tissue integrity and wound care

Question 1

impaired tissue integrity

Answer 1

• reduced perfusion
• pain
• infection

Question 2

primary intention

Answer 2

tissue/skin is closed
- wound edges are approximated and uncomplicated

Question 3

secondary intention

Answer 3

wound left open to heal by itself to fill in and close naturally
- left open and wound heals from bottom up

Question 4

hemostasis

first step of inflammation

Answer 4

process of blood clot formation at the site of injury

Question 5

inflammatory phase

second step of inflammation

Answer 5

immediate response to trauma; damaged cells and pathogens removed from wound are
- days 0-3

Question 6

proliferation phase

thirs step of inflammation

Answer 6

wound rebuilt with new granulation tissue composed of collagen and extracellular maxtrix
- days 3-21

Question 7

maturation phase

fourth step of inflammation

Answer 7

ongoing collagen synthesis to rebuild and strengthen tissue
- day 21 - 2 years

Question 8

asepsis

Answer 8

keeping microorganisms away; practices that keep area free from microorganisms
- sterile gloves and field, use clean dedicated area

Question 9

clean technique

Answer 9

medical asepsis; can use non-sterile gloves

Question 10

most common sites of infection

Answer 10

• wounds
• urinary tract
• respiratory tract
• bloodstream

Question 11

signs of systemic infection

Answer 11

hypotension, tachycardia, tachypnea, SOB, shivering, diaphoresis

Question 12

interventions for tissue/wound integrity

Answer 12

• medical treatment for infetion
• lab tests
• collecting specimens
• administer meds
• surgery

Question 13

hypovolemic shock

Answer 13

decrease in blood volume leading to inadequate filling of vasculature and decreased CO
- d/t hemorrhage, trauma, low intake, vomitting

Question 14

s/s of hypovolemic shock

Answer 14

• tachycardia
• thirst
• cool peripheries
• hypotension
• low RR
• irritable

Question 15

complications of hypovolemic shock

Answer 15

• metabolic acidosis
• GI ischemia
• ARDS

Question 16

cardiogenic shock

Answer 16

ineffective pumping of heart to meet body demands
- low CO, low SBP, hypoperfusion, hypoxia
- may be caused by MI, STEMI

Question 17

septic shock

Answer 17

due to infection
- severe hypotension, decreased LOC, rapid shallow breathing

Question 18

superficial burn

Answer 18

• epidermis
• no blister
• painful, dry, red

Question 19

partial thickness burn

Answer 19

• epidermis and dermis
• blisters
• painful, red, weeping
• can be waxy

Question 20

full thickness burn

Answer 20

• dermis and subcutaneous tissues
• no blister
• waxy appearance
• no pain or sensation

Question 21

burn treatment

Answer 21

• cool water for 20 min
• cool compresses
• analgesia
• protect with loose sterile gauze
• hydration

Question 22

complications with burns

Answer 22

• edema
• hypovolemia
• clotting
• infection
• hypoxia

Question 23

fat embolism syndrome

Answer 23

complication of fracture; rare; onset in 24-72 hr
- most common in long bone fractures (femur and pelvis)
- fat from marrow enters blood stream

Question 24

fat embolism s/s and treatment

Answer 24

• dyspnea, hypoxemia, tachypnea, seizure risk, confusion, petechial rash
• treat with supportive care (O2, intubation, fluids)

Question 25

petechial rash

Answer 25

small red and purple dots clustered

Question 26

DVT diagnosis

Answer 26

ultrasound - can use compression stockings to prevent

Question 27

PE diagnosis

Answer 27

CT

Question 28

compartment syndrome

Answer 28

increased pressure in enclosed compartment which compromises circulation; fascia unable to stretch - occurs in soft tissue injuries and fractures - necrosis can occur after 4 hours - elevate to level of heart, NOT higher

Question 29

6 P's of compartment syndrome

Answer 29

- pain out of proportion to injury (hallmark sign) - parathesia - pallor - pulseless - paralysis - temp

Question 30

stage 1 ulcer

Answer 30

- intact skin - redness to localized area - discoloration, warmth, hard

Question 31

stage 2 ulcer

Answer 31

- partial thickness; shallow open wound bed that is red/pink - no slough

Question 32

stage 3 ulcer

Answer 32

- full thickness; subcu fat visible - some slough present - tunneling - usually located on buttocks

Question 33

stage 4 ulcer

Answer 33

- tissue loss - exposed bone or tendon - slough with underminning and/or tunneling

Question 34

hydrocolloid dressings

Answer 34

minimal-moderate drainage absorption and maintain moist wound envrionment - provide cushioning - used for partial/full thickness wounds, stage 2-3 pressure injuries, dry necrosis, dry slough, dry granulation - do NOT use for infected wounds

Question 35

hydrogel wound dressings

Answer 35

maintain a moist environment with minimal drainage absorption; do not adhere to wound and require secondary dressing to secure' - used for partial-full thickness wounds, stage 2-4 pressure injuries, infected and non-infected wounds, dry necrosis, dry slough, dry and deep granulation, epithelializing, first and second degree burns, dry wounds

Question 36

alginate wound dressings

Answer 36

absorb exudate and maintain moist envrionment; require secondary dressing to secure - used for wet necrosis, wet slough, wet granulation, partial/full thickness wounds, stage3-4 pressure, infected and non infected, moderate-heavy exudate, tunneling wounds, do NOT use for minimal drainage wounds

Question 37

foam wound dressings

Answer 37

maintain a moist environment to insulate wound and are highly absorbant - used for wet necrosis, wet/shallow slough, wet granulation, partial/full thickness wounds, stage 2-4 injuries, surgical wounds, around tubes and drains

Question 38

antimicrobial wound dressings

Answer 38

anibacterial action to prevent infection and can be highly absorbant - use for burns, partial/full thickness, stage 2-4 injuries, nonhealing wounds, acute and chronic