Pressure Ulcers, Wounds, and Wound Management - ATI - Chapter 55 Flashcards
Wounds are a result of injury to the ____.
skin.
Although there are many different methods and degrees of injury, the ______ of healing are essentially the same for most wounds.
basic phases
A pressure ulcer (formerly called a _______) is a specific type of tissue injury from unrelieved pressure or friction over bony prominences that results in ischemia and damage to the underlying tissue.
decubitus ulcer
The stages of wound healing
Inflammatory Stage
Proliferative Stage
Maturation or remodeling Stage
Inflammatory stage begins with the injury and lasts _____ days.
3-6 days
Controlling bleeding with vasoconstriction and retraction of blood vessels, and with ______ in the inflammatory stage.
clot formation
During the ______ stage oxygen, white blood cells, and nutrients are delivered to the area via the blood supply.
inflammatory stage
____ occurs along with fibrin formation during the inflammatory stage.
hemostasis
____ engulf microorgansims and cellular debris (phagocytosis) during the inflammatory stage.
macrophages
The ____ stage lasts the next 3 to 24 days in the wound healing process.
proliferative
During the proliferative stage lost tissue is replaced with ______ or ______ tissue or collagen.
connective or granulated
During the proliferative stage the wound’s edges are ____.
contracting
Resurfacing of new _______ occurs during the proliferative stage.
epithelial cells
____ stage occurs after day 21 and involves the strengthening of the collagen scar and the restoration of a more normal appearance.
maturation or remodeling stage
It can take more than a year to complete, depending on the extent of the original wound during the _____ stage.
maturation or remodeling stage
The types of the healing processes
primary intention
secondary intention
tertiary intention
Little or no tissue loss Edges approximated, as with a surgical incision Heals rapidly Low risk of infection No or minimal scarring
i.e. closed surgical incision with staples or sutures or liquid glue to seal laceration.
primary intention
Loss of tissue Wound edges widely separated, unapproximated (pressure ulcers, open burn areas) Longer healing time Increase for risk of infection Scarring Heals by granulation
i.e. pressure ulcer left open to heal
secondary intention
Widely separated Deep Spontaneous opening of a previously closed wound Closure of wound occurs when free of infection Risk of infection Extensive drainage and tissue debris Closed later Long healing time
i.e. Abdominal wound initially left open until infection is resolved and then closed.
Tertiary intention
Factors affecting wound healing
Age Overall Wellness Decreased leukocyte count Some medications malnourished clients tissue perfusion low Hgb levels obesity chronic diseases smoking wound stress
Increased ___ delays healing.
age
A wound in a young, healthy client will heal faster than a wound in an older adult who has a chronic illness due to the _______ risk factor that affects wound healing.
overall wellness
_____ delays wound healing because the immune system function is to fight infection by destroying invading pathogens.
decreased leukocyte count
Age effects wound healing because of the following (8)
loss of skin turgor skin fragility decrease in peripheral circulation and oxygenation slower tissue regeneration decrease in absorption of nutrients decrease in collagen impaired immune system function dehydration due to decreased thirst sensation
_____ interfere with the body’s ability to respond to and prevent infection.
some medication
what medications interfere with the body’s ability to respond to and prevent infection.
anti-inflammatory
antineoplastic
_______ do not get the nutrition they need which provides energy and elements for wound healing.
malnourished clients
______ provides circulation that delivers nutrients for tissue repair and infection control can effect wound healing.
tissue perfusion
_____ effect wound healing because Hgb is essential for oxygen delivery to healing tissues.
low Hgb levels
______ can effect wound healing because fatty tissue lacks blood supply.
obesity
______ such as diabetes mellitus and cardiovascular disorders, place additional stress on the body’s healing mechanisms which effect wound healing.
chronic diseases
_____ such as from vomiting or coughing, puts pressure on the suture line and disrupts the wound healing process.
wound stress
Wounds impair ____.
skin integrity
_____ is a localized protective response to injury or destruction of tissue.
inflammation
Wounds heal by various processes and in ______.
stages
Wound _____ result from the invasion of pathogenic micro-organisms.
infections.
Principles of wound care include assessment, _____, and protection.
cleansing
During assessment/data collection note the ______ of the open wounds.
color
A ____ wound means there is healthy regeneration of tissue.
red
A ____ colored wound means there is a presence of purulent drainage and slough.
yellow
A ____ wound means there is a presence of eschar that hinders healing and requires removal.
black
Assess the length, width, and ____ of wounds, and any undermining, sinus tracts or ______, and redness or swelling.
depth
tunnels
When assessing wounds use a ____ with 12:00 toward the client’s head to document the location of sinus tracts.
clock face
Use the RYB color guide for wound care:
Red = cover
Yellow = ____
Black = _____
Yellow = clean
Black = debride, removal of necrotic tissue
With ___ wounds skin edges should be well-approximated.
closed wounds
________ is a result of the healing process and occurs during the inflammatory and proliferative phases of healing.
drainage (exudate)
Note the amount, odor, and _____ and color of drainage from a drain or on a dressing.
consistency
Not the _____ of the surrounding skin.
integrity
With each cleansing, observe the skin around a drain for ______ and breakdown.
irritation
For accurate measurement of drainage, ____ the dressing.
weigh
Note and document the _____ of dressings and frequency of dressing changes.
number
The portion of the blood (serum) that is watery and clear or slightly yellow in appearance (i.e. fluid blisters) is called _____
serous drainage
_____ drainage contains serum and red blood cells. It is thick and appears reddish. Brighter drainage indicates fresh bleeding; darker drainage indicates older _____.
sanguineous drainage
bleeding drainage
_______ drainage contains both serum and blood. It is watery and appears blood-streaked or blood tinged.
serosanguineous drainage
____ drainage is the result of inflection.
purulent
______ drainage is a mixed drainage of pus and blood (i.e. newly infected wound)
purosanguineous
____ drainage is thick and contains white blood cells, tissue debris, and bacteria. It may have a foul odor, and its color such as yellow, tan, brown reflects the type of organism present (green for Pseuduomonoas aeroguinosa infection).
purulent
Types of wound closures (3)
staples
sutures
wound-closure strips
Note the location, quality, intensity, timing, setting, associated manifestations, and aggravating/relieving factors associated with any ____.
pain
In the assessment collect these (5) things
appearance drainage wound closure status (drains or tubes) pain
When they are asking about the _____ of a wound note if there are any drains or tubes.
status
A nursing intervention involving wound care requires you provide adequate hydration and meet _____ and calorie needs.
protein
Encourage an intake of ____ to ____ mL of fluid/day from food and beverage sources if not contraindicated (heart and chronic kidney disease).
2,000 to 3,000
A nursing intervention involving wound care involves _____ about good sources of protein (meat, fish, poultry, eggs, dairy products, beans, nuts, and grains.)
education
Note if serum ____ levels are low (below 3.5 g/dL) because of a lack of protein increases the risk for a delay in wound healing and infection.
albumin
Provide nutritional support (vitamin and mineral supplements, nutritional supplements, and enteral and parental nutrition). Most adult clients need at leas ____ kcal/day for nutritional support.
1500
For clean wounds, such as a surgical incision, cleanse from the ____ contaminated (the incision) toward the ____ contaminated (the surrounding skin).
least
most
Use gentle ____ when cleansing or applying solutions to the skin to avoid bleeding or further injury to the wound.
friction
Although the provider might prescribe other mild cleansing agents, ______solutions remain the preferred cleaning agent.
isotonic
Never use the same ____ to cleanse across an incision or wound more than once.
gauze
Do not use _____ or other products that shed fibers when you perform wound cleansing.
cotton balls
If irrigating, use a piston syringe or a _____ for deep wounds with small openings when cleaning a wound. Apply 5 to 8 psi of pressure. A ___ to ___ mL syringe with a 19 gauge needle provides approximately 8 psi. Use normal saline, lactated Ringer’s, or an antibiotic/antimicrobial solution.
sterile straight catheter
30 to 60
When you perform wound cleaning remove sutures and ____.
staples
Administer ____ and monitor for effective pain management when performing wound cleansing.
analgesics
Administer _____ (topical,systemic) and monitor for effectiveness (reduced fever, increase in comfort, decreasing WBC count) when wound cleansing.
antimicrobials
Document the location and _____ of wound and incision, the status of the wound and type of drainage, the type of dressing and materials, client teaching, and how the client tolerated the procedure while performing wound cleansing.
type of
____ protect the wound from microbes.
protects
_____ absorbs exudate from the wound.
Woven gauze sponges
_____ does not stick to the wound bed. (type of wound dressing)
nonadherent material
_____ are used to mechanically debride a wound until granulation tissue starts to form in the wound bed. Must keep moist at all times to prevent pain and disruption of wound healing.
damp to damp 4 inch by 4 inch dressings
_____ are a temporary “second skin” ideal for small, superficial wounds.
self adhesive, transparent film
_____ is an occlusive dressing that swells in the presence of exudate; composed of gelatin and pectin, it forms a ____ at the wound’s surface to prevent evaporation of moisture from the skin.
Hydrocolloid
seal
Hydrocolloid maintains a ____ wound bed.
granulating
Hydrocolloid can stay in place up to _____.
7 days
_____ composition is mostly water. Gels after contact with exudate, promoting autolytic debridement and cooling. Rehydrates and fills dead space.
hydrogel
_____ is for infected, deep wounds, or necrotic tissue.
hydrogel
Hydrogel is not for moderately to heavily _____.
draining wounds
Hydrogel provides a _____ wound bed.
moist
Hydrogel can stay in place for _____ days.
3
Use of foam strips laid into the wound bed with an occlusive sealed drape applied and suction tubing is placed for negative pressure (suction) to occur once the tubing is connected to the _____ system therapy unit.
vacuum-assisted closure
A vacuum-assisted closure system decreases swelling, _____, and enhances healing in a moist protected environment.
speed tissue generation
____ is a partial or total rupture (separation) of sutured wound, usually with separation of underlying skin layers.
dehiscence
_____ is a dehiscence that involves the protrusion of visceral organs through a wound opening.
evisceration
Manifestations of dehiscence and evisceration (4)
a significant increase in the flow of serosanguineous fluid on the wound dressing
Immediate history of sudden straining (coughing, sneezing, vomiting)
Client report of a change or “pooping” or “giving way’ in the wound area
Visualization of viscera
Part of the prevention of dehiscence and evisceration is to take a thin, folded blanket or small pillow over surgical wounds when client ____ in order to support the wound.
coughs
Risk Factors for dehiscence and evisceration
chronic disease advanced age obesity invasive abdominal cancer vomiting excessive straining, coughing, sneezing dehydration, malnutrition ineffective suturing abdominal surgery infection
Evisceration and dehiscence require ___.
emergency treatment
If eviscceration and dehiscence occurs call for help. Notify the provider immediately due to the need for ______. Stay with the client. Cover the wound and any protruding organs with ____ or dressings soaked with sterile normal saline solution to decrease the chance of bacteria invasion and drying of the tissues. Do not attempt to reinsert the organs. Position the client supine with the hips and ____ bent if possible. Observe for indications of shock. Maintain a calm environment. Keep the client _____ in preparation for returning to surgery.
surgical intervention
sterile towels
knees
NPO
_____ can be caused by clot dislodgement, broken stitch, or blood vessel damage.
hemorrhage
Internal bleeding (hemorrhage) will present with swelling or ____ in the area and sanguineous drainage.
distention
Hematoma is a local area of blood that appears as a _____.
red/blue bruise
Wound hemorrhage is an ____. Pressure dressing should be applied, with notification of the provider and monitoring of vital signs.
emergency
Risk factors for Infection
extremes in age (immature immune system, decrease in immune function)
impaired circulation and oxygenation (COPD, peripheral vascular disease)
wound condition and nature (gunshot wound vs. surgical incision)
impaired or suppressed immune system
malnutrition, such as with alcohol use disorder
chronic disease, such as diabetes mellitus or hypertension
poor wound care, such as breaches in aseptic technique
Manifestations with infection occur ___ to ___ days after injury or surgery.
3 to 11
Manifestations with infection (8)
purulent drainage pain redness, edema ( in and around the wound) fever chills odor increased pulse, respiratory rate increase in WBC count
One nursing intervention to prevent infection includes using aseptic technique when performing _____.
dressing changes.
One nursing intervention to prevent infection includes providing _____ to promote the immune response.
optimal nutrition
One nursing intervention to prevent infection includes providing adequate _____ to promote healing.
rest
One nursing intervention to prevent infection includes administering _____ after collecting specimens for culture and sensitivity testing.
antibiotic therapy
The National Pressure Ulcer Advisory Panel (NPUAP) classifies pressure ulcers in s____ stages/categories.
6
With suspected _____ the depth is unknown. Discoloration is apparent but the skin is intact from damage to underlying tissue.
deep tissue injury
Stage _____ is a non blanchable erythema.
1
Stage ____ is a partial thickness.
2
Stage ____ pressure ulcer is intact skin with an area of persistent, nonblanchable redness, typically over a bony prominence, that can feel warmer or cooler than the adjacent tissue. The tissue is swollen and has congestion, with possible discomfort at the site. With darker skin tones, the ulcer can appear ____ or ____.
1
blue or purple
Stage ___ involves the epidermis and the dermis. The ulcer is visible with reddish-pinkish bed without slough or bruising, superficial, and can appear as an abrasion, blister, or shallow crater. Edema persists. The ulcer can become infected, possibly with ____ and scant drainage.
2
pain
Stage ____ pressure ulcers involve full thickness tissue loss.
4
Stage _____ pressure ulcers include damage to or necrosis of subcutaneous tissue. The ulcer can extend down to, but not through, underlying fascia. The ulcer appears as a deep crater with or without undermining or tunneling of adjacent tissue and without exposed muscle or bone. Drainage and ____ are common.
3
infection
Stage ___ pressure ulcers involve full thickness skin loss.
3
Stage _____ pressure ulcers include destruction, tissue necrosis, or damage to muscle, bone, or supporting structures. There can be sinus tracts, deep pockets of infection, tunneling, undermining, eschar (black scab-like material), or slough (tan, yellow, or green scab-like material).
4
_____ pressure ulcers are full-thickness skin or tissue loss, but the depth is unknown.
unstageable/unclassified
_____ pressure ulcer’s stage cannot be determined because eschar or slough obscures the wound. the actual depth of injury is unknown.
unstageable/unclassified
The primary focus of prevention and treatment of pressure ulcers is to ____ the pressure and provide optimal nutrition and hydration.
relieve
During the assessment/data collection of pressure ulcers monitor all clients regularly for ____ status and for risk factors that contribute to impaired skin integrity.
skin-integrity
During the assessment/data collection of pressure ulcers use a _____ tool (Braden, Norton scales) for periodic systemic monitoring for skin breakdown risk.
risk assessment
Pressure ulcers are a significant source of ____ and mortality among older adults and those who have limited mobility.
morbidity
Risk factors for Pressure Ulcers (15)
Aging skin (older adult clients) Immobility Incontinence, excessive moisture skin friction, shearing vascular disorders obesity inadequate nutrition, hydration anemia fever, dehydration impaired circulation edema sensory deficits impaired cognitive functioning, neurological disorders chronic diseases (diabetes mellitus, chronic kidney disease, heart failure, chronic lung disease) sedation that impairs spontaneous repositioning
Nursing interventions for Pressure Ulcers
avoid skin trauma
provide supportive devices
maintain skin hygiene
encourage proper nutrition
To avoid skin trauma (pressure ulcers), keep skin clean, dry and intact. Provide a firm, ____ foundation with wrinkle-free linens.
wrinkle-free
To avoid skin trauma (pressure ulcers), reposition the client in bed at least every ___ hours and every ____ in a chair. Document position changes.
2 hours - bed
1 hour - chair
To avoid skin trauma (pressure ulcers), keep the head of the bed at or below a ____- angle (or flat), unless contraindicated, to relieve pressure on the sacrum, buttocks, and heels.
30 degree
To avoid skin trauma (pressure ulcers), raise _____ off the bed to prevent pressure.
heels
To avoid skin trauma (pressure ulcers), ____- clients as soon and as often as possible.
ambulate
To avoid skin trauma (pressure ulcers), instruct client who are mobile to shift their weight ever _____ when sitting.
15 min
A nursing intervention to prevent pressure ulcers is to avoid skin trauma (pressure ulcers), keep clients from sliding down in bed, as this increases ______ that pull tissue layers apart and cause damage. Lift, rather than pull, clients up in bed or in a chair, because pulling creates friction that can damage the outer layer of skin (epidermis).
shearing forces
A nursing intervention to prevent pressure ulcers is to provide supportive devices. Use _________ and devices ( overlays; replacement mattresses; specialty beds; kinetic therapy; foam, gel, or air cushions).
pressure-reducing surfaces
A nursing intervention to prevent pressure ulcers is to ______ the skin frequently and document the client’s risk using a tool such as the Braden Scale.
inspect
A nursing intervention to prevent pressure ulcers is to ____ the skin with a mild cleansing agent, and pat it dry immediately following urine or stool incontinence.
clean
A nursing intervention to prevent pressure ulcers is to bathe with _____ water and avoid scrubbing.
tepid
A nursing intervention to prevent pressure ulcers is to apply ______ or alcohol-free barrier films to the skin of clients who have incontinence.
dimethicone-based moisture barrier creams
A nursing intervention to prevent pressure ulcers is to not use _____ or cornstarch to prevent friction or repel moisture due to their abrasive grit and aspiration potential.
powder
A nursing intervention to prevent pressure ulcers is to implement active and ____ exercises for clients who are immobile.
passive
A nursing intervention to prevent pressure ulcers is to not _____ bony prominences.
massage
A nursing intervention to prevent pressure ulcers is to provide adequate ______ and meet protein and calorie needs.
hydration (2,000 - 3,000 mL/day)
Note if serum albumin levels are low (less than ____) because a lack of protein puts the client at greater risk for skin breakdown, slowed healing, and infection.
3.5 g/dL
Provide _______ as indicated, such as vitamin and mineral supplements (especially A, C, zinc, copper) nutritional supplements, and enteral and parenteral nutrition.
nutritional support
When encouraging proper nutrition to prevent pressure ulcers monitory _____.
lymphocyte count
Lift, rather than ____, client up in bed or in a chair, because _____ creates friction that can damage the outer layer of skin (epidermis).
pulls
pulling
Treatment for deep tissue injury and stage 1 pressure ulcers involve relieving the ____ .
pressure
Treatment for deep tissue injury and stage 1 pressure ulcers involve the encouragement of frequent ______ and re-positioning.
turning
Treatment for deep tissue injury and stage 1 pressure ulcers involve the implementation of _______ such as air mattresses and foam mattresses.
pressure-reduction surfaces
Treatment for deep tissue injury and stage 1 pressure ulcers involve keeping the client dry, ______, and hydrated.
well-nourished
Treatment for stage 2 pressure ulcers involve maintaining a ______ healing environment (saline or occlusive dressing). Apply a _____ dressing.
moist
hydrocolloid
Treatment for stage 2 pressure ulcers involve promoting natural healing while preventing the formation of ______.
scar tissue
Treatment for stage 2 pressure ulcers involve providing ______.
nutritional supplements
Treatment for stage 2, 3, and 4 pressure ulcers involve administering _____ for pain management.
analgesics
Treatment for stage 3 pressure ulcers involve cleaning and/or ____ the following; prescribed dressing, surgical intervention and proteolytic enzymes.
debriding
Treatment for stage 4 pressure ulcers involve performing nonadherent dressing changes every _____.
12 hours
Treatment for stage 4 pressure ulcers can include ______ or specialized therapy such as hyperbaric oxygen.
skin grafts
Treatment for stage 3 and 4 pressure ulcers involve providing nutritional ______.
supplements
Treatment for stage 3 and 4 pressure ulcers involve administering ________ (topical and or/systemic)
antimicrobials
Deterioration to higher-stage ulceration or infection can occur if you do not check the ulcer frequently and report an increase in the size or depth of lesion, changes in ______ (color, tissue), and changes in exudates (color, quantity, odor).
granulation
To ensure there is no further deterioration to higher-stage ulceration or infection follow the facility’s ______ for ulcer treatment.
protocol
To ensure there is no further deterioration to higher-stage ulceration or infection you might need to confer with _______ specialist.
wound care
Monitoring for indications of _____ (changes in level of consciousness, persistent recurrent fever, tachycardia, tachypnea, hypotension, oliguria, or an increase in WBC count) is important to avoid systemic infection with pressure ulcers.
sepis
Prevent infection by using _____ when performing ulcer treatment and dressing changes to avoid systemic infection with pressure ulcers.
asepsis
Provide optimal _______ to promote the immune response systemic infection with pressure ulcers.
nutrition
Ensure adequate rest to promote _______ to avoid systemic infection with pressure ulcers.
healing
Administer antibiotic therapy after collecting ______ for culture and sensitivity testing.
specimens
In suspected deep tissue injury and stage 1 use ____ devices such as an air fluidized bed.
pressure relieving devices
