Week 4 Wound Flashcards
1
Q
What is tissue Integrity?
A
the ability of the human body to regenerate and maintain normal physiologic functioning
2
Q
What are the main functions of the skin?
A
regulates temperature
protects body against temp changes
eliminatres waste and suppors underlying strucures
3
Q
What does skin do with temp?
A
regulates
4
Q
What are the layers of the skin?
A
epidermis, dermis, hypodermis
5
Q
What does skin eliminate?
A
waste
6
Q
What age group is most at risk for pressure injuries and wounds?
A
age
people with mobility issues
weight
spina bifida, cerebal palsy
cancer
malnutrition
7
Q
What happens to the skin’s physiology as we age?
A
Thinner with lost elasticity
sluggish blood supply
8
Q
What are some skin complications as we age?
A
shear,
friction
pressure
9
Q
Where are the most pressure ulcers in a supine positioned person?
A
head
shoulder
elbow
lower back and but
inner knee
heel
10
Q
What is the epidermis’ function?
A
house melanocytes
merkel cells
langerhans cells
11
Q
What layer of skin is the largest portion of the skin; main function is to sustain and support epidermis by providing strength and flexibility; made of connective tissue with capillaries; blood vessels; lymph vessels; nerves; sweat and sebaceous glands; hair roots; elastic fibers; and collagen
A
Dermis
12
Q
What structures are in the dermis?
A
connective tissue with capillaries; blood vessels; lymph vessels; nerves; sweat and sebaceous glands; hair roots; elastic fibers; and collagen
13
Q
What is the function of the subcutaneous layer?
A
insulates the body, absorbs shock, and pads the internal organs and structures
14
Q
What are some key terms of a Stage one pressure injury?
A
Non-blanchable erythema
15
Q
What are some key terms of a Stage two pressure injury?
A
Partial thickness, skin loss, blister
16
Q
What are some key terms of a Stage three pressure injury
A
Full thickness, skin loss, and granulation tissue
17
Q
What are some key terms of a Stage four pressure injury
A
Full thickness, skin loss
Bone
Tendons
Cartilage visible
18
Q
What does T stand for in the TIME mnemonic for describing pressure injury?
A
Tissue integrity and how the tissue looks, wound color, and dead necrotizeed tissue
19
Q
What does I stand for in the TIME mnemonic for describing pressure injury?
A
Inflamation or infection
redness, warmth, swelling, discharge, and swelling
20
Q
What does M stand for in the TIME mnemonic for describing pressure injury?
A
moist or macerated
21
Q
What does E stand for in the TIME mnemonic for describing pressure injury?
A
Edge of wound
22
Q
What are the factors influencing wound healing? “DIDN’T HEAL”
A
D= Diabetes
I= Infection
D= Drugs
N= Nutritional problems
T= Tissue necrosis
H= Hypoxia
E= Extensive tension
A= Another wound
L= Low temperatures
23
Q
Why is it necessary to measure the wound?
A
so we know if the wound is healing or not
24
Q
Who are more susceptible for chronic wounds?
A
those with poor vasculature and circulation
25
Why do you document the color of exudate?
to see if the wound is healing properly
26
What is Dehiscence?
the wound edges separate
27
What causes dehiscence?
pooping, coughing, etc
28
What is priority action for dehiscence and eviscerations
cover and call surgeon
29
What are examples of open drainage devices?
penrose
30
What are some examples of closed drainage?
31
What is the purpose of a Wound Vac?
so wounds can heal faster by encouraging cells to release granulocytes
32
What is the the acronymn for type of wound drainage?
TACO
33
What is the Braden Scale used for?
It's to see the risk of pressure wounds
34
What is an AP allowed to do with wound care?
Take off dressing, but not put it on
35
What is purulent drainage a sign of?
Green/yellow pus means infection
36
What kind of drainage is high priority?
Purulent
37
What is a delicense?
Surgical site splits open
38
What is an evisceration?
Evisceration-when it separates and the intestine protrudes (comes out)
39
What should you see a dehiscence or evisceration?
Cover,
soaked sterile dressing,
Call MD
40
What can an LVN do to a wound dressing?
Can dress
41
Who is at high risk for pressure ulcers?
Older
Post-op
Confused
42
Why is pain decreased in stage IV wound?
There are no more cutaneous nerve endings
43
what is the outer most layer of the skin called?
Epidermis
44
What types of cells forms the basal layer of the skin?
Keratinocytes
45
What kind of cells produce melanin?
Melanocytes
46
What is the function of melanin?
Absorb radiant energy from the sun and protect the skin from UV rays
47
What kind of cells detect touch especially in the soles of the feet and the palms of the hands?
Merkel cells
48
What kind of cells in the skin and Justin package for an antigen to be presented to lymphocytes?
Langerhans cells
49
What layer of the skin sustains and supports the upper dermis by providing strength, flexibility, and nourishment
Dermis
50
What kind of fibers are found in the dermis?
Collagen and elastin
51
What is the subcutaneous layer mostly made of?
Adipose tissue
52
What is it called when there is an irritation of the epidermidis caused by moisture?
Maceration
53
What populations are clients most at? Risk for developing alterations and tissue integrity?
infancy, early childhood, and late adulthood
54
What is it called when the skin is red and irritated by urine stoma effluent and wound secretions
Dermatitis
55
what is it called when the top layer of the skin is lost by mechanical forces
Skin tears
56
What are some conditions that predispose clients to alterations and tissue integrity
Spina bifida cerebral palsy
Chronic diseases
Liver failure
Kidney disease
Cancer
Congenital condition
57
What are the most frequently occurring skin problems associated with skin frailty?
Skin tears
Pressure injuries
Infection of the skin such as cellulitis
58
What are some skin changes and contributing factors of neonate and children?
Immature skin
Prolong duration of pressure
Moisture or maceration
Poor perfusion
59
What are skin changes and contributing factors of people who have decreased mobility
Reduced blood circulation
Alterations in thermoregulation
Incontinence
Lots of collagen
Muscle atrophy
Impaired sensation
60
what are some skin changes and contributing factors for those who are obese?
Decreased moisture
Dry skin
Maceration
Elevated skin temperature
Decreased blood, and in Fattic flow
61
What are some skin problems of obese people?
Skin tears
Pressure ulcers
Diabetic ulcers
Moisture lesions
Skinfold rashes
62
What are some skin changes and contributing factors of people who have cancer?
Radiation can cause inflammation
Skin surface damage
Decreased blood supply
Radiation induced dermatitis
Delayed wound healing
Pressure injuries
63
What are some skin changes and contributing factors of people who have chronic illnesses?
Skin changes due to:
Hepatic disease
Renal disease
CVD
Malnutrition
Stomas
Psychosocial issues
64
How often should the skin be assessed?
Upon admission and every day or once per shift there after
65
What are the two types of erythema?
Blanchable, and non-blanchable
66
What does non-blanchable skin indicate
There is structural damage in the small vessels, supply blood to the underlying skin and tissues
67
What is the difference between an unintentional and intentional wound?
Intentional wounds can be surgically created
68
What are some examples of unintentional wounds
GSW
Punctures
Burns
69
What kind of wounds have a jaggedor irregular shape?
Simple or complicated wounds that are caused by blood or sharp objects
70
Where are skin tears mostly found
Upper and lower extremities, and the back of the hands usually by removing tape
71
What kind of bones are braided? Intentionally during surgery?
Hey surgical
72
What kind of surgical wounds have been a little bacterial loads and are closed of completion of the procedure?
Clean and clean, contaminated wounds
73
What kind of surgical wounds have higher bacterial loads of me interfere with healing
Contaminated and dirty wounds
74
What kind of loans are left open usually after procedures and require long-term wound management for healing to occur
Contaminated and dirty loon 
75
What kind of fluid is secreted by the body during the inflammatory phase of healing?
Edema and exudate
76
What is the wound healing process timeline?
Incision appears red on days one to four
Bright pink on days, 5 to 14
Pale pink from days 15 to one year
Epithelial closure by day four
Wound closure and sutures and staples removed between days nine and 14
77
What can predispose clients to moisture associated skin damage?
Abnormal skin pH
Deep skin folds
Increased local skin temperature
Excessive sweating
78
What are examples of chronic wounds?
Venous insufficiency
Peripheral artery disease
Diabetes mellitus
Smokers
Undernourished
79
What are some risk factors to pressure injury
Immobility
Malnutritio
Reduce perfusion
Altered sensation and decreased level of consciousness
80
What are some factors that can lead to pressure injury?
Exposure to moisture
Terry
Cuts
Bruises
Fiction
81
How does hypo perfusion affect tissue integrity
Low oxygen levels can occur when a client develops acute blood loss or low blood pressure
82
What is the Braden scale used for?
Risk assessment tool for use in hospitalize clients to classify risk for alterations in skin integrity
83
What are the categories that the Braden scale uses to assess skin integrity
Sensory perception
Moisture
Activity
Mobility
Nutrition
Friction and sheer
84
what is a bad score on the Braden scale
12 to 6 out of 23
85
What stage is it called when did tissue have formed and undermining and tunneling may be present, but the muscles and bones are not visible
Stage three
86
What stage is it called if a wound bed is covered in yellow slough or Eschar a hard, non-viable tissue
Unstageable pressure injury
87
What is it called when skin has localized non-blanchable, deep red, maroon, or purple discoloration and may be intact or broken
Deep, tissue, pressure injury, or DTP I
88
What kind of medical devices can cause pressure injuries?
Oxygen masks
Cervical collars
Compression stockings
Urinary catheters
IVs
89
What is it called when there is damage caused by pressure related to the insertion or placement of a foreign device on a opening in the skin such as the mouth
Mucosal membrane pressure injury
90
What are some tips to classify pressure injuries on dark pigmented skin?
Skin temperature and level of moisture
Edema
Hardened skin
Localized pain
91
What kind of patients are at risk for under assessment and under treatment of pain and why?
Older adults with dementia, because they are unable to advocate for themselves
92
What should you document on a pressure injury?
Locat
Stage and size
Description of the tissue
Color of the wound bed
Condition of surrounding tissue
Appearance of the wound edges
Any undermining or tunneling
Odor
93
What is a purpose of debridement?
Remove debris and tissue that may cause infection
94
What is the purpose of irrigation?
Remove surface materials and decreases bacterial levels in the wound
95
What are some various enzymatic agents to clear dead tissue and debris?
Papaya extract,
Pineapple extract
collagenase
96
What kind of agent can target necrotic tissue and facilitate wound healing?
Collagenase
97
What is a benefit of a wound dressing?
Heals faster than those that are not covered
98
what are examples of open dressings?
Gauze bandages 
99
What are semi open dressings?
Three layer dressings where the bottom is a layer of knit gauze infused with therapeutic ointment
Middle layer contains padding and absorbent cause
Final layer is adhesive
100
What is a drawback of semi open dressings
They do not control drainage well, and placed a client at risk for poor wound healing and breakdown of tissue adjacent to the wound
101
what do semi occlusive dressing’s do?
They cover wounds and control, moisture and bacteria
102
What are some examples of semi inclusive dressings?
Films
Hydrocolloid dressing’s
Alginate dressings
Hydro fiber dressings
Foams
Polymeric membranes
Hydrogels
103
Why should films not be used for addressing wounds with significant exudate?
If leaks occur, it can cause skin maceration an injury to the epidermal layer
104
What is an advantage of using films as semi inclusive dressings?
It allows moisture to evaporate, while still maintaining a moist wound bed
Allows oxygen to enter the wound, while decreasing risk of microorganism entrance
Easy to apply and where
105
What kind of dressing should be used for small abrasion superficial burns, and pressure injuries and postoperative balloons
Hydrocolloid dressing
106
What are some advantages to hydrocolloid dressing’s?
Maintain a moist wound bed
Bacteriostatic properties
Stimulate new granulation tissue
Comfortable and produce less maceration as other dressings
107
What are some disadvantages to hydrocolloid dressings?
can cause contact dermatitis
Can trap foul smells
Bacteria is trapped on the underside of the dressing
108
What kind of dressing is recommended for moderate to highly exuded wounds?
Alginate dressings
109
What are some drawbacks to Hydro fiber dressings
Provide hi absorbency
Can stay in the wound for several days
110
What is a disadvantage to alginate dressing?
A secondary dressing is needed to cover the alginate, so it increases the overall cost of management
111
What are some advantages to alginate dressing?
Provide hemostasis
Hi absorptive abilities
Can remain in the mood for several days
112
What is an advantage of Hydro fiber dressings?
provide hi absorbency and can stay in the mood for several days
113
What are some places to use foam dressing’s?
Wounds with mild to moderate exudate
114
What are some drawbacks of foam dressing?
They may produce a malodorous discharge
Require more frequent dressing changes than other dressings
115
What do polymeric membrane dressings do?
Used in mildly exudative balloons, and stimulate growth of new epithelium
Do not stick into the wound bed, resulting in less, to granulation tissue
116
What kind of dressing or wound care can be used for debridement of necrotized tissue and eschar?
Hydrogels
117
What is the main advantage of hydrogels?
They can provide moisture drama, sure way to the wound, depending on the needs of the wound
They have a soothing effect and cause a little trauma to the wound bed
118
What is one disadvantage of hydrogels?
May require frequent dressing changes
119
What is a key benefit of using staples over sutures?
They can be removed faster because healing is faster with a stapled wound. approximately 7 to 14 days
120
When are skin adhesive used?
Small minor wounds that have straight edges on the face head, parts of arms, legs and torso
121
What kind of wound therapy is used to heal and close large ones by reducing edema
Negative pressure wound therapy
122
What kind of surgeries often require drain placement
Those involving the chest area
Abdomen
Thyroid
And plastic surgeries utilizing flap procedures
123
What is the purpose of a wound drain
Decrease accumulation of fluid
Reduce accumulation of air
Collectible and drainage for testing and identification
124
what is a type of passive drain and why?
Penrose drain relies on gravity to remove accumulated fluid from a body cavity or wound
125
What are examples of active drains and why?
Portable wound bowl suction devices use negative pressure to suction drainage from lumens or body cavities
126
What happens if a train is removed too early from a surgical wound?
Hematoma or Seratoma can form
127
What kind of gauze should be placed around a Penrose drain?
sterile 4 x 4 for 24 to 48 hours
128
 How often should a portable wound bulb suction device be emptied?
At least every eight hours or when it is more than half full
129
what kind of drainage should you use? If larger amount of fluid is expected?
Higher pressure large bottle
130
What type of device is designed to continuously suction drainage from a wound by providing low, vacuum pressure
Circular, portable, wound suction, device, or Wound vac
131
After a drainage collection device begins. What color should the fluid be?
Sanguineous, and then more serosanguineous as the wound heals
132
What are expected findings for the first several days after a drains insertion?
Tenderness and edema
133
How should clients shower with a drain?
Allow soap and water to flow gently over the drain site and padded gently after a shower
134
What should a drain be removed?
When the drainage is less than 30 to 100 mL per day
135
What are two main components of preventing pressure injuries
Identification of client at risk
Implementation of interventions that are designed to reduce risk
136
What are some factors that can delay wound healing?
Decrease blood supply to the wound
Tension along, suture line
Long-term steroid use
Immunosuppression therapy
Certain autoimmune disorders
Malnutrition
137
Why are antibiotics only recommended for ones that look clinically infected
Wounds may contain bacteria but not all wounds are infected by harmful ones
138
What are some clinical manifestations of localized infection?
Cellulitis or redness around the moon
Warm skin
Exudate
Foul odor
139
What are some signs of sepsis?
Fever, chills, and nausea vomiting
Hypotension
High blood sugar
Increased WBC count
Altered mental status
140
What are SSIs?
Surgical site infections
141
What is classified as a superficial surgical site infection
Infections related to operative procedures that occur near the surgical incision site within 30 days of the procedure and
deep surgical incision site infections as infections are related through operative procedures that occur near the surgical incision 30 or 90 days after the operative procedure
142
What is the most common causative agent of SSI?
A staphylococcus aureus
143
What kind of complication generally occur seven to 10 days after surgery, often preceded by a serosanguineous discharge from the wound
Dehiscence
144
what is the mortality rate of dehiscence?
30%
145
What are the nursing interventions for a dehiscence?
Cover the one with moist sterile dressing
Implement IV therapy
Notify the provider or MD
146
What is it called when the wound and all the layers of tissue under the bone separate resulting in protrusion of the intraabdominal organs through the suture line
Evisceration
147
What is it called when the blood clotting mechanisms fail?
Hematoma and seroma can occur
148
Why is a hematoma and seroma bad for an infection?
They can cause an incision to separate and make that wound at risk for infection for bacteria to enter the deeper layers of the skin and infect the accumulated fluid
149
What can increase pressure and compression to the blood vessels caused by hematomas and seromas do to the wound
They can increase blood pressure and ischemia’s can occur, leading to necrosis
150
How does the body deal with dehydration with compensatory mechanism?
elevated BUN, blood serum
lowered BP
raised HR
151
What condition is macerated associated with?
dermatitis
152
What does DIDN'T HEAL mean?
D= Diabetes
I= Infection
D= Drugs
N= Nutritional problems
T= Tissue necrosis
H= Hypoxia
E= Extensive tension
A= Another wound
L= Low temperatures
153
What is dead tissue called?
slough or eschar
154
What stage can you see undermining or tunneling?
Stages 3 & 4
155
How does maceration occur in older patients?
Incontinent and moisture related problems
156
what is debridement?
dead tissue are removed with a scalpel or scissors
157
What is a fistula?
an abnormal passage from an internal organ or vessel to another.
