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Skills > Test 2- Wound Care > Flashcards

Test 2- Wound Care Flashcards

1
Q

largest organ of the body

A

skin

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2
Q

major function of the skin

A

protection
sensation
temperature regulation
fluid/electrolyte balance (thru excretion)

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3
Q

factors that influence the ability to maintain intact skin and heal wounds

A 
age
mobility
nutrition
hydration
moisture underlying conditions
medications
contamination/infection
diminished sensation
cognitive impairment
hygiene 
lifestyle
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4
Q

intrinsic factors affecting skin integrity

A

age
mobility status
nutrition/hydration
sensation level

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5
Q

how can age affect skin integrity

A

older adult skin:

  • less elastic
  • drier
  • reduced collagen
  • areas of pigmentation
  • more prone to injury
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6
Q

how can mobility affect skin integrity

A

increased pressure, shearing, and friction can lead to breakdown

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7
Q

how can nutrition/hydration affect skin integrity

A

poor nutrition
less regeneration
decreased healing potential
dehydration= poor turgor

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8
Q

how can sensation level affect skin integrity

A
  • diminished sensation leads to increased risk for pressure and breakdown
  • fever
  • impaired circulation
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9
Q

extrinsic factors affecting skin integrity

A

-extrinsic factors leading to pressure ulcers are those that alter the skin and tissue integrity and blood supply

  • friction
  • pressure
  • shearing
  • moisture
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10
Q

friction

A

(extrinsic factor)

-two surfaces rubbing together

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11
Q

pressure (extrinsic factor)

A

-when a body part is pushing against something else

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12
Q

shearing

A

(extrinsic factor)

-sliding across a surface

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13
Q

moisture

A

(extrinsic factor)

-caused by sweating, urine, or loose stool

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14
Q

how can medications affect skin integrity

A

side effects: itching, rashes

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15
Q

how can infection affect skin integrity

A

it can slow healing

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16
Q

how can lifestyle affect skin integrity

A

tanning beds, piercing, and tattoos

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17
Q

other factors that can affect skin integrity

A

pregnancy and swelling of the lower extremities

  • occupation that require long periods of standing
  • smoking and accidental wounds such as cuts, lacerations and abrasions
  • chemical expores
  • animal and bug bites
  • necrotizing fascitis- flesh eating bacteria
18
Q

classification of wounds

A
  • open/closed
  • acute/chronic
  • clean/contaminated/infected
  • deep tissue injury– area can be dark purple or dark red area
19
Q

stage 1 wound

A

non-blanchable reddened area

20
Q

stage 2 wound

A

superficial open area

-involve partial-thickness skin loss of epidermis, dermis, or both

21
Q

stage 3 wound

A

full thickness wound where fat is exposed in wound bed

22
Q

stage 4 wound

A

full-thickness skin loss with extensive destruction; tissue necrosis; damage to bone, muscle, or support structures

23
Q

unstageable

A

dark leathery area of dead tissue

24
Q

stages 1-4

A

classifies by tissue involvement

25
Q

stages 3-4

A

involve tissue necrosis

26
Q

nursing intervention: pressure ulcers

A
  1. prevention is #1
  2. skin care using barrier creams
  3. moisture control
  4. adequate nutrition- added protein if applicable and not a nephrology patient
  5. frequent repositioning with use of added cushioning devices such as wedges, added pillows, heel protectors
  6. therapeutic mattresses or clinitron beds
  7. client/family teaching
27
Q

type of wound drainage:

SEROUS EXUDATE

A

clear and straw-colored

28
Q

type of wound drainage:

SANGUINEOUS

A

bloody drainage

29
Q

type of wound drainage:

SEROSANGUINEOUS

A

mix of bloody and straw-colored fluid

30
Q

type of wound drainage:

PURULENT

A

yellow, contains pus

31
Q

complications of wound healing

A 
hemorrhage
infection
dehiscence 
evisceration 
fistula formation
32
Q

dehiscence

A

surgical complication in which a wound ruptures along a surgical incision

33
Q

evisceration

A

a rare but severe surgical complication where the surgical incision opens (dehiscence) and the abdominal organs then protrude or come out of the incision (evisceration). Evisceration is an emergency and should be treated as such

34
Q

wound documentation/assessment

A
  • location
  • size and depth and if there is any tunneling–how deep is the tunneling
  • appearance: color of tissue inside wound bed; if there is a darkened area the size needs to be noted
  • drainage
  • any other defining factors and if there is redness or edema with the surrounding tissues
35
Q

purpose of wound drainage systems

A

to remove blood and fluid that may build up under the skin after surgery

36
Q

nursing intervention for wound drainage systems

A
  • monitor the drain
  • site care
  • open and empty device
  • record findings
37
Q

type of wound drainage system:

hemovac

A

open to drain and squeeze together the top and bottom and close

  • it works under negative pressure
  • if you do not “flatten” it, then it will not properly drain
38
Q

type of wound drainage system:

jackson-pratt system

A
  • open the port, drain, squeeze and replace the cap

- negative pressure device

39
Q

wound vacuum system

A
  • applied directly to the wound with a sealed dressing

- the system pulls the fluid and blood from the site and aids in increased blood supply for improved and faster healing

40
Q

topical therapy principles for wound care: DIWAMOPI

A 
D- debride
I- identify and treat infection
W- wick dead spaces
A- absorb excess exudate
M- maintain moist wound surface
O-open or excise closed edges
P-protect healing wound from infection/trauma
I-insulate

Skills (11 decks)

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