Test 2- Wound Care

Question 1

largest organ of the body

Answer 1

skin

Question 2

major function of the skin

Answer 2

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

Question 3

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

Answer 3

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

Question 4

intrinsic factors affecting skin integrity

Answer 4

age
mobility status
nutrition/hydration
sensation level

Question 5

how can age affect skin integrity

Answer 5

older adult skin:

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

Question 6

how can mobility affect skin integrity

Answer 6

increased pressure, shearing, and friction can lead to breakdown

Question 7

how can nutrition/hydration affect skin integrity

Answer 7

poor nutrition
less regeneration
decreased healing potential
dehydration= poor turgor

Question 8

how can sensation level affect skin integrity

Answer 8

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

Question 9

extrinsic factors affecting skin integrity

Answer 9

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

• friction
• pressure
• shearing
• moisture

Question 10

friction

Answer 10

(extrinsic factor)

-two surfaces rubbing together

Question 11

pressure (extrinsic factor)

Answer 11

-when a body part is pushing against something else

Question 12

shearing

Answer 12

(extrinsic factor)

-sliding across a surface

Question 13

moisture

Answer 13

(extrinsic factor)

-caused by sweating, urine, or loose stool

Question 14

how can medications affect skin integrity

Answer 14

side effects: itching, rashes

Question 15

how can infection affect skin integrity

Answer 15

it can slow healing

Question 16

how can lifestyle affect skin integrity

Answer 16

tanning beds, piercing, and tattoos

Question 17

other factors that can affect skin integrity

Answer 17

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

Question 18

classification of wounds

Answer 18

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

Question 19

stage 1 wound

Answer 19

non-blanchable reddened area

Question 20

stage 2 wound

Answer 20

superficial open area

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

Question 21

stage 3 wound

Answer 21

full thickness wound where fat is exposed in wound bed

Question 22

stage 4 wound

Answer 22

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

Question 23

unstageable

Answer 23

dark leathery area of dead tissue

Question 24

stages 1-4

Answer 24

classifies by tissue involvement

Question 25

stages 3-4

Answer 25

involve tissue necrosis

Question 26

nursing intervention: pressure ulcers

Answer 26

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

Question 27

type of wound drainage: | SEROUS EXUDATE

Answer 27

clear and straw-colored

Question 28

type of wound drainage: | SANGUINEOUS

Answer 28

bloody drainage

Question 29

type of wound drainage: | SEROSANGUINEOUS

Answer 29

mix of bloody and straw-colored fluid

Question 30

type of wound drainage: | PURULENT

Answer 30

yellow, contains pus

Question 31

complications of wound healing

Answer 31

``` hemorrhage infection dehiscence evisceration fistula formation ```

Question 32

dehiscence

Answer 32

surgical complication in which a wound ruptures along a surgical incision

Question 33

evisceration

Answer 33

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

Question 34

wound documentation/assessment

Answer 34

- 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

Question 35

purpose of wound drainage systems

Answer 35

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

Question 36

nursing intervention for wound drainage systems

Answer 36

- monitor the drain - site care - open and empty device - record findings

Question 37

type of wound drainage system: | hemovac

Answer 37

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

Question 38

type of wound drainage system: | jackson-pratt system

Answer 38

- open the port, drain, squeeze and replace the cap | - negative pressure device

Question 39

wound vacuum system

Answer 39

- 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

Question 40

topical therapy principles for wound care: DIWAMOPI

Answer 40

``` 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 ```