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NURS 309 > T4: Skin integrity and wound care > Flashcards

T4: Skin integrity and wound care Flashcards

1
Q

Use an __________ to flush the wound with a constant low-pressure flow of solution

A

irrigation syringe

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2
Q

irrigation cleans wound of __ and ____

A

exudate and debris

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3
Q

irrigation is particularly useful for

A
  • open, deep wounds
  • wounds involving an inaccessible body part such as the ear canal
  • when cleaning sensitive body parts such as the conjunctival lining of the eye
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4
Q

Use ____ syringe with a ___ gauge soft angiocatheter for open wound irrigation

A
  • 35 mL syringe

- 19 gauge

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5
Q

Never occlude a wound opening with a syringe because

A

this results in the introduction of irrigating fluid into a closed space

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6
Q

Major drawback of staging system is that

A

you cannot stage an injury when it is covered with necrotic tissue

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7
Q

Necrotic wound must be _______ to expose the wound base to allow for assessment

A

debrided or removed

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8
Q

intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin

A

stage 1 pressure injury

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9
Q

wound color change of purple or maroon discoloration indicate

A

deep tissue pressure injury

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10
Q
  • partial-thickness skin loss with exposed dermis
  • Wound bed is visible, pink or red, and moist and may also present as an intact or ruptured serum-filled blister
  • Adipose tissue is not visible and deeper tissue is not visible
  • Granulation tissue, slough, and eschar are not present
A

stage 2 pressure injury

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11
Q

stage 2 pressure injury commonly result from

A

adverse microclimate and shear over pelvis and heel

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12
Q
  • Full-thickness skin loss
  • Adipose tissue is visible
  • Granulation tissue and epibole (rolled wound edges) are often present
  • Slough and/or eschar may be visible
  • Depth of tissue damage varies by anatomical location
  • Undermining and tunneling may occur
  • Fascia, muscle, tendon, ligament, cartilage, and/or bone are not exposed
A

Stage 3 pressure injury

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13
Q
  • full thickness and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer
  • Slough and/or eschar may be visible
  • Epibole, undermining, and/or tunneling often occurs
A

stage 4 pressure injury

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14
Q

obscured full-thickness skin and tissue loss

A

unstageable pressure injury

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15
Q

If slough or eschar is removed on an unstageable pressure injury:

A

staging is possible

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16
Q

Stable eschar on heel or ischemic limb:

A

should not be softened or removed

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17
Q

intact or nonintact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration, or epidermal separation revealing a dark wound bed or blood-filled blister

A

deep tissue pressure injury

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18
Q

on deep tissue pressure injury, ______ and ______ often precede skin color changes

A

pain and temperature change

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19
Q

deep tissue pressure injury results from

A

intense/prolonged pressure and shear forces at the bone-muscle interface

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20
Q

deep tissue pressure injuries are not used to describe:

A

vascular, traumatic, neuropathic, or dermatologic conditions

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21
Q

occurs when the skin or underlying tissues are subjected to sustained pressure or shear from medical devices or equipment

A

Medical adhesive-related skin injury (MARSI)

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22
Q

MARSI occur because

A

Attachment between the skin and an adhesive is stronger than the skin cells, causing the surface epidermal to detach from the underlying layers

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23
Q

localized damage to the skin and underlying soft tissue, usually developing over a bony prominence or related to pressure from a medical device or other device

A

pressure injury

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24
Q

tolerance of soft tissue for pressure and shear can be affected by (5)

A
  • microclimate
  • nutrition
  • perfusion
  • comorbidities
  • conditions of soft tissue
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25
Q

contributing factors of pressure injuries

A
  • decreased mobility
  • decreased sensory perception
  • fecal/urinary incontinence
  • poor nutrition
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26
Q

______ is the major element that causes pressure injuries

A

pressure

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27
Q

top down skin damage is caused by

A

superficial shear or friction

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28
Q

bottom-up skin damage is caused by

A

pressure intensity
pressure duration
tissue tolerance

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29
Q

minimal amount of pressure required to collapse a capillary

A

capillary closing pressure

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30
Q

pressure exceeds normal capillary pressure and the vessels occlude for a prolonged period

A

tissue ischemia

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31
Q

redness from an excess of blood in the vessels supplying a particular area

A

hyperemia

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32
Q

area appears red and warm and turns a lighter color with palpation

A

blanchable hyperemia

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33
Q

redness that persists after palpation, indicating tissue damage

A

nonblanchable hyperemia

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34
Q

sliding movement of skin and subcutaneous tissue while the underlying muscle and bone are stationary

A

shear

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35
Q

force of two surfaces moving across one another

A

friction

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36
Q

friction injuries affect the

A

epidermis

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37
Q

t/f: friction injuries are classified as a pressure injury

A

false

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38
Q

disruption of the integrity and function of tissues I the body

A

wound

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39
Q

two major types of wounds

A

open and closed

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40
Q

surface of skin remains intact, but the underlying tissues may be damaged

A

closed wound

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41
Q

skin is split, incised, or cracked, and the underlying tissues are exposed to the outside environment

A

open wound

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42
Q

classification of wounds based on onset and duration

A

acute vs chronic

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43
Q

proceeds through an orderly and timely reparative process that results in sustained restoration of anatomical and functional integrity

A

acute wound

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44
Q

wound that fails to proceed through an orderly and timely process to produce anatomical and functional integrity

A

chronic wound

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45
Q

cause of acute wound

A

trauma and/or surgical incision

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46
Q

cause of chronic wound

A

vascular compromise
chronic inflammation
repetitive insults to tissue

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47
Q

indications of acute wound

A

wound edges are clean and intact

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48
Q

indications of chronic wound

A

continued exposure to insult impedes wound healing

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49
Q

Primary intention of wound healing

A

approximated: wound is closed

50
Q

cause of primary intention

A

hematoma, surgical incision that is sutured or stapled

51
Q

indication of primary intention

A

healing occurs by epithelialization; heals quickly with minimal scar formation

52
Q

wound edges not closed or approximated

A

secondary intention

53
Q

cause of secondary intention

A

surgical wounds that have tissue loss or contamination

54
Q

indication of secondary intention

A

wound heals by granulation tissue formation, wound contraction, and epithelialization

55
Q

wound that is left open for several days; then wound edges are approximated

A

tertiary intention

56
Q

cause of tertiary intention

A

wounds that are contaminated and require observation for signs of infection

57
Q

indication of tertiary intention

A

closure of wound is delayed until risk of infection is resolved

58
Q

partial loss of skin layers (epidermis and superficial dermal layers)

A

partial-thickness wounds

59
Q

partial-thickness wounds loss heals by

A

regeneration

60
Q

three components of regeneration

A
  • inflammatory response
  • epithelial proliferation
  • reestablishment of the epidermal layer
61
Q

in regeneration, inflammatory response occurs within:

A

first 24 hours

62
Q

in regeneration, epithelial proliferation and migration starts at ______1_______
if kept moist, can resurface in __2___
if left open to air, can resurface within __3___

A
  1. starts at both the wound edges and the epidermal cell lining the epidermal appendages
  2. 4 days
  3. 6-7 days
63
Q

total loss of skin layers (epidermis and dermis)

A

full-thickness wound

64
Q

full-thickness wound heals by:

A

forming new tissue

65
Q

4 phases of forming new tissue

A
  • hemostasis
  • inflammatory phase
  • proliferation and new tissue formation
  • remodeling and maturation
66
Q

injured blood vessels constrict and platelets gather to stop bleeding

A

hemostasis

67
Q

hemostasis is a physiological event designed to:

A

control blood loss, establish bacterial control, and seal the defect that occurs when there is an injury

68
Q

hemostasis is impaired when patients are on ___1______ or have specific diseases that affect _____2_____

A
  1. anticoagulants

2. platelet production or blood clotting

69
Q

damaged tissue and mast cells secrete histamine, resulting in vasodilation of surrounding capillaries, and movement or migration of serum and white blood cells into the damaged tissue

A

inflammatory phase of new tissue formation

70
Q

inflammatory phase of new tissue formation results in

A

localized redness, edema, warmth, and throbbing

71
Q

leukocytes reach wound within _____ during _______ phase

A
  • few hours

- inflammatory phase

72
Q

primary acting leukocytes

A

neutrophils

73
Q

neutrophils function:

A

ingest bacteria and small debris

74
Q

secondary acting leukocytes

A

monocytes

75
Q

monocytes function

A

transform into macrophages that clean a wound of bacteria, dead cells, and debris by phagocytosis

76
Q

macrophages release ______ that attract fibroblasts, which ______

A

growth factors

synthesize collagen

77
Q

collagen appears as early as ________ during inflammatory phase and is the ______ component of scar tissue

A
  • 2nd day

- main component

78
Q

proliferation and new tissue formation begins _______ after injury and can last as long as _______

A
  • 3-4 days

- 2 weeks

79
Q

main activities of proliferation and new tissue formation

A
  • Filling wound with granulation tissue
  • Wound contraction
  • Wound resurfacing by epithelialization
80
Q

during proliferation and new tissue formation, collagen mixes with ______ to from a _____

A
  • granulation tissue

- matrix

81
Q

impairment of proliferation and new tissue formation results from

A

systemic factors such as age, anemia, hypoproteinemia, and zinc deficiency

82
Q

the final stage of full-thickness wound healing, ____________, begins _______ after injury and continues for more than ______, depending on the depth and extent of the wound

A
  • remodeling and maturation
  • several weeks
  • more than a year
83
Q

removal of nonviable, necrotic tissue

A

debridement

84
Q

complications of wound healing (4)

A
  • hemmorhage
  • infection
  • dehiscence
  • evisceration
85
Q

partial or total separation of wound layers

A

dehiscence

86
Q

total separation of wound layers

A

evisceration

87
Q

Risk assessment for pressure injuries

A

braden scale

88
Q

Braden scale for predicting pressure ulcer risk includes: (6)

A
  • Ability to respond appropriately to pressure-related discomfort
  • Degree to which skin is exposed to moisture
  • Degree of physical activity
  • Ability to change and control body position
  • Usual food intake pattern
  • Exposure to friction and shearing
89
Q

nutrients in wound healing (6)

A
  • calories
  • protein
  • vitamin C
  • vitamin A
  • zinc
  • fluids
90
Q

types of wound drainage (4)

A
  • serous
  • purulent
  • serosanguineous
  • sanguineous
91
Q

wound drainage is clear, watery plasma

A

serous

92
Q

wound drainage is thick, yellow, green, tan, or brown

A

purulent

93
Q

wound drainage is pale, pink, watery; mixture of clear and red fluid

A

serosanguineous

94
Q

wound drainage is bright red; indicates active bleeding

A

sanguineous

95
Q

types of drains

A
  • penrose
  • Jackson-pratt
  • hemovac
96
Q

lies under a dressing; at the time of placement a pin or clip is placed through the drain to prevent it from slipping farther into the wound

A

Penrose drain

97
Q

bulb at end of drainage tube that helps pull drainage from site

A

Jackson-pratt drain

98
Q

larger, disk like container attached to end of drainage tube that helps pull drainage from site

A

hemovac drain

99
Q

assessment of drains (4)

A
  • number and type
  • drain placement
  • character of drainage
  • condition of collecting equipment
100
Q

application of subatomospheric pressure to a wound through suction toe facilitate healing and collect wound fluid

A

Negative-pressure wound therapy

101
Q

Negative-pressure wound therapy supports wound healing by

A

removing wound exudates and reducing edema, macro-deformation and wound contraction, and micro-deformation and mechanical stretch perfusion

102
Q

secondary effects of negative-pressure wound healing

A
  • angiogenesis
  • granulation tissue formation
  • reduction in bacterial bioburden
103
Q

indications of negative-pressure wound therapy (5)

A
  • chronic, acute, traumatic, subacute, and dehisced wounds
  • Partial-thickness burns
  • Injuries
  • Flaps and grafts once nonviable tissue is removed
  • Select high-risk postoperative surgical incisions
104
Q

wear time for dressing after negative-pressure wound therapy is anywhere from _____ to ______

A

24 hours to 5 days

105
Q

contraindications of negative pressure wound therapy (7)

A
  • Necrotic tissue with eschar present
  • Untreated osteomyelitis
  • Non-enteric and unexplored fistulas
  • Malignancy in the wound
  • Exposed vasculature
  • Exposed nerves, anastomotic sites, or organs
  • High risk for bleeding or hemorrhage
106
Q

device that helps in wound closure by applying localized negative pressure to draw the edges of a wound together

A

Vacuum-assisted closure (VAC)

107
Q

therapeutically beneficial in increasing muscle and ligament flexibility; promoting relaxation and healing; and relieving spasms, joint stiffness, and pain

A

moist heat application

108
Q

moist heat application is most commonly used following

A
  • acute phase of a musculoskeletal injury

- during and after childbirth surgery, and superficial thrombophlebitis

109
Q

physiological response to moist heat application (5)

A
  • Vasodilation
  • Reduced blood viscosity
  • Reduced muscle tension
  • Increased tissue metabolism
  • Increased capillary permeability
110
Q

therapeutic benefits of moist heat application (6)

A
  • Improves blood flow to injured body part
  • Promotes delivery of nutrients and removal of waste
  • Improves delivery of leukocytes and antibiotics to wound site
  • Promotes muscle relaxation
  • Reduces pain from spasm or stiffness
  • Provides local warmth
111
Q

__________ also used to reduce pain and increase healing by increasing blood flow in tissues and can be used at a low level for a longer period with little chance of tissue injury

A

dry heat

112
Q

refers to the superficial application of cold to the surface of the skin, with or without compression and with or without a mechanical recirculating device to maintain cold temperatures

A

cold therapy

113
Q

cold therapy is designed to treat

A

localized inflammatory response of an injured body part that presents as edema, hemorrhage, muscle spasm, or pain

114
Q

cold therapy is most commonly used

A

immediately after soft tissue and musculoskeletal injuries such as sprains or strains

115
Q

cold therapy has been used postoperatively with patients who have under gone: (3)

A
  • orthopedic surgeries
  • spinal fusion
  • lumbar discectomy
116
Q

physiological response to cold therapy (5)

A
  • Vasoconstriction
  • Local anesthesia
  • Reduced cell metabolism
  • Increased blood viscosity
  • Decreased muscle tension
117
Q

therapeutic effect of cold therapy (6)

A
  • Reduces blood flow to injury site, preventing edema formation
  • Reduces inflammation
  • Reduces localized pain -Reduces oxygen needs of tissue
  • Promotes blood coagulation at injury site -Relieves pain
118
Q

conditions that increase risk of injury from heat and cold application (7)

A
  • age (very young and very old)
  • open wounds, broken skin, or stomas
  • areas of edema or scar formation
  • peripheral vascular disease
  • confusion or unconsciousness
  • spinal cord injury
  • abscessed tooth or appendix
119
Q

supports large abdominal incisions that are vulnerable to tension or stress as a patient moves or coughs

A

abdominal binder

120
Q

extra protection and therapeutic benefits of abdominal binders (6)

A
  • Creating pressure over a body part
  • Immobilizing a body part
  • Supporting a wound
  • Reducing or preventing edema
  • Securing a splint
  • Securing dressing
121
Q

abdominal binders allow patients to _______ sooner and reduce ________

A
  • ambulate

- postoperative complications

NURS 309 (10 decks)

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