Skin Integrity & Wound Care Flashcards
(T/F) If fluid, protein, and vitamin C intake is deficient, skin loses elasticity and becomes prone to breakdown.
True
Incision
Caused by cutting or sharp instrument; wounds edges in close approximation and aligned.
Contusion
Caused by blunt instrument, overlying skin remains intact, with injury to underlying soft tissue; possible resultant bruising and/or hematoma.
Abrasion
Caused by friction; rubbing or scraping epidermal layers of the skin; top layer of skin abraded.
Laceration
Caused by tearing of skin and tissue with blunt or irregular instrument; tissue not aligned, often with loose flaps of skin and tissue.
Puncture
Caused by blunt or sharp instrument puncturing the skin; intentional (such as venipuncture) or accidental.
Penetrating
Caused by a foreign object entering the skin or mucous membrane and lodging in underlying tissue; fragments possibly scattering throughout the tissues.
Avulsion
Caused by tearing a structure from normal anatomic position; possible damage to blood vessels, nerves and other structures.
Irradation
Caused by ultraviolet light or radiation exposure
Pressure Ulcers
Caused by compromised circulation secondary to pressure or pressure combined with friction
Venous Ulcers
Caused by injury and poor venous return, resulting from underlying conditions, such as incompetent valves or obstruction
Arterial Ulcers
Caused by injury and underlying ischemia, resulting from underlying conditions, such as arteriosclerosis or thrombosis
Why should you not tape all four corners of a dressing?
This blocks air flow
Describe Rebound Phenomenon
Using heat therapy for too long can actually cause constriction of blood vessels after a while
Describe a chronic wound?
Wounds that remain in the inflammatory phase of healing; chronic wounds include any wound that does not heal along the expected continuum.
(T/F) If a wound that is healing by primary intention becomes infected, it will heal by secondary intention.
True
What are the four phases of wound healing?
1) Hemostasis Phase
2) Inflammatory Phase
3) Proliferation Phase
4) Maturation
Describe the difference between wounds that heal by primary, secondary, and tertiary intetion?
1) Primary Intention - Intentional wounds with minimal tissue loss. (i.e. surgical wounds). Has clean approximated edges.
2) Secondary Intention - Wounds with edges that are not well approximated. (i.e. large open wounds, burns, traumas). These wounds may be packed with moist gauze.
3) Tertiary Intention - Wounds intentionally left open for several days to allow edema or infection to resolve or exudate to drain, and is then closed.
What are the characteristics of the Hemostasis Phase of wound healing?
1) Occurs at the time of injury
2) Blood vessels constrict and clotting begins
3) Then, Blood vessels dilate and capillary permeability increases
4) Exudate formation (causes swelling and pain)
When does the Inflammatory Phase of wound healing occur? What are the stages? What are the systemic symptoms?
1) From day 0 to day 4-6
2) Stages - Inflammation > phagocytosis > epithelialization
3) Systemic Symptoms - Increased temperature, WBC and ESR; and generalized malaise.
When does the Proliferation (Fibroblastic) Phase of wound healing occur? What happens during this phase?
1) From day 0 to day 21
2) -New tissue is built by action of fibroblasts
- Wound is lighter in color
- Systemic symptoms disappear
- Need for adequate nutrition, oxygen, prevention strain of wound tissue
How are the following vitamins and mineral essential to efficient wound healing?
1) Vitamin A
2) Vitamin B
3) Vitamin C
4) Vitamin K
4) Zinc, Copper & Iron
5) Manganese
1) Vitamin A - Collagen synthesis and epithelialization
2) Vitamin B Complex - Cofactor of enzymes needed for wound healing.
3) Vitamin C - Collagen synthesis, capillary formation, and resistance to infection.
4) Vitamin K - Prothrombin synthesis.
4) Zinc, Copper & Iron - Collagen synthesis.
5) Manganese - Enzyme activator
Is granulation tissue visible in wounds that heal by primary intention?
No - Epidermal cells seal these wounds within 24 to 48 hours, so the granulation tissue is not visible.
When does the Maturation (Remodeling) Phase of wound healing occur? What happens during this phase?
1) From day 1 to 1-2 years
2) -Collagen deposition and remodeling
- Scar tissue becomes smaller
- Keloid scars form
(T/F) Fatty tissue is more difficult to suture, is more prone to infection, and takes longer to heal.
True
When does wound infection usually become apparent after an injury or surgery?
usually within 2 to 7 days
Wound infections can lead to other complications, including osteomyelitis and sepsis. What is osteomyelitis and sepsis?
1) Osteomyelitis - Bone Infection
2) Sepsis - Presence of pathogenic organisms in the blood or tissues.
What are the 5 different complications that can develop from a wound?
1) Infection
2) Hemorrhage
3) Dehiscence
4) Evisceration
5) Fistula
Define Dehiscence and Evisceration
1) Dehiscence - The partial or total separation of wound layers as a result of excessive stress on wounds that are not healed.
2) Evisceration - When the wound completely separates and protrusion of the viscera through the incisional area happens.
Give some examples of types of patients who are at greater risk for dehiscence and eviceration.
1) Obese PTs
2) Malnourished PTs
3) Smokers
4) Anticoagulant users
5) PTs with infected wounds
6) Coughing, vomiting or straining PTs
Is Erythemia a normal finding in a new wound?
YES - Normal infection signs (redness, warmth, etc.,) is noral in a new wound but should subside within 6 days.
What are the 7 local factors that affect wound healing?
1) Type, size and location of wound
2) Pressure
3) Hydration
4) Trauma
5) Edema
6) Infection
7) Necrosis
What are the 5 systemic factors that affect wound healing?
1) Age
2) Oxygenation and Circulation
3) Nutritional status
4) Wound condition
5) Health status
Increased pain and increased serosanguinous fluid from a wound between postoperative days 4 and 5 may be a sign of which wound complication?
Dehiscence
If dehiscence occurs, what should the nurse do? What should the nurse do in the case of evisceration?
Dehiscence
1) Cover the wound w/sterile 0.9% NaCl solution
2) Notify physician
Evisceration
1) Place the patient in the low fowler’s position
2) Cover the exposed abdominal contents and do not leave PT alone
3) Notify the physician
In addition to immobility, nutrition, dehydration, skin moisture, age and mental status, what are some additional conditions that increase a PT’s risk for pressure ulcer?
1) Incontinence 2) Diabetes Millitus
3) Diminished pain awareness 4) Fractures
5) Immunosuppression 6) Multisystem trauma
7) Poor circulation 8) Obesity and thinness
Describe a Stage1 pressure ulcer.
1) Non-blanchable Intact skin, and persistent redness.
2) The area may be painful, firm, soft, warmer or cooler compared to adjacent tissue.
Describe a stage 2 pressure ulcer.
1) Partial thickness skin loss of the epidermis, dermis or both.
2) Superficial and presents as an abrasion, shallow crater, or as an intact or open/rupture serum-filled blister.
Describe a Stage 4 pressure ulcer.
1) Full thickness tissue loss with exposed bone tissue, or muscle.
2) Slough or eschar may be present.
3) Often includes undermining or tunneling.
4) May extend into muscle or underlying structures making osteomyelitis possible.
Describe a stage 3 pressure ulcer.
1) Full thickness tissue loss
2) SQ fat may be visible, but bone tendon, or muscle are not exposed.
3) May include undermining or tunneling.
Describe an Unstageable pressure ulcer.
1) Full thickness tissue loss in which the base of the ulcer is covered my slough and/or eschar in the wound bed. Eschar and slough has to be removed to expose the base of the ulcer before the true depth ad stage of the ulcer can be determined.
How would you treat an open wound if the following colors were present in it?
1) Red
2) Yellow
3) Black
4) Mixed
1) Red - PROTECT the wound (red = granulation tissue and stage is in the proliferative stage).
2) Yellow - Clean the wound (yellow = purulent draining).
3) Black - Debride wound (black = eschar).
4) Mixed - When all colors are present, the wound is treated first for the most serious color ( black > yellow > red).
(T/F) Eschar deridement requires care for by advanced practice nurse?
True
What 6 things are assessed to comprise a braden scale for predicting a pressure sore risk score?
1) Sensory perception - Ability to respond meaningfully to pressure -related discomfort.
2) Moisture - Degree to which skin is exposed to moisture.
3) Activity - Degree of physical activity.
4) Mobility - Ability to change and control body position.
5) Nutrition - Food intake pattern.
6) Friction and Shear
Describe the scoring involved in the Braden Scale for Predicting Pressure Sore Risk.
1) 19 to 23 - Not at risk
2) 15 to 18 - Low risk
3) 13 to 14 - Moderate risk
4) 10 to 12 - high risk
5) 9 and less - very high risk
(T/F) The presence of odor in a wound could be indicative of certain types of bacteria and should be done only AFTER cleaning the wound?
True
Describe Serous dainage
Clear and watery
Describe Sanguineous Drainage
Consists of large numbers of RBCs and looks like blood.
Describe Serosanguineous Drainage
A mixture of serum and RBCs. It is light pink to blood tinged.
Describe Purulent drainage
Made up of WBCs, liquified dead tissue debris, and both dead and alive bacteria. It is thick and often has a musty odor. It varies in color from dark yellow or green depending on causative bacteria.
Name the 5 common types of drains, describe their purpose and give an example of when you would use each one?
1) Penrose - Provides sinus tract (drainage of abscess).
2) T-tube - For bile drainage (gall bladder surgery).
3) Jackson-Pratt - Decrease dead space by collecting drainage (after breast removal).
4) Hemovac - Decrease dead space by collecting drainage (Orthopedic surgery).
5) Gauze, Iodoform Gauze, & NuGauze - Allowing healing from base of wound (Infected wounds, removal of hemorrhoids).
Why do wounds left open to the air heal more slowly?
Because wound drying produces a dried eschar or scab.
What is the difference between an open drainage system and a closed drainage system? Give an example of each.
1) Open drainage systems - Drains into dressings (i.e., penrose).
2) Closed drainage system - Drains into a suction device (i.e., Jackson-Pratt and Hemvoac).
What are the systemic effects of extensive, prolonged heat therapy?
1) Increased cardia output
2) Sweating
3) Increased pulse rate
4) Decreased blood pressure
What are the systemic effects of extensive, prolonged cold therapy?
1) Increased blood pressure
2) Shivering
3) Goose bumps
Describe the rebound phenomenon as it applies to heat ad cold therapy?
1) Heat Therapy - Heat produces max vasodilation in 20 to 30 mins, after that, tissue congestion and vasoconstriction occurs.
2) Cold Therapy - Maximum vasoconstriction occurs when the skin reaches 15 degrees C (60 degrees Farenheit), then vasodilation begins.
