Wound Care Flashcards
Protective layer of keratin
Epidermis
This layer is made of collagen
Dermis
Types of wound healing
Rapid healing, no infection, well approximated, sutured edges, (Surgical Wounds)
Primary intention
Heal by granulation (burns, pressure ulcers, wounds with large pieces of missing skin) Risk for Infection
Secondary intention
Wound is left open to heal (Infected Wounds)
Tertiary intention
_____ 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.
Granulation
4 stages of wound healing starting at the beginning
Hemostasis
Inflammatory
Proliferation
Maturation
Phases of wound healing
Construction and then dilation of vessels
Formation of exudate (swelling, pain)
Stimulates cell migration
Immediately after injury
Hemostasis
Phases of wound healing
Debris ingested and growth factors released
Mild temperature elevation
Leukocytosis
General malaise
Inflammatory phase
Phases of wound healing
Regeneration phase
Granulation phase
Systemic symptoms disappear
Clotting occurs
Nutrition and oxygen are key
Profileration phase
Phases of wound healing
Collagen remodeled
Scar becomes flat, thin line
Can affect mobility
Maturation phase
Local factors affecting wound healing
Pressure
Desiccation (Define)
Maceration (Define)
Trauma
Edema
Infection
Necrosis
Lack of O²
Desiccantion (Dehydration)
Maceration (Over hydration, pH levels)
Presence of bacteria which does not cause local or systemic signs of an infection
Colonization
Dehiscence in the context of a wound refers to….
the partial or complete separation of the layers of a surgical incision or a previously closed wound
_______ 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.
Evisceration
An abnormal or surgically made passage between a hollow or tubular organ and the body surface OR
Between two hollow or tubular organs
Fistuals
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 _____
Crohns disease
Fistula
Bile duct and surface of skin (Gallbladder surgery)
Cervix and vagina
Space inside skull and nasal sinus
Bowel and vagina
Are all common
Sites for fistulas
Give an example of a purposefully created fistula
AV fistula
Provide circulation access for kidney dialysis
A collection of infected fluid that has not drained
Abscess
An abscess is a Collection of infected fluid that has not drained and applies pressure to the surrounding tissues causing a _____
Fistula
Access the wound
T
I
M
E
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
Cornified or dried out dead tissue black
Eschar
Liquefied or wet dead tissue
Slough
Bigger area of tissue damage that can be seen (extends under the edge)
Undermining
Tracts extending out from the wound
Tunneling
Drainage Color
Serous
White
Drainage Color
Sanguineous
Red
Drainage Color
Serosanguineous Drainage
Pinkish
Drainage Color
Purulent
Yellowish
Open wounds
Red
____ stage of healing, reflect color of normal granulation
Proliferative stage
Color classification of open wounds
Black
Covered with thick eschar
Require _____ to analyze open wound
Debridement
Yellow Open Wound indicates
Slough: loose, necrotic tissue
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 ____
Exudate, eschar, necrotic material
Moisten with sterile saline to collect sample
_____ can occur when a patient is moved carelessly or slides down in bed
Shearing forces
Pressure ulcer stage
Intact skin with Non-blanchable redness of a localized area usually over a bony prominence
Stage 1
Describes pressure ulcer
Partial thickness loss dermis presenting as a shallow OPEN ulcer with a red,pink wound bed, usually without slough
Stage II
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
Stage 3
Describes Pressure Ulcer
Full thickness tissue loss with exposed bone, tendon or muscle.
Slough or eschar maybe present
Often includes Undermining and Tunneling
Stage IV
A wound is considered “Unstageable” if…
Obscured by Slough Or Eschar
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
Contact with hard surface like floor / MRI machine
Deformación of muscle cells
____forms of DTI follow periods of prolonged immobility with hypotension.
Prolonged Emergency Dept. Gurney
Following Cardiac Arrest
Ischemic forms if DTI
Pressure Ulcer Care
Stage I
Turning; pressure relieving devices
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
Pressure relieving devices
Pressure Ulcer Care
Occlusive Dressing
Impermeable to air and fluids.
Moist environment around the wound, which can promote faster healing.
Stage II
Pressure Ulcer Care
Wet to Dry dressings; debridement of eschar (chemical/ manual/ SX)
Stage III
Moisture Associated Skin Damage
(MASD)
Incontinence-Associated dermatitis
Describe
What is / What isn’t
Is: Erythematosus/ Painful
Shallow Irregular edges
KISSING LESIONS (Skin folds mirror eachother
NOT: Slough, Eschar, or granulation tissue.
Extravasation is…
Movement of drug solution ( Antineoplastic, Osmotically Active “containing 10% glucose, calcium Chloride, Calcium Gluconate”)
_____ 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.
Extravasation
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
Deep Tissue Pressure Injury
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)
Deep Tissue Pressure Injury
DTPI
In DTPI Deep Tissue Pressure Injury
Damage is concentrated…
Tissue adjacent to bony prominence
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. 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
Mucosal membrane pressure injury is staged just like skin
True or False
False.
It is unstagebale
___ 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
Occiput
Heels & Sacrum
Medical Device Related (MDR)
If device can be removed do so
Non removable include: cast, Endotracheal Tube, pressure dressing
2 steps to document
- Use staging system
- Note whether is related to medical device
Initial inflammatory Response
Epithelial proliferation and migration
Reestablishment of Epidermal Layers
Describe the healing process for
Partial Thickness Pressure Injuries
During the inflammatory phase of the healing process (3)
Hemostatis
Neutrophils/ macrophages migrate and eat bacteria
Cytokines released during this period promete cell proliferation
Hemostasis is the process of….
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
Epitheliazation appears along the wound edge as tissue that is, thin and these colors
Pearly, silvery, shiny
3 types of wounds that can be confused with pressure injuries
Most common in lower extremities
Arterial injury
Venus injury
Diabetic foot injury
Causes
Atherosclerosis
Arteriosclerosis
Lower Extremity Arterial Disease
Aka
PAD
Risk factors
Age
Smoking
DM
Hypertension
Dyslipidemia
Chronic Kidney disease
Arterial Injuries
Cooler, skin temp
Thin, shiny skin
Decreased/ absent hair
Skin Pallor on foot elevation/ dusky Rubor on dependency
Is this type of Injury
Arterial Injury
Arterial Injuries are classified as
Partial or Full Thickness
Characteristics of _____ injury
Round and regular shape
Pale wound bed
Well defined edges
Necrotic tissue may obscure
Minimal drainage
Sever pain
Arterial
____ 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
Venous Injuries
___ Injuries
Shallow in depth
Irregular shaped / Wound edge
Moderate to large amount of drainage
Yellow fibrous film covers
Variable pain (mild to sever)
Venous Injuries
Charcots foot
Foot normal contour altered due to diabetes
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.
Peripheral Neuropathy
Peripheral Neuropathy
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.
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
Diabetic foot injuries
Risk factors for ____ lower extremity injuries
Visual impairment
Peripheral arterial disease/ neuropathy
Foot deformity
Limited ankle ROM
Diabetic Foot Injury
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
Diabetic Foot Injury
Osteomyelitis
Incontinence Associated Dermatitis
Prolonged exposure to urine or fecal incontinence
Intertriginous Dermatitis
Prolonged exposure to perspiration in Skin Fold
Periwound Moisture Associated Dermatitis
Prolonged Exposure to Wound Exudate
Peristomal Moisture Associated Dermatitis
Prolonged Exposure to Effluent from an Ostomy
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
Incontinence-Associated Dermatitis
Epidermal stripping
Tension injury or blister
Skin tear
Irritant / Allergic Contact dermatitis
Maceration from trapped moisture
Folliculitis
Can all come from
Medical Adhesive-Related Skin Injury
MARSI
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.
secondary
Healing by ________
The tissues approximated by surgical sutures or tapes with minimal loss of tissue
Primary Intention
____ 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.
Tertiary intention
Evisceration is associated with (Dry /Moisture or Generalized Edema)
Dehiscence is associated with (Dry /Moisture or Generalized Edema)
Evisceration = Generalized Edema
Dehiscence = Dry/ Moisture
Deep Tissue Injury is a Dark Purple and associated with Falls
Inside-Out or Outside-In
Describes how the Injury happens
Inside-Out
______ 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
Deep tissue pressure injuries (DTPI)
Venous Statis Ulcer:
Inner leg or Outer Leg
Inner leg
Arterial lower leg wound:
Inner leg or Outer leg
Outside of leg
Braden Scale is used for…
Pressure injuries
Hydrocolloid dressings provide (Moist/Dry) environment and are water proof
Used to help bed sores heal
Moist
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?
2
Low to medium
Hydrates
Yes , Aids in autolytic debridement
Alginate dressings
Amount of exudate for use?
Wound packing?
Do they help control bleeding with hemostasis properties?
Dont have Autolytic Debridement properties
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
Mepilex foam is mostly used for this purpose
Provides care for ulcers up to this level
Prevención
Up to stage 2
Wound Care Vaccum
Negative Pressure: The system creates negative pressure at the wound site, which serves several purposes:
(4)
Reducing edema (swelling)
Enhancing blood flow
Removing excess wound fluid (exudate)
Promoting a moist wound environment
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.
Penrose
A nurse does (3) things to ensure a JP drain is working properly
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:
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.
Cold therapy
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.
Hot therapy
Sick day concerns
Increased stress causes increase in hormones that will (Raise or Lower) Glucose levels
Raise
Abrasions
Superficial
Autolytic Debridement
Protection to wound
Not much exudate
Abrasian
Tegaderm
transparent film dressing produced by 3M.
____ wound intention, refers to when doctors close a wound using staples, stitches, glues, or other forms of wound-closing processes.
Primary
_______ 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.
secondary
_____ wound healing, or healing by delayed primary closure, occurs when there is a need to delay the wound-closing process
Tertiary
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.
Hydrogel
Do hydrogels which rehydrate necrotic tissue, Have a High Absorptive Property
Yes
_____ dressings adhere directly to the wound and do not usually require a secondary dressing to keep them in place.
Hydrocolloid
_____ cool the wound and provide excellent pain relief.
Hydrogels
_____ provide padding that can relieve pressure over bony prominences and so are also suited for chronic ulcers.
Foam padding
What is a deciding factor for which type of dressing to use
Moisture (Exudate)
Non-blanchable reddness localized over boney prominence.
Dark pigments may not have visible blanching- may differ in color from surrounding area
Stage 1
Partial Thickness Loss
Open ulcer with red/pink wound bed
Usually without Slough
Stage II
Full thickness SQ Fat visible
NOT bone, tendon, muscle
Slough maybe present but doesn’t obscure depth of tissue loss
Stage III
Full thickness loss
Exposed Bone, Tendon, Muscle
Slough or Eschar maybe present
Stage IV
Occulsive dressings are used for this stage in Pressure Ulcers
Transparent Films:
Hydrocolloid Dressings:
Hydrogel gel:
Foam Dressings:
Stage 2
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.
Hydrogel
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.
Hydrocolloid dressings
______ 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.
Foam dressings
Wet to Dry dressings; debridement of eschar (chemical / manual / SX)
DESCRIBES PRESSURE ULCER CARE
THIS STAGE
Stage III
is death of body tissue due to a lack of blood flow or a serious bacterial infection
Gangrene
These types of injuries are a potential serious consequence of all IV therapy
Extravasation
Cellulitis infections occur with Venous or Arterial problems
Venous
The (Higher/ Lower) the number in the Braden Scale the higher the risk for Pressure Ulcer
Lower
6 lowest - 24 Highest
Autolytic debridement
Stage 2 & 3
Moist wound environment
3 - 5 days
Duoderm,, Tegasorb
Hydrocolloid dressings
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
Hydrocolloid dressings
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
Hydrogel
Maintain moist environment
Require 2nd dressing to secure
Absorbs upto heavy Exudate
NOT FOR USE WITH DRY ESCHAR
3 -5 DAYS
Foam
Allows exchange of O² between wound and environmental
Waterproof
No absorption
Prevents loss of wound fluid
Tegaderm, 3M
Transparent
Secures intravenous catheters, nasal cannula, chest tube dressing
Stage 1 pressure injuries
Minimal drainage
4-7 days
COVER DRESSINGS FOR GELS, FOAMS, GAUZE
3M, Tegaderm
Transparent films
How do you know if the JP drain is not suctioning properly
It is fully expanded
Not compresses / Flat
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
Acute
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
Chronic
