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NURS 1245 > Wound Care > Flashcards

Wound Care Flashcards

1
Q

Protective layer of keratin

A

Epidermis

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2
Q

This layer is made of collagen

A

Dermis

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3
Q

Types of wound healing

Rapid healing, no infection, well approximated, sutured edges, (Surgical Wounds)

A

Primary intention

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4
Q

Heal by granulation (burns, pressure ulcers, wounds with large pieces of missing skin) Risk for Infection

A

Secondary intention

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5
Q

Wound is left open to heal (Infected Wounds)

A

Tertiary intention

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6
Q

_____ in wound healing refers to the formation of new connective tissue and tiny blood vessels (capillaries) in the wound bed during the later stages of the healing process.

A

Granulation

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7
Q

4 stages of wound healing starting at the beginning

A

Hemostasis
Inflammatory
Proliferation
Maturation

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8
Q

Phases of wound healing

Construction and then dilation of vessels

Formation of exudate (swelling, pain)

Stimulates cell migration

Immediately after injury

A

Hemostasis

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9
Q

Phases of wound healing

Debris ingested and growth factors released

Mild temperature elevation

Leukocytosis

General malaise

A

Inflammatory phase

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10
Q

Phases of wound healing

Regeneration phase

Granulation phase

Systemic symptoms disappear

Clotting occurs

Nutrition and oxygen are key

A

Profileration phase

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11
Q

Phases of wound healing

Collagen remodeled

Scar becomes flat, thin line

Can affect mobility

A

Maturation phase

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12
Q

Local factors affecting wound healing

Pressure

Desiccation (Define)

Maceration (Define)

Trauma

Edema

Infection

Necrosis

Lack of O²

A

Desiccantion (Dehydration)

Maceration (Over hydration, pH levels)

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13
Q

Presence of bacteria which does not cause local or systemic signs of an infection

A

Colonization

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14
Q

Dehiscence in the context of a wound refers to….

A

the partial or complete separation of the layers of a surgical incision or a previously closed wound

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15
Q

_______ of a wound refers to the protrusion or extrusion of internal organs or tissues through an open or ruptured wound, often due to the failure of wound closure.

A

Evisceration

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16
Q

An abnormal or surgically made passage between a hollow or tubular organ and the body surface OR

Between two hollow or tubular organs

A

Fistuals

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17
Q

Inflammation of the intestines caused by immune response to an infection

Is this disease ____

Lining of intestine may ulcerate and form channels of infections called _____

A

Crohns disease

Fistula

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18
Q

Bile duct and surface of skin (Gallbladder surgery)

Cervix and vagina

Space inside skull and nasal sinus

Bowel and vagina

Are all common

A

Sites for fistulas

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19
Q

Give an example of a purposefully created fistula

A

AV fistula

Provide circulation access for kidney dialysis

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20
Q

A collection of infected fluid that has not drained

A

Abscess

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21
Q

An abscess is a Collection of infected fluid that has not drained and applies pressure to the surrounding tissues causing a _____

A

Fistula

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22
Q

Access the wound

T

I

M

E

A

Tissue: Both in and around the wound- granulation, necrotic black, pink, mix

Infection: Any open area always has the potential for infection

Moisture: (exudate) This determines type of dressing needed to maintain balance.

Edges: Are they contracted, rolling, undermining

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23
Q

Cornified or dried out dead tissue black

A

Eschar

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24
Q

Liquefied or wet dead tissue

A

Slough

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25
Q

Bigger area of tissue damage that can be seen (extends under the edge)

A

Undermining

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26
Q

Tracts extending out from the wound

A

Tunneling

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27
Q

Drainage Color

Serous

A

White

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28
Q

Drainage Color

Sanguineous

A

Red

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29
Q

Drainage Color

Serosanguineous Drainage

A

Pinkish

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30
Q

Drainage Color

Purulent

A

Yellowish

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31
Q

Open wounds

Red

____ stage of healing, reflect color of normal granulation

A

Proliferative stage

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32
Q

Color classification of open wounds

Black

Covered with thick eschar

Require _____ to analyze open wound

A

Debridement

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33
Q

Yellow Open Wound indicates

A

Slough: loose, necrotic tissue

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34
Q

Wound Culture

Clean: with sterile saline

Identify: 1 cm² area clean

Rotate: applicator for 5 seconds applying pressure to produce fluid from wound

Don’t take specimen from ____,____,____

If wound isn’t oozing ____

A

Exudate, eschar, necrotic material

Moisten with sterile saline to collect sample

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35
Q

_____ can occur when a patient is moved carelessly or slides down in bed

A

Shearing forces

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36
Q

Pressure ulcer stage

Intact skin with Non-blanchable redness of a localized area usually over a bony prominence

A

Stage 1

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37
Q

Describes pressure ulcer

Partial thickness loss dermis presenting as a shallow OPEN ulcer with a red,pink wound bed, usually without slough

A

Stage II

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38
Q

Describes Pressure Ulcer

Full thickness tissue loss

Subcutaneous fat maybe visible

Tendon, Bone, or Muscle NOT EXPOSED

Slough maybe present but doesn’t obscure the depth of tissue loss

Undermining & Tunneling present

A

Stage 3

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39
Q

Describes Pressure Ulcer

Full thickness tissue loss with exposed bone, tendon or muscle.

Slough or eschar maybe present

Often includes Undermining and Tunneling

A

Stage IV

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40
Q

A wound is considered “Unstageable” if…

A

Obscured by Slough Or Eschar

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41
Q

Deep Tissue Injury (DTI)

Purple localized skin or blood filled blister

Damage of underlying soft tissue by _______ and/or sheer

How does this physiologically happen

A

Contact with hard surface like floor / MRI machine

Deformación of muscle cells

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42
Q

____forms of DTI follow periods of prolonged immobility with hypotension.
Prolonged Emergency Dept. Gurney
Following Cardiac Arrest

A

Ischemic forms if DTI

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43
Q

Pressure Ulcer Care

Stage I

A

Turning; pressure relieving devices

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44
Q

Pressure-Relieving Mattresses:

Alternating Pressure Mattresses
Foam Mattresses with Pressure
Redistribution Properties
Low-Air-Loss Mattresses
Pressure-Relieving Cushions:

Gel Cushions
Foam Cushions
Air Cushions (e.g., ROHO cushions)
Heel and Elbow Protectors:

Soft Gel Heel and Elbow Protectors
Foam Heel and Elbow Protectors
Positioning Devices:

Wedges and Pillows for Proper Body Alignment
Turning and Repositioning Systems
Specialized Beds:

Clinitron Beds (fluidized therapy beds)
Rotating Beds
Footboard and Heel Suspension Devices:

Devices to elevate the heels and prevent pressure on the heels

A

Pressure relieving devices

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45
Q

Pressure Ulcer Care

Occlusive Dressing

Impermeable to air and fluids.

Moist environment around the wound, which can promote faster healing.

A

Stage II

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46
Q

Pressure Ulcer Care

Wet to Dry dressings; debridement of eschar (chemical/ manual/ SX)

A

Stage III

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47
Q

Moisture Associated Skin Damage
(MASD)

Incontinence-Associated dermatitis

Describe
What is / What isn’t

A

Is: Erythematosus/ Painful
Shallow Irregular edges
KISSING LESIONS (Skin folds mirror eachother

NOT: Slough, Eschar, or granulation tissue.

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48
Q

Extravasation is…

A

Movement of drug solution ( Antineoplastic, Osmotically Active “containing 10% glucose, calcium Chloride, Calcium Gluconate”)

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49
Q

_____ refers to the leakage or escape of a fluid, such as blood, chemotherapy drugs, or other medications, from a blood vessel into the surrounding tissues. This can occur unintentionally during the administration of intravenous (IV) therapy or medications.

A

Extravasation

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50
Q

Intact or non-intact skin
Non-blanchable deep red, marron, purple
Epidermal separation revealing dark wound bed or blood filled blister

Pain/ Temp change preceed color change

A

Deep Tissue Pressure Injury

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51
Q

Intense / prolonged pressure / shear force at bone muscle interface

May evolve rapidly revealing extent of injury, may resolve without tissue loss

If necrotic , subcutaneous, granulation, fascia, muscle or underlying structures are visible this indicates (Unstagable, Stage 3 , or 4)

A

Deep Tissue Pressure Injury

DTPI

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52
Q

In DTPI Deep Tissue Pressure Injury

Damage is concentrated…

A

Tissue adjacent to bony prominence

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53
Q

In a mucosal membrane tissue injury

A. Non-blanchable erythema can be seen in the mucous membranes

B. It is difficult to distinguish between superficial/ deeper full thickness loss

C. What is soft coagulum and what does it look like?

D. Are bone and muscle ever seen?

A

A. Non-blanchable erythema cannot be seen in Mucous Membranes

B. True. It is difficult to distinguish between superficial/deeper tissue loss

C. Soft coagulum is a blood clots
It looks like slough

D. Muscle is seldom seen and bone is not present

54
Q

Mucosal membrane pressure injury is staged just like skin

True or False

A

False.

It is unstagebale

55
Q

___ is the largest bony prominence in pediatric population and common location of pressure injuries

As children age the location shifts to ____ & _____ which includes the largest boney prominence

A

Occiput

Heels & Sacrum

56
Q

Medical Device Related (MDR)

If device can be removed do so

Non removable include: cast, Endotracheal Tube, pressure dressing

2 steps to document

A
  1. Use staging system
  2. Note whether is related to medical device
57
Q

Initial inflammatory Response

Epithelial proliferation and migration

Reestablishment of Epidermal Layers

Describe the healing process for

A

Partial Thickness Pressure Injuries

58
Q

During the inflammatory phase of the healing process (3)

A

Hemostatis

Neutrophils/ macrophages migrate and eat bacteria

Cytokines released during this period promete cell proliferation

59
Q

Hemostasis is the process of….

A

the wound being closed by clotting

Hemostasis starts when blood leaks out of the body. The first step of hemostasis is when blood vessels constrict to restrict the blood flow.

Next, platelets stick together in order to seal the break in the wall of the blood vessel

60
Q

Epitheliazation appears along the wound edge as tissue that is, thin and these colors

A

Pearly, silvery, shiny

61
Q

3 types of wounds that can be confused with pressure injuries

A

Most common in lower extremities

Arterial injury
Venus injury
Diabetic foot injury

62
Q

Causes

Atherosclerosis
Arteriosclerosis
Lower Extremity Arterial Disease
Aka
PAD

Risk factors
Age
Smoking
DM
Hypertension
Dyslipidemia
Chronic Kidney disease

A

Arterial Injuries

63
Q

Cooler, skin temp
Thin, shiny skin
Decreased/ absent hair
Skin Pallor on foot elevation/ dusky Rubor on dependency

Is this type of Injury

A

Arterial Injury

64
Q

Arterial Injuries are classified as

A

Partial or Full Thickness

65
Q

Characteristics of _____ injury

Round and regular shape
Pale wound bed
Well defined edges
Necrotic tissue may obscure
Minimal drainage
Sever pain

A

Arterial

66
Q

____ Injury

Hyperpigmentation lower calf / ankel

Lipodermatosclerosis: Thickening and fibrosis of skin and subQ tissue from chronic inflammation

Edema worsens when standing

Dry scaly skin, itchy crust

Weepy skin

A

Venous Injuries

67
Q

___ Injuries

Shallow in depth
Irregular shaped / Wound edge
Moderate to large amount of drainage
Yellow fibrous film covers
Variable pain (mild to sever)

A

Venous Injuries

68
Q

Charcots foot

A

Foot normal contour altered due to diabetes

69
Q

Weakness, numbness, and pain from nerve damage, usually in the hands and feet.

A common cause is diabetes, but it can also result from injuries, infections, and exposure to toxins.

A

Peripheral Neuropathy

70
Q

Peripheral Neuropathy

A

Weakness, numbness, and pain from nerve damage, usually in the hands and feet.

A common cause of peripheral neuropathy is diabetes, but it can also result from injuries, infections, and exposure to toxins.

71
Q

Skin assessment for _____

Decreased sensation in foot w/ monofilament testing
Warm skin, maybe dry
Callous formation, skin cracks, fissures
Abnormal toe nail growth
Plantar foot pad atrophy
Foot deformity: hammer toe, claw toes, Charcot’s foot

A

Diabetic foot injuries

72
Q

Risk factors for ____ lower extremity injuries

Visual impairment
Peripheral arterial disease/ neuropathy
Foot deformity
Limited ankle ROM

A

Diabetic Foot Injury

73
Q

Wound characteristics Lower Extremities

Depth varies from partial to full thickness w/ bone involvement
Regular wound margins
Often surrounded by rim of calloused skin
Low to moderate amount of drainage

Assess for signs of inflammation or infection

Suspect ______ if bone is visible

A

Diabetic Foot Injury

Osteomyelitis

74
Q

Incontinence Associated Dermatitis

A

Prolonged exposure to urine or fecal incontinence

75
Q

Intertriginous Dermatitis

A

Prolonged exposure to perspiration in Skin Fold

76
Q

Periwound Moisture Associated Dermatitis

A

Prolonged Exposure to Wound Exudate

77
Q

Peristomal Moisture Associated Dermatitis

A

Prolonged Exposure to Effluent from an Ostomy

78
Q

Denuded skin, skin erosion, vesicles, bullae, Serous Exudate, Usually Partial Thickness Loss, Burning Pain, Itching

Blanchable/ Non-blanchable

One or more islands of erosion

No slough or eschar

A

Incontinence-Associated Dermatitis

79
Q

Epidermal stripping
Tension injury or blister
Skin tear

Irritant / Allergic Contact dermatitis

Maceration from trapped moisture
Folliculitis

Can all come from

A

Medical Adhesive-Related Skin Injury
MARSI

80
Q

Surgical wounds healing by ______ intention are open surgical wounds that are left to heal from the base up. They are often slow to heal and are prone to infection.

This done because the wound cannot be stitched/stapled back together.

A

secondary

81
Q

Healing by ________
The tissues approximated by surgical sutures or tapes with minimal loss of tissue

A

Primary Intention

82
Q

____ healing is delayed primary wound healing after 4–6 days. This occurs when the process of secondary intention is intentionally interrupted and the wound is mechanically closed.

This usually occurs after granulation tissue has formed.

A

Tertiary intention

83
Q

Evisceration is associated with (Dry /Moisture or Generalized Edema)

Dehiscence is associated with (Dry /Moisture or Generalized Edema)

A

Evisceration = Generalized Edema

Dehiscence = Dry/ Moisture

84
Q

Deep Tissue Injury is a Dark Purple and associated with Falls

Inside-Out or Outside-In

Describes how the Injury happens

A

Inside-Out

85
Q

______ are persistent non-blanchable deep red, purple or maroon areas of intact skin, non-intact skin or blood-filled blisters caused by damage to the underlying soft tissues

A

Deep tissue pressure injuries (DTPI)

86
Q

Venous Statis Ulcer:

Inner leg or Outer Leg

A

Inner leg

87
Q

Arterial lower leg wound:

Inner leg or Outer leg

A

Outside of leg

88
Q

Braden Scale is used for…

A

Pressure injuries

89
Q

Hydrocolloid dressings provide (Moist/Dry) environment and are water proof

Used to help bed sores heal

A

Moist

90
Q

Hydrogel promotes a moist environment and is used mostly for pressure ulcers at this stage

Use: (Low or High Exudate)

(Hydrates or Drys) wounds

Aids in autolytic debridement?

A

2

Low to medium

Hydrates

Yes , Aids in autolytic debridement

91
Q

Alginate dressings

Amount of exudate for use?

Wound packing?

Do they help control bleeding with hemostasis properties?

Dont have Autolytic Debridement properties

A

Exudate: Moderate to heavily exuding wounds.

Wound Packing: They can be used for packing wounds, particularly those with irregular shapes or deep wounds.

Hemostasis: Alginate dressings have hemostatic properties, helping to control bleeding in certain wounds.

False Support Autolytic Debridement: Alginate dressings support autolytic debridement by maintaining a moist environment, facilitating the removal of dead tissue from

92
Q

Mepilex foam is mostly used for this purpose

Provides care for ulcers up to this level

A

Prevención

Up to stage 2

93
Q

Wound Care Vaccum

Negative Pressure: The system creates negative pressure at the wound site, which serves several purposes:

(4)

A

Reducing edema (swelling)
Enhancing blood flow
Removing excess wound fluid (exudate)
Promoting a moist wound environment

94
Q

The _____ drain is a thin, flexible tube with an open end. It does not have a reservoir or collection bag like some other drainage systems.

Commonly employed in various surgical procedures, including abdominal and orthopedic surgeries. They may be used when continuous drainage is necessary during the early stages of wound healing.

A

Penrose

95
Q

A nurse does (3) things to ensure a JP drain is working properly

A

Monitor Drainage Output: Regularly assess the amount and characteristics of fluid collected in the JP drain reservoir. Significant changes may indicate potential issues.

Maintain Suction: Ensure the suction bulb or reservoir remains compressed and functions properly. If it’s a bulb, squeezing it gently to maintain suction is crucial.

Check Tubing and Connections:

96
Q

Acute Injuries:

(Hot or Cold) therapy is often applied during the initial stages of acute injuries, such as sprains, strains, or bruises. It helps reduce swelling and numbs the area, providing pain relief.

Inflammation: is effective in managing inflammatory conditions, like arthritis flares or tendonitis, by decreasing blood flow and reducing inflammation.

A

Cold therapy

97
Q

Muscle Stiffness:

(Cold or Hot) therapy is often used for conditions involving muscle stiffness or tightness, such as muscle spasms or tension.

Chronic Pain:

Can be beneficial for chronic conditions like arthritis or ongoing muscle pain by promoting blood flow, relaxing muscles, and easing stiffness.

A

Hot therapy

98
Q

Sick day concerns

Increased stress causes increase in hormones that will (Raise or Lower) Glucose levels

A

Raise

99
Q

Abrasions
Superficial
Autolytic Debridement
Protection to wound

Not much exudate

Abrasian

A

Tegaderm
transparent film dressing produced by 3M.

100
Q

____ wound intention, refers to when doctors close a wound using staples, stitches, glues, or other forms of wound-closing processes.

A

Primary

101
Q

_______ intention wound healing, occurs when a wound that cannot be stitched causes a large amount of tissue loss. Doctors will leave the wound to heal naturally in these cases.

A

secondary

102
Q

_____ wound healing, or healing by delayed primary closure, occurs when there is a need to delay the wound-closing process

A

Tertiary

103
Q

The main purpose of this wound care product is:

hydrate wounds, re-hydrate eschar and aid in autolytic debridement.

are insoluble polymers that expand in water and are available in sheet, amorphous gel or sheet hydrogel-impregnated dressings.

A

Hydrogel

104
Q

Do hydrogels which rehydrate necrotic tissue, Have a High Absorptive Property

A

Yes

105
Q

_____ dressings adhere directly to the wound and do not usually require a secondary dressing to keep them in place.

A

Hydrocolloid

106
Q

_____ cool the wound and provide excellent pain relief.

A

Hydrogels

107
Q

_____ provide padding that can relieve pressure over bony prominences and so are also suited for chronic ulcers.

A

Foam padding

108
Q

What is a deciding factor for which type of dressing to use

A

Moisture (Exudate)

109
Q

Non-blanchable reddness localized over boney prominence.

Dark pigments may not have visible blanching- may differ in color from surrounding area

A

Stage 1

110
Q

Partial Thickness Loss

Open ulcer with red/pink wound bed

Usually without Slough

A

Stage II

111
Q

Full thickness SQ Fat visible

NOT bone, tendon, muscle

Slough maybe present but doesn’t obscure depth of tissue loss

A

Stage III

112
Q

Full thickness loss

Exposed Bone, Tendon, Muscle

Slough or Eschar maybe present

A

Stage IV

113
Q

Occulsive dressings are used for this stage in Pressure Ulcers

Transparent Films:
Hydrocolloid Dressings:
Hydrogel gel:
Foam Dressings:

A

Stage 2

114
Q

high water content, providing a cooling and hydrating effect. They are useful for wounds with minimal to moderate exudate and can help facilitate autolytic debridement.

A

Hydrogel

115
Q

Absorbent and form a gel when in contact with wound exudate. They create a moist environment, promote autolytic debridement, and offer protection against bacterial contamination. Are suitable for partial and full-thickness pressure ulcers.

A

Hydrocolloid dressings

116
Q

______ are absorbent and provide a cushioning effect. They are suitable for wounds with moderate to heavy exudate, helping to maintain a moist wound environment and prevent maceration of surrounding skin.

A

Foam dressings

117
Q

Wet to Dry dressings; debridement of eschar (chemical / manual / SX)

DESCRIBES PRESSURE ULCER CARE

THIS STAGE

A

Stage III

118
Q

is death of body tissue due to a lack of blood flow or a serious bacterial infection

A

Gangrene

119
Q

These types of injuries are a potential serious consequence of all IV therapy

A

Extravasation

120
Q

Cellulitis infections occur with Venous or Arterial problems

A

Venous

121
Q

The (Higher/ Lower) the number in the Braden Scale the higher the risk for Pressure Ulcer

A

Lower

6 lowest - 24 Highest

122
Q

Autolytic debridement

Stage 2 & 3

Moist wound environment

3 - 5 days

A

Duoderm,, Tegasorb

Hydrocolloid dressings

123
Q

Partial & Full thickness wounds

Prevención at high risk friction areas

Light to moderate drainage (Slough & necrosis)

1st & 2nd degree burns

NOT FOR USE INFECTED WOUNDS

A

Hydrocolloid dressings

124
Q

Does not adhere to wound bed

Moist environment
Gel
Autolytic Debridement
Not for heavy drainage
Reduce pain
Require 2nd dressing to secure
Stage 2 - 4
INFECTED WOUNDS
dry wounds

A

Hydrogel

125
Q

Maintain moist environment
Require 2nd dressing to secure
Absorbs upto heavy Exudate
NOT FOR USE WITH DRY ESCHAR
3 -5 DAYS

A

Foam

126
Q

Allows exchange of O² between wound and environmental
Waterproof
No absorption
Prevents loss of wound fluid

A

Tegaderm, 3M

Transparent

127
Q

Secures intravenous catheters, nasal cannula, chest tube dressing
Stage 1 pressure injuries
Minimal drainage
4-7 days
COVER DRESSINGS FOR GELS, FOAMS, GAUZE

A

3M, Tegaderm

Transparent films

128
Q

How do you know if the JP drain is not suctioning properly

A

It is fully expanded

Not compresses / Flat

129
Q

Incisions:

Result from surgical procedures where the skin is intentionally cut using a scalpel or another sharp instrument.

Lacerations:

Irregular, torn wounds with jagged edges, often caused by traumatic injuries or accidents.

Abrasions:

Superficial wounds caused by friction or rubbing against a rough surface, resulting in the removal of the top layer of skin.

Contusions (Bruises):

Puncture Wounds:

Caused by a pointed object penetrating the skin, such as stepping on a nail or being punctured by a sharp object.

Crush Injuries:

Result from a forceful compression of tissues, often seen in accidents involving heavy objects.

Result from blunt force trauma that damages blood vessels beneath the skin, leading to discoloration.

Acute or Chronic Wounds

A

Acute

130
Q

Pressure Ulcers (Bedsores):

Caused by prolonged pressure on the skin, typically in areas with bony prominences. Common in immobile or bedridden individuals.

Venous Ulcers:

Result from venous insufficiency, leading to poor circulation and skin breakdown, usually around the lower legs.

Arterial Ulcers:

Caused by inadequate blood supply to the tissues, often associated with peripheral arterial disease. Commonly found on the lower extremities.

Diabetic Foot Ulcers:

Develop in individuals with diabetes due to a combination of factors, including poor circulation, neuropathy, and pressure.

Neuropathic Ulcers:

Associated with nerve damage, often seen in individuals with neuropathy. Lack of sensation can lead to unnoticed injuries.
Chronic Surgical Wounds:

Wounds that fail to progress through normal healing phases, often due to underlying health conditions, infection, or poor wound management.

Acute or Chronic Wounds

A

Chronic

NURS 1245 (12 decks)

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