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Fundamentals 2 Exam 4 Flashcards > Skin Integrity & Wound Care Flashcards > Flashcards

Skin Integrity & Wound Care Flashcards

1
Q

This is the largest organ of the body and protects the body from injury =

A

Skin

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2
Q

How do you assess a wound using your senses?

A

Sight:
Assess Location + Size Shape + Color + Exudate + Bleeding Necrosis

Feel:
Textural Changes

Smell:
Can tell about the presence of infectious organisms

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3
Q

What are all of the important things to assess about a wound?

A

Location

Measure length, width, and depth in centimeters

Any odor?

Describe drainage

Stage the ulcer

Describe surrounding tissue

Undermining or sinus tracts?

Describe wound bed tissue

Any clinical signs of infection?

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4
Q

What is Serous Exudate like?

A

Clear, Watery Serum

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5
Q

What is Purulent Exudate like?

A

Thick Yellow, Green, Tan, or Brown

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6
Q

What is Sanguineous Exudate like?

A

Bright Red

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7
Q

What is Serosanguineous Exudate like?

A

Pale, Red, Watery

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8
Q

What is Purosanguineous Exudate like?

A

Pus & Blood

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9
Q

What do you do for a Red wound?

A

Protect & Cover

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10
Q

What do you do for a Yellow wound?

A

Cleanse

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11
Q

What do you do for a Black wound?

A

Debride

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12
Q

What does the color of an open wound determine?

A

It determines the treatment

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13
Q

What do you do if there is more than one color present on a wound?

A

Treat the most serious first. Black, then Yellow, then Red.

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14
Q

Does the depth or size determine what kind’ve treatment you’d give for a wound?

A

No, just the color

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15
Q

Most common site for pressure ulcers =

A

Sacral Area

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16
Q

What is a Pressure Ulcer?

A

Localized injury to the skin and/or underlying tissue, caused by force or a combination of force and movement over bony prominences

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17
Q

Most Pressure Ulcers are-

A

Preventable + Heal by secondary intention

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18
Q

How many recognized stages of Pressure Ulcers are there?

A

4

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19
Q

How do Stage 3 and Stage 4 Pressure Ulcers heal?

A

By filling in with scar tissue (Not new dermis and subcutaneous tissue)

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20
Q

What is Granulation?

A

Scar Tissue

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21
Q

A stage 4 Pressure Ulcer is healing nicely. Can it be downgraded to a Grade 3 after a month passes?

A

No, Pressure Ulcers can not be downgraded

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22
Q

As a Stage 4 Pressure Ulcer heals, what should it be referred to as?

A

A healing / healed Stage 4 Pressure Ulcer (Because they can’t be downgraded)

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23
Q

What is a Stage 1 Pressure Ulcer like?

A

No tissue loss, but non-blanchable red skin over a bony prominence

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24
Q

Pressure ulcer with a loss of Epidermis tissue and possibly Dermis tissue =

A

Stage 2 Pressure Ulcer

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25
Pressure ulcer with a loss of Epidermis, Dermis, and Hypodermis Tissue =
Stage 3 Pressure Ulcer
26
Full-thickness skin loss involving muscle, bone, or other supporting structures such as tendons or joint capsules. Undermining and sinus tracts may be present also =
Stage 4 Pressure Ulcer
27
Subcutaneous Tissue is the same thing as-
Hypodermis Tissue
28
A stage 2 pressure ulcer may be present as-
An Abrasion, a Blister, or a Very Shallow Crater
29
You have a pt with a pressure ulcer that you can’t visually see the wound bed and the depth is unknown. What would you call this pressure ulcer?
An Unstageable Pressure Ulcer
30
What can make a Pressure Ulcer Unstageable?
Full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar on the wound bed
31
What is Slough?
Yellow, Tan, Gray, Green, or Brown (Dead Tissue)
32
What is Eschar?
Tan, Brown, or Black (Dead Tissue)
33
Necrotic Tissue means the same thing as-
Dead Tissue
34
What are the 3 phases of wound healing?
Inflammatory Phase Proliferative Phase Maturation (Remodeling) Phase
35
This phase starts immediately after injury =
Inflammatory Phase
36
How long does the Inflammatory Phase last?
3-6 Days
37
What are the 2 processes that occur during the Inflammatory Phase?
Hemostasis Phagocytosis
38
Hemostasis =
The mechanism that leads to cessation of bleeding from a blood vessel
39
Phagocytosis =
Cells ingesting and eliminating other cells
40
Granulation =
Scarring
41
What’s the second phase of wound healing called?
Proliferative Phase
42
What does the Proliferative Phase of wound healing start?
Begins 3-4 days after injury, lasts until 21 days post-injury
43
What are the processes that occur during Proliferative Phase?
Granulation Epithelialization
44
Epithelialization =
The formulation of epithelial tissue covering an injury
45
What’s the last phase of wound healing?
The Maturation Phase
46
When does the Maturation Phase start? When does it end?
Starts from about day 21, lasts 1-2 years post surgery
47
What process occurs during the Maturation Phase?
The continued synthesis of Collagen
48
What intrinsic factors affect wound healing?
Age (Kids heal faster, elderly heal slower) Chronic Illness Altered Sensation
49
What extrinsic factors affect wound healing?
Meds, Chemotherapy, Stress, Illness, Diet
50
What does the type of dressing for a wound depend on?
Location, size, and type of wound Amount of exudate Wound require debridement? Wound infected? Frequency of dressing change Ease or difficulty of dressing application Cost
51
Why do we Irrigate a wound?
To remove debris, excess slough, necrotic tissue, bacteria, and other microbes
52
To irrigate a wound, you should use a piston syringe with pressures of-
4-15 Pounds Per Square Inch (psi)
53
How many psi can a 30-60 mL syringe with 19 G needles provide?
8 psi
54
Can you delegate a wound irrigation to a UAP?
Nah
55
What are the 4 types of Debridement?
Sharp Debridement / Surgical Debridement Mechanical Debridement Chemical Debridement Autolytic Debridement
56
Using a Scalpel or Scissors for Debridement is an example of-
Sharp Debridement / Surgical Debridement
57
Using a Scrubbing or Wet-To-Dry Dressing for Debridement is an example of-
Mechanical Debridement
58
Using an Enzyme Agent for Debridement is an example of-
Chemical Debridement
59
Using the body’s own enzymes to break down Necrosis for Debridement is an example of-
Autolytic Debridement
60
What is done for Negative Wound Therapy?
Sterile foam sponges placed in clean wound Covered with transparent occlusive drape Hole cut in drape to insert vacuum tubing Negative pressure applied
61
What can be done to prevent a Pressure Ulcer?
Nutrition Good skin hygiene Bathe Lotion Avoid skin trauma Proper lifting & turning Wrinkle free sheets Provide Supportive devices Turn & reposition frequently Pressure reduction devices
62
Used to identify clients at risk for pressure ulcer development =
Braden Scale
63
How many subscales does the Braden Scale consist of?
6
64
What are the subscales that the Braden Scale consists of?
Sensory Perception Moisture Activity Mobility Nutrition Friction & Shear
65
What score is a severe risk on the Braden Scale?
9
66
What score is a high risk on the Braden Scale?
10-12
67
What score is a moderate risk on the Braden Scale?
13-14
68
What score is a mild risk on the Braden Scale?
15-18
69
What lab data can be used to assess wound progression?
WBC Count + Hemoglobin + Platelet Count + Serum Protein + Albumin + Wound Cultures + Sensitivity Reports
70
Decreased WBC’s =
Delayed wound healing + more risk of infection
71
Low hemoglobin =
Less oxygen being delivered to tissues, delayed wound healing
72
Low Platelet count =
Not enough coagulation, excessive bleeding, prolonged clot absorption
73
What can a serum protein analysis provide?
An indication of the body’s nutritional reserves for rebuilding cells
74
Low serum protein =
Less rebuilding cells, delayed wound healing
75
Low albumin =
Indicates that the pt’s nutrition is bad. Decreased wound healing time + more risk of infection
76
A wound culture can analyze the presence of -
An Infection
77
Sensitivity reports can indicate-
Which antibiotic is appropriate for healing
78
Can you delegate obtaining a Wound Culture to a UAP?
Nope
79
What do you need to do 30 minutes prior to obtaining a wound culture?
Administer Analgesics
80
Aside from administering analgesics, what else do you need to do prior to obtaining a wound culture?
Cleanse the wound, determine if the wound culture is anaerobic or aerobic
81
How do you obtain a wound culture?
Obtain by rotating swab back & forth over clean granulated wound tissue
82
What is Debridement?
The removal of necrotic tissue or foreign tissue from a wound

Fundamentals 2 Exam 4 Flashcards (12 decks)

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