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Fundamentals of Nursing > Skin Integrity and Wound Care > Flashcards

Skin Integrity and Wound Care Flashcards

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1
Q

wound

A

break or disruption in the normal integrity of the skin and tissues

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2
Q

wound types

A

closed/open
clean/dirty

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3
Q

what is an example of clean wound

A

surgical

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4
Q

what is an example of dirty wound

A

pressure injury

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5
Q

venous ulcer is caused by

A

venous insufficiency

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6
Q

arterial ulcer is caused by

A

arterial insufficiency

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7
Q

incision

A

edges well aproximated
no gaping
clean cut

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8
Q

contusion

A

bruise

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9
Q

abrasion

A

rug burn

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10
Q

puncture

A

IV

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11
Q

laceration

A

injury to skin or soft tissue under skin and results in tearing of tissue

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12
Q

partical thickness

A

epidermis and dermis

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13
Q

full thickness

A

down to subq and muscle

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14
Q

acute wound

A

wound that heals in normal expected time

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15
Q

chronic wound

A

wound that takes extended time to heal

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16
Q

intentional wound

A

surgery

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17
Q

unintentional wound

A

trauma

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18
Q

PI

A

pressure injury

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19
Q

what is the first line of defense

A

skin

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20
Q

what does the skin need

A

circulation
nutriton
hydration

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21
Q

ability to heal depends on the

A

extent of the wound and persons general health

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22
Q

why might obese people have difficulty healing

A

more subq
subq doesn’t have blood vessel
no circulation

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23
Q

primary intention

A

edges well approximated
surgical incision
not missing any tissue
stitched up

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24
Q

secondary intention

A

edges are not approximated
tissue loss
longer reapir time
scarring
increased infection

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25
Q

secondary intention is for clean or dirty wounds

A

dirty

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26
Q

what intention leaves the wound open

A

secondary

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27
Q

tertiary intention

A

wound are left open for 3-5 days then closed with sutures

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28
Q

stages of wound healing

A

hemostasis
inflammatory
proliferation
maturation/remodling

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29
Q

hemostatis

A

occurs within hours
clot formation

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30
Q

inflammatory

A

wound reddens, swelling, pain
macrophages come in
up to 4 days

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31
Q

proliferation

A

4-21 days
new capillaries, epithelial cells
collagen deposit
proliferation

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32
Q

maturation/remodiling

A

wound remodles
collagen remodels

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33
Q

is the scar just as strong as skin prior to breakdown

A

no

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34
Q

what are healed pressure injuries at risk for

A

break down again

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35
Q

serous

A

plasma
clear
yellowish
clear

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36
Q

sanguineous

A

blood

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37
Q

serosanguineous

A

pink, blood and plasma

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38
Q

purulent

A

pus
green, yellow, brown
pathogens and infection

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39
Q

what does bright red blood indicate

A

fresh bleeding

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40
Q

what does dark red blood indicate

A

older bleeding

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41
Q

biofilms

A

bacteria grow in clot

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42
Q

biofilms lead to

A

chronic wound inflammation and infection

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43
Q

biofilms lead to

A

CAUTI

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44
Q

hemorrhage

A

bleeding

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45
Q

what stage of healing did not occur with hemorrhage

A

hemostasis

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46
Q

dehiscence

A

rips open to the muscle

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47
Q

eviseration

A

ripping through muscle to organs

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48
Q

who’re at risk for dehiscence and eviseration

A

obese, coughing, vomiting

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49
Q

where are dehiscence and eviseration most common

A

midline abdominal wounds

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50
Q

what do we teach pts to prevent dehiscence and eviseration

A

splint
hold pillow over stitches and then cough

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51
Q

fistula

A

tube or hole connecting 2 things that are not supposed to be connected

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52
Q

psychologic effects

A

body image
- burns
- masectomy
- amputation

53
Q

what actions do you do if you discover eviseration

A

cover with saline soaked sterile gauze
call physian

54
Q

what does it mean when elderly have decreased blood flow (vasculature)

A

no circulation

55
Q

what does it mean when elderly have decreased collagen formation

A

skin cannot repair or go through remodeling phase

56
Q

what does it mean when elderly have decrease immune system

A

increase infection so need to keep skin intact

57
Q

what does it mean when elderly have decrease nutritional status

A

decrease skin
skin needs nutrients, hydration, and circulation

58
Q

what does it mean when elderly have decreased subq and dermal

A

decrease buffer, increased risk of breakdown

59
Q

what does it mean when elderly have maturation of epidermal cells is prolonged

A

longer time to heal

60
Q

what does it mean when elderly have diabetes and CV disease

A

decrease blood flow

61
Q

who might have circualtion and oxygenation issues

A

smokers, diabetes, peripheral vascular disease

62
Q

what vitamins are needed for wound healing

A

vit a, c, iron, ZINC, copper

63
Q

why might smokers be a risk for wound healing

A

lack of circulaiton
CO2: vasoconstrictor

64
Q

why might pressure affect wound healing

A

capillary breakdown

65
Q

what is desiccation

A

dry skin

66
Q

who is at risk for dessication

A

elderly
decrease sebatious glands

67
Q

maceration

A

pruning of skin after swimming

68
Q

why might steroids affect wound healing

A

decrease immune response

69
Q

why might aspirin affect wound healing

A

blood thinner
affects hemostasis

70
Q

antieoplastic (chemo)

A

kills all cells

71
Q

edema is not good for wound healing

A

no good blood flow

72
Q

is pink granulation good

A

yes

73
Q

RYB color code

A

red protect
yellow clean
black debride

74
Q

albumin measures

A

protein 6 weeks ago

75
Q

pre albumin measures

A

protein now

76
Q

why might mobility affect wound healing

A

circulation
risk factor for pressure breakdown

77
Q

moisture and incontience can

A

contaminate wound

78
Q

why do we look at WBC

A

to see if its infected

79
Q

what value of WBC says its infected

A

> 10,000

80
Q

why do we get a wound culture

A

see what organisms are on the surface

81
Q

how do we get a wound culture

A

lavine method
- clean before
- make z track over wound

82
Q

why do we want to know HGB A1C

A

diabetic
blood sugar control
increase sugar affects negatively healing

83
Q

a Penrose drain is

A

passive

84
Q

is a Penrose drain sutured in

A

no

85
Q

JP (Jackson pratt) drain is active or passive

A

active

86
Q

is JP drain sutured in

A

yes

87
Q

is hemovac active or passie

A

active

88
Q

is hemovac sutured in

A

yes

89
Q

what is the difference between JP and Hemovac

A

hemovac holds more fluid

90
Q

when do we use heat therapy

A

few days after injury

91
Q

when do we use cold therapy

A

initially

92
Q

what is the affects of heat on the blood flow

A

increased flow

93
Q

since heat increases the blood flow what does that mean for O2, nutrients and leukocytes

A

increased amounts to area

94
Q

what is the affect of heat on smooth muscle

A

increased relaxation

95
Q

what is the affect of heat on cellular metabolism

A

increased

96
Q

what is the affect of heat on pain

A

decreased

97
Q

what is the affect of cold on blood flow

A

decreased
vascoconstricts

98
Q

since we know cold decreases the amount of blood flow what does that mean for edema, inflammation, and bleeding

A

decreased edema, inflammation, and bleeding

99
Q

what is the affect of cold on muscle spasm

A

decreased

100
Q

what is the affect of cold on cellular metabolism

A

decreased

101
Q

what does this tell you if the cold has decreased cellular metabolism

A

slows bacterial growth

102
Q

cold has a local ________ effect

A

anesthetic

103
Q

why do we use cold therapy initally

A

vasoconstriction so decreased blood flow to promote hemostatsis and decreased cellular metabolism so decreased amounts of pathogens

104
Q

why do we use heat therapy a few days after

A

to increased blood flow which supplies O2, nutrients and leukocytes to the area to promote with inflammation and proliferation phase

105
Q

what is normal saline

A

0.9 NS

106
Q

what is 0.9NS

A

normal saline

107
Q

what is always safe to use

A

normal saline

108
Q

if we know a procedure is going to occur that is going to be painful for the patient what should we do

A

premeditate

109
Q

what are the 3 ways to debride

A

surgical
chemical
mechanical

110
Q

surgical debridement

A

cut it out in the OR

111
Q

chemical debridement

A

dakins bleach solution on dressing

112
Q

mechanical debridement

A

4x4 wet to dry and rip out tissue

113
Q

if we have orders for chemical debridement but the tissue is pink granulation what do we do

A

do not procede with the chemical debridement

114
Q

what type of environment do we want to maintain

A

moist wound environment

115
Q

how do we maintain a moist wound environment

A

wet to moist dressing

116
Q

if we have an order for a wet to moist dressing and the dressing is now dry what do we do

A

apply normal saline onto the dressing to make it wet and then remove

117
Q

braden score less than what gets a mepiplex on the sacrum

A

18

118
Q

what is tegaderm used for

A

IV site, redness
(clear sticker)

119
Q

what are mepilex used for

A

prevent pressure wounds
waterproof
worn up to 7 days
absorbs drainage
never use for infected wounds
protect wound and surrounding skin

120
Q

why do we not use mepilex for infected wounds

A

it seals it in and the infection will be worse

121
Q

mepilx prevents friction and

A

shear

122
Q

when might someone get a mepilex

A

> 65, mechanical ventilation, surgery longer than 4 hours

123
Q

what do negative pressure wound therapy promotes

A

draws out fluid
decreases bacterial growth
increases blood flow
brings together wound edges

124
Q

what does negative pressure wound therapy stimulates

A

growth of epithelial growth

125
Q

silvadine cream is good for what types of trauma

A

burns

126
Q

hydrogel is what

A

water goop, keep moisture in, put on pink granulation

127
Q

silver in silvadine cream is

A

antibacterial properties

128
Q

what types of dressing are best for healing

A

wet to moist

129
Q

how do we clean a wound

A

from wound away

Fundamentals of Nursing (23 decks)

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