Skin Integrity and Wound Care Flashcards
1
Q
wound
A
break or disruption in the normal integrity of the skin and tissues
2
Q
wound types
A
closed/open
clean/dirty
3
Q
what is an example of clean wound
A
surgical
4
Q
what is an example of dirty wound
A
pressure injury
5
Q
venous ulcer is caused by
A
venous insufficiency
6
Q
arterial ulcer is caused by
A
arterial insufficiency
7
Q
incision
A
edges well aproximated
no gaping
clean cut
8
Q
contusion
A
bruise
9
Q
abrasion
A
rug burn
10
Q
puncture
A
IV
11
Q
laceration
A
injury to skin or soft tissue under skin and results in tearing of tissue
12
Q
partical thickness
A
epidermis and dermis
13
Q
full thickness
A
down to subq and muscle
14
Q
acute wound
A
wound that heals in normal expected time
15
Q
chronic wound
A
wound that takes extended time to heal
16
Q
intentional wound
A
surgery
17
Q
unintentional wound
A
trauma
18
Q
PI
A
pressure injury
19
Q
what is the first line of defense
A
skin
20
Q
what does the skin need
A
circulation
nutriton
hydration
21
Q
ability to heal depends on the
A
extent of the wound and persons general health
22
Q
why might obese people have difficulty healing
A
more subq
subq doesn’t have blood vessel
no circulation
23
Q
primary intention
A
edges well approximated
surgical incision
not missing any tissue
stitched up
24
Q
secondary intention
A
edges are not approximated
tissue loss
longer reapir time
scarring
increased infection
25
secondary intention is for clean or dirty wounds
dirty
26
what intention leaves the wound open
secondary
27
tertiary intention
wound are left open for 3-5 days then closed with sutures
28
stages of wound healing
hemostasis
inflammatory
proliferation
maturation/remodling
29
hemostatis
occurs within hours
clot formation
30
inflammatory
wound reddens, swelling, pain
macrophages come in
up to 4 days
31
proliferation
4-21 days
new capillaries, epithelial cells
collagen deposit
proliferation
32
maturation/remodiling
wound remodles
collagen remodels
33
is the scar just as strong as skin prior to breakdown
no
34
what are healed pressure injuries at risk for
break down again
35
serous
plasma
clear
yellowish
clear
36
sanguineous
blood
37
serosanguineous
pink, blood and plasma
38
purulent
pus
green, yellow, brown
pathogens and infection
39
what does bright red blood indicate
fresh bleeding
40
what does dark red blood indicate
older bleeding
41
biofilms
bacteria grow in clot
42
biofilms lead to
chronic wound inflammation and infection
43
biofilms lead to
CAUTI
44
hemorrhage
bleeding
45
what stage of healing did not occur with hemorrhage
hemostasis
46
dehiscence
rips open to the muscle
47
eviseration
ripping through muscle to organs
48
who're at risk for dehiscence and eviseration
obese, coughing, vomiting
49
where are dehiscence and eviseration most common
midline abdominal wounds
50
what do we teach pts to prevent dehiscence and eviseration
splint
hold pillow over stitches and then cough
51
fistula
tube or hole connecting 2 things that are not supposed to be connected
52
psychologic effects
body image
- burns
- masectomy
- amputation
53
what actions do you do if you discover eviseration
cover with saline soaked sterile gauze
call physian
54
what does it mean when elderly have decreased blood flow (vasculature)
no circulation
55
what does it mean when elderly have decreased collagen formation
skin cannot repair or go through remodeling phase
56
what does it mean when elderly have decrease immune system
increase infection so need to keep skin intact
57
what does it mean when elderly have decrease nutritional status
decrease skin
skin needs nutrients, hydration, and circulation
58
what does it mean when elderly have decreased subq and dermal
decrease buffer, increased risk of breakdown
59
what does it mean when elderly have maturation of epidermal cells is prolonged
longer time to heal
60
what does it mean when elderly have diabetes and CV disease
decrease blood flow
61
who might have circualtion and oxygenation issues
smokers, diabetes, peripheral vascular disease
62
what vitamins are needed for wound healing
vit a, c, iron, ZINC, copper
63
why might smokers be a risk for wound healing
lack of circulaiton
CO2: vasoconstrictor
64
why might pressure affect wound healing
capillary breakdown
65
what is desiccation
dry skin
66
who is at risk for dessication
elderly
decrease sebatious glands
67
maceration
pruning of skin after swimming
68
why might steroids affect wound healing
decrease immune response
69
why might aspirin affect wound healing
blood thinner
affects hemostasis
70
antieoplastic (chemo)
kills all cells
71
edema is not good for wound healing
no good blood flow
72
is pink granulation good
yes
73
RYB color code
red protect
yellow clean
black debride
74
albumin measures
protein 6 weeks ago
75
pre albumin measures
protein now
76
why might mobility affect wound healing
circulation
risk factor for pressure breakdown
77
moisture and incontience can
contaminate wound
78
why do we look at WBC
to see if its infected
79
what value of WBC says its infected
>10,000
80
why do we get a wound culture
see what organisms are on the surface
81
how do we get a wound culture
lavine method
- clean before
- make z track over wound
82
why do we want to know HGB A1C
diabetic
blood sugar control
increase sugar affects negatively healing
83
a Penrose drain is
passive
84
is a Penrose drain sutured in
no
85
JP (Jackson pratt) drain is active or passive
active
86
is JP drain sutured in
yes
87
is hemovac active or passie
active
88
is hemovac sutured in
yes
89
what is the difference between JP and Hemovac
hemovac holds more fluid
90
when do we use heat therapy
few days after injury
91
when do we use cold therapy
initially
92
what is the affects of heat on the blood flow
increased flow
93
since heat increases the blood flow what does that mean for O2, nutrients and leukocytes
increased amounts to area
94
what is the affect of heat on smooth muscle
increased relaxation
95
what is the affect of heat on cellular metabolism
increased
96
what is the affect of heat on pain
decreased
97
what is the affect of cold on blood flow
decreased
vascoconstricts
98
since we know cold decreases the amount of blood flow what does that mean for edema, inflammation, and bleeding
decreased edema, inflammation, and bleeding
99
what is the affect of cold on muscle spasm
decreased
100
what is the affect of cold on cellular metabolism
decreased
101
what does this tell you if the cold has decreased cellular metabolism
slows bacterial growth
102
cold has a local ________ effect
anesthetic
103
why do we use cold therapy initally
vasoconstriction so decreased blood flow to promote hemostatsis and decreased cellular metabolism so decreased amounts of pathogens
104
why do we use heat therapy a few days after
to increased blood flow which supplies O2, nutrients and leukocytes to the area to promote with inflammation and proliferation phase
105
what is normal saline
0.9 NS
106
what is 0.9NS
normal saline
107
what is always safe to use
normal saline
108
if we know a procedure is going to occur that is going to be painful for the patient what should we do
premeditate
109
what are the 3 ways to debride
surgical
chemical
mechanical
110
surgical debridement
cut it out in the OR
111
chemical debridement
dakins bleach solution on dressing
112
mechanical debridement
4x4 wet to dry and rip out tissue
113
if we have orders for chemical debridement but the tissue is pink granulation what do we do
do not procede with the chemical debridement
114
what type of environment do we want to maintain
moist wound environment
115
how do we maintain a moist wound environment
wet to moist dressing
116
if we have an order for a wet to moist dressing and the dressing is now dry what do we do
apply normal saline onto the dressing to make it wet and then remove
117
braden score less than what gets a mepiplex on the sacrum
18
118
what is tegaderm used for
IV site, redness
(clear sticker)
119
what are mepilex used for
prevent pressure wounds
waterproof
worn up to 7 days
absorbs drainage
never use for infected wounds
protect wound and surrounding skin
120
why do we not use mepilex for infected wounds
it seals it in and the infection will be worse
121
mepilx prevents friction and
shear
122
when might someone get a mepilex
>65, mechanical ventilation, surgery longer than 4 hours
123
what do negative pressure wound therapy promotes
draws out fluid
decreases bacterial growth
increases blood flow
brings together wound edges
124
what does negative pressure wound therapy stimulates
growth of epithelial growth
125
silvadine cream is good for what types of trauma
burns
126
hydrogel is what
water goop, keep moisture in, put on pink granulation
127
silver in silvadine cream is
antibacterial properties
128
what types of dressing are best for healing
wet to moist
129
how do we clean a wound
from wound away
