned first? Incision or drain?
Incision always then the drain
What should a nurse do if skin surrounding a wound is not intact?
Clean the area with saline and apply a protective moisture barrier and consider Montgomery straps
Taping a dressing (ALL STEPS)
- Wash hands and put on gloves
- Place the patient in a comfortable position
- ensure the surrounding skin is dry and clean
- Choose the type of tape to use
- Tear or cut strips that extend 1 to 1.5 inches beyond edge of wound
- Place tape perpendicular to incision without pulling or stretching it
What angle should a joint be taped at?
- At a right angle to the direction of joint movement
What 6 factors should be considered when choosing an appropriate tape?
Wound
- size
- location
- amount of drainage
- frequency of dressing changes
- patients activity
- type of dressings used
How should hair that obstructs tape adhesion be removed?
- By scissors not with a razor as this can cause infection
What should be done if a patient has fragile skin and needs to be taped?
- Use skin sealants or the least adhesive tape possible
Applying bandages (Step 1-5)
- Choose appropriate width bandage
- Clean and dry the part getting covered
- Remove excess moisture by patting
- Stand facing the patient
- Bandage the body part in a comfortable position
Applying bandages (Step 6-10)
- Always work from distal to proximal
- If a wound is present apply a primary dressing
- Apply the bandage (ensure appropriate tightness)
- If possible leave the fingers exposed
- Begin the wrap
Applying bandages (Step 11-13)
- Pad bony prominences
- Change bandages whenever they become wet or soiled
- Assess circulation after bandaging
What should you do if drainage breaks through a bandage?
- Determine where it is coming from and stop it
Can wound drainage system emptying be delegated to other personnel?
- Yes it can be delegated to a UAP but assessing the wound must be done by a trained professional
Emptying a closed wound drainage system (Step 1-5)
- Read device instructions
- Perform hand hygiene
- Unfasten drainage device
- Open drainage port into measuring cup
- Compress the device with one palm
Emptying a closed wound drainage system (Step 6-10)
- Clean emptying port with alcohol
- attach the device to the patients gown
- Measure the drainage and discard in biohazard bin
- Remove gloves
- Document drainage amount
What should you do if drainage spills while emptying drainage device?
- Clean it up with gloves and discard everything in the biohazard bin
WBC count (What is it used for and what is its normal range?)
5000-10000
- Measures white blood cells in the blood and can indicate the presence of infection when elevated
- Low count may indicate healing
Serum protein test (What is it used for and what is its normal range?)
6-8 g/dL
- Is used to detect the ability of the body to heal a wound or prevent pressure injuries
Serum albumin test (What is it used for and what is its normal range?)
3.4-4.8 g/dL
- if low may detect nutritional deficits
Erythrocyte sedimentation rate (ESR) (What is it and what is its normal range?)
0-15 (people under 50)
0-20 (people above 50)
- Can indicate the presence of infection and necrosis
Partial thromboplastin time, activated (What is its normal range and what is it used to detect?)
70-53 seconds is normal
- Measures the amount of time it takes for blood to clot.
Prothrombin time (What is its normal range and what is it used to detect?)
Above 20 seconds
- Indicates the bloods ability to clot
International normalized ratio (INR) (What is it and what is its normal range?)
less than 2.0 (2-3 if receiving anticoagulation therapy)
- Standardized test to evaluate clotting times
Wound cultures (What are they used to detect)
Negative result is good
- Used to detect bacterias in the wound
Tissue Biopsy (What are they used to detect?)
Negative is good
- Not considered infected unless bacteria amount is more than 100,000 per gram per tissue
- BETAHOMOLYTIC STREPLOCOCCI IN ANY NUMBER FAILS THIS TEST
Braden Scale (What are the 6 areas of assessment)
- Sensory perception 1-4
- Moisture 1-4
- Activity 1-4
- Mobility 1-4
- Nutrition 1-4
- Friction and shear 1-3
HIGHER IS BETTER
Can Wound culture gathering be Delegated?
No, not to anyone but RN’s
In what order to the three forms of healing produce the least scaring?
(Least) Primary
Tertiary
(Most) Secondary
What should be done immediately in the event of evisceration?
- Cover the wound with sterile towels
- Have patient stay in bed with knees bent
- Do NOT put a binder on
- Notify the surgeon
How long does a wound have to exist for before it is considered chronic?
- 2-4 weeks
What are 3 side effects of cold therapy?
- Increased blood pressure
- Shivering
- Tissue damage from prolonged exposure
What are 3 side effects of Heat therapy?
- Increases blood flow to an area
- Promotes the delivery of nutrients and removal of waste products
- Promotes relaxation
