Wound Care Flashcards
What are four ways to maintain healthy skin?
SKIN: Support surfaces, Keep moving, Incontinence control, Nutrition
What is the largest organ in the body?
The skin
How often should you reposition bed bound patients?
Every 2 hours
What degree should you position the HOB if a patient is at risk for pressure ulcers?
Less than 30 degrees
What are the top three reasons that foleys leak?
- constipation
- dehydration
- uti
What are three interventions to prevent dermatitis?
Cleanse (routine daily cleansing for everyone), moisturize (cleanse and moisturize after each major incontinent episode), protect (apply moisture barrier for significant incontinence)
What kinds of wounds are stageable?
Pressure ulcers
Which stage of pressure ulcers are reportable to State DHS?
Stages III & IV
Which assessment tool is used to evaluate a person’s risk for skin breakdown?
Braden scale
What does a low number indicate on the Braden scale?
A high risk
What does a high number indicate on the Braden scale?
A low risk
Define pressure ulcer.
Localized area of tissue breakdown resulting from compression of soft tissue between a bony prominence and an external surface
Which bony prominences have the highest incidence of pressure ulcers?
Sacrum and heels
Define stage I pressure ulcer.
Non-blanchable erythema of intact skin (may include discoloration, warmth/coolness, edema, change in tissue consistency)
Define stage II pressure ulcer.
Partial thickness loss of dermis
Define stage III pressure ulcer.
Full thickness skin loss (with or without undermining, eschar/slough may be present, subcut fat may be visible)
Define stage IV pressure ulcer.
Full thickness skin loss (with visible or palpable muscle/bone/tendon, may include undermining/sinus tracts)
Define unstageable pressure ulcer.
Ulcer bed is covered with eschar or slough so that the full extent of the injury cannot be assessed
Define suspected deep tissue injury.
Purple or maroon area of intact skin, or blood filled blister due to damage of underlying tissue. May evolve into ulcer.
What are the four cardinal signs of inflammation?
Rubor (redness), tumor (swelling), calor (heat), dolor (pain)
Define proliferation.
To grow by rapid production of new cells (first stage of wound healing)
Which nursing measures can optimize wound healing preoperatively?
Nutrition, reduce steroids, eliminate aspirin, patient education to reduce anxiety
Which nursing measures can optimize wound healing postoperatively?
Pain control, warmth, hydration, oxygenation, support binders
Define acute wound.
Wounds with sudden onset including superficial, penetrating, perforating, laceration, abrasion, contusion, skin tear, surgical wound
Define chronic wound.
Any acute wound that fails to heal or pressure, venous, arterial, diabetic and neuropathic wounds
Define undermining.
Tissue destruction to underlying intact skin along wound edges
Define tunneling.
A measurable tract extending from the wound bed
Define serous wound exudate.
Clear, watery plasma
Define sanguineous wound exudate.
Bright red; indicates active bleeding
Define serosanguineous wound exudate.
Pale pink, watery drainage; mixture of clear and red fluid
Define purulent wound exudate.
Thick, yellow, green or brown drainage.
What might a foul smelling wound indicate?
Infection (or expected in the presence of eschar or slough)
What would a red-colored wound indicate?
Usually granulation tissue
What would a yellow-colored wound indicate?
Slough (soft-necrotic tissue)
What would a black-colored wound indicate?
Eschar (firm/hard necrotic tissue)
What is the most basic principle of wound healing?
Keep the wound warm, dark, moist and protected
What is the best way to prevent pressure ulcers on the heels?
Float heels
How is a wound measured?
Length x width x depth
How do you care for a dehisced wound?
Keep it open and pack lightly (must heal from the inside out to prevent an abscess from forming)
Which area of the body never gets debrided if it is intact and not infected?
Heels (too thin of tissue, debriding would reveal bone easily)
What is wound healing by primary intention?
Wound approximating; healing occurs by epithelialization; wound approximates quickly and with minimal scar formation (ex: staples, sutures)
What is wound healing by secondary intention?
Wound not approximating;heals by granulation, wound contraction and epithelialization (ex: pressure ulcers)
What is wound healing by tertiary intention?
Closure of wound is delayed to resolve risk of infection, then wound is approximated
Why would a wound be debrided?
To rid the wound of source of infection, enable visualization of wound bed, or provide a clean base necessary for healing
Normal Values: prealbumin
15-36 mg/dL
Normal values: albumin
3.5-5 g/dL
