Wound Care : Info from Mosby's Canadian Textbook for the Support Worker - E-Book – Sheila A. Sorrentino, Leighann Remmert, Mary J. Wilk, Rosemary Newmaster Flashcards
A partial-thickness wound caused by the scraping away or rubbing of skin.
abrasion
An open wound on the lower legs and feet caused by poor arterial blood flow.
arterial ulcer
A wound that does not heal easily.
chronic wound
An open wound on the lower legs and feet caused by decreased blood flow through arteries or veins.
circulatory ulcer
Also known as vascular ulcer .
A wound that is not infected; microbes have not entered the wound.
clean wound
A wound occurring from the surgical portal of entry into the urinary, reproductive, or digestive system.
clean-contaminated wound
A wound in which tissues are injured but skin is not broken.
closed wound
A wound with a high risk of infection; microbes have entered the wound.
contaminated wound
A closed wound caused by a blow to the body.
contusion
The separation of wound layers.
dehiscence
Swelling in tissues caused by an accumulation of fluid.
edema
Separation of the wound accompanied by protrusion of abdominal organs.
evisceration
Resistance that skin encounters when it rubs against another surface such as clothing, bedding, or another fold of skin.
friction
A wound in which the dermis, epidermis, and subcutaneous tissue are penetrated; muscle and bone may be involved.
full-thickness wound
A condition in which tissue dies and then decays.
gangrene
The collection of blood under skin and tissues.
hematoma
Localized tissue death as a result of disease or injury.
necrotic tissue
A wound in which skin or the mucous membrane is broken.
open wound
A wound in which the dermis and epidermis of skin are broken.
partial-thickness wound
The excessive loss of blood within a short period.
hemorrhage
An open wound with clean, straight edges; usually intentionally created with a sharp instrument.
incision
A wound containing large amounts of bacteria and showing signs of infection. Also known as dirty wound .
infected wound
A wound created for treatment.
intentional wound
An open wound with torn tissue and jagged edges.
laceration
An open wound in which skin and underlying tissues are pierced.
penetrating wound
A type of soap that is used to wash skin. It is used primarily as a cleanser and deodorizer of the perineal area soiled by urine and feces. It also emulsifies (breaks up) feces to aid gentle, easy cleaning. Because it is pH balanced to the acid mantle (covering) of skin, it does not have to be rinsed off like other harsher soaps.
peri-wash
A type of dressing in which the tape is applied to all four edges to reduce the likelihood of the dressing wrinkling or falling off.
picture-frame dressing
A type of edema that is evident by (1) first compressing your fingers into the swollen tissues, (2) then removing your fingers, and (3) observing an impression of your fingers left in the skin.
pitting edema
Any injury caused by unrelieved pressure.
pressure ulcer
Also known as decubitus ulcer , bedsore , or pressure sore .
puncture wound
An open wound made by a sharp object; entry into skin and underlying tissues may be intentional or unintentional.
Thick drainage from a wound or body orifice; this drainage is yellow, green, or brown and may indicate an infection.
purulent drainage
Tearing of skin tissue caused when the skin sticks to a surface (usually the bed or chair) and deeper tissues move downward, exerting pressure on the skin.
shearing
The condition that results when there is not enough blood supply to organs and tissues.
shock
A break or rip in skin; the epidermis separates from the underlying tissue.
skin tear
A type of adhesive bandage in which thin strips are applied across a skin tear; the dressing will bring the skin edges together and hold them together while the wound heals.
steri-strip
A group of similar cells that perform a similar function together.
tissue
An accident or violent act that injures skin, mucous membranes, bones, or internal organs or causes an emotionally painful, distressful, or shocking result, which often leads to lasting mental and physical effects
trauma
Open wounds on the lower legs and feet caused by poor blood return through the veins.
venous ulcer
Also known as stasis ulcer .
A break in the skin or mucous membrane.
wound
What is the purpose of the skin?
protecting the body from infection and disease.
Heat regulation.
Excrete toxins.
List the age-related changes in the skin
- Skin dryness
- Fragile and weak capillaries
- General thinning of the skin
- Loss of fatty layer under the skin
- Decreased sensation to touch, heat, and cold
- Decreased mobility • Sitting in a chair or lying in bed most or all of the day
- Persistent diseases (e.g., diabetes, high blood pressure)
- Diseases that decrease circulation
- Poor nutrition
- Poor hydration
- Incontinence
- Moisture in the dark areas of the body (skin folds, under breasts, between toes, and perineal areas)
- Pressure on bony parts
- Poor care of fingernails or toenails • Friction and shearing
A wound that —has a high risk of infection; unintentional wounds (such as a stabbing) are wounds that are not created under sterile conditions, also occurs from breaks in surgical asepsis and from the spillage of intestinal contents.
contaminated wound
A wound that —contains large amounts of bacteria and shows signs of infection; for example, old wounds, surgical incisions into infected areas (such as a ruptured appendix), and traumatic injuries that rupture the bowel
Infected wound (dirty wound)
Skin tears occur due to
shearing, pulling, or direct pressure on skin.
Skin tears are commonly caused by:
- Bumping a hand, arm, or leg on any hard surface such as a bed, bed rail, chair, wheelchair footrest, or table
- Holding on to a client’s arm or leg too tightly
- Repositioning, moving, or transferring a client without a transfer sheet or other non-friction surface, which can cause the client’s skin to rub against the surface and even tear
- Bathing, dressing, and other tasks
- Pulling buttons or zippers across fragile skin
Clients at risk for skin tears include those who:
- Require moderate to complete help in moving
- Have poor nutrition or are very thin
- Are poorly hydrated • Have altered mental awareness; for example, clients with dementia may resist care and move quickly and without warning, which can cause skin tears
- Are older
What can a PSW do to avoid causing client skin tears?
- Follow the care plan for moving, lifting, repositioning, transferring, dressing, and bathing the client. • Keep the skin moisturized. Follow the care plan.
- Offer fluids. Follow the care plan.
- Dress and undress the client carefully.
- Dress the client in soft clothing with long sleeves and long pants. Allow the client to make choices.
- Keep your fingernails short and filed smooth.
- Keep the client’s fingernails short and filed smooth. Report client’s long and rough toenails to your supervisor.
- Do not wear rings with large or raised stones or edges that could snag on anything.
- Follow safety guidelines when transferring or lifting the client to and from a bed or wheelchair
- Prevent friction and shearing during lifting, moving, transferring, and repositioning.
- Use a turning sheet to move and turn the client in bed.
- Use pillows to support arms and legs. Follow the care plan.
- Be patient and calm when the client is confused or agitated or resists care.
- Ensure that bed rails and wheelchair arms, footrests, and leg supports are padded. Follow the care plan.
- Provide good lighting to prevent the client from bumping into furniture, walls, and equipment.
Pressure points that are moist with perspiration or body excretions are especially prone to developing a pressure ulcer, as well as bacterial infections that are very difficult to treat once they set in.
T or F
True
The supine pressure points are:
back of head, shoulders, spine elbows, sacrum, heels
In obese people, pressure ulcers can develop in areas where friction is caused by skin-to-skin contact.
T or F
True
Some high risk areas for pressure ulcers are:
Skin over a bony prominence is squeezed between hard surfaces.
Skin to skin areas
Skin fold areas—under breasts, between abdominal folds, on legs and buttocks, and between toes
Clients at risk for pressure ulcers are those who:
- Are confined to bed or a chair
- Require moderate to complete help in moving
- Have loss of bowel or bladder control
- Have poor nutrition • Have altered mental awareness
- Have problems sensing pain or pressure
- Have circulatory problems
- Are older • Are obese or very thin
The first sign of a pressure ulcer is
pale skin or a warm, reddened area.
Colour changes in skin may be hard to notice in dark-skinned clients, so if the client is complaining of pain, burning, itching, or tingling in the area, you should report this to your supervisor.
T or F
True
Clients will always notice something unusual if they are developing a pressure sore.
T or f
False
Some clients may not feel anything unusual, so it is important that you observe your client and look for other signs of poor blood flow to the area.
Which stage of pressure ulcers is this: The skin is gone, and the underlying tissues are exposed and damaged. There may be drainage from the area.
Stage 3
Which stage of pressure ulcers is this: The skin is red. The colour does not return to normal when the skin is relieved of pressure
Stage 1
Which stage of pressure ulcers is this: The skin cracks, blisters, or peels. There may be a shallow crater.
Stage 2
Which stage of pressure ulcers is this: Muscle and bone are exposed and damaged. Drainage is likely.
Stage 4
Good support care to prevent pressure ulcers includes:
Frequent position changes and ensuring a proper diet with lots of fluid, cleanliness, and skin care are essential.
Repositioning for pressure ulcers should be at least
every two hours
Massage massage pressure points to relieve stress.
T or f
False
Never rub or massage reddened areas, but massage the skin around the reddened area. Be careful to never scratch or irritate the skin.
What can you do to keep the client’s heels off the bed?
Use pillows or other devices as directed. Place the pillows or devices under the lower legs from mid-calf to the ankles.
What can you do to prevent skin on skin contact?
Use pillows and blankets to prevent skin-to-skin contact and to reduce moisture and friction.
Remind clients sitting in chairs to shift their positions every 15 minutes to decrease pressure on bony points.
T or f
True
To reduce the likelihood of shearing, do not raise the head of the bed to more than 45 degrees. Always follow your client’s care plan.
T or F
False
do not raise the head of the bed to more than 30 degrees
Apply a moisturizer on dry areas—hands, elbows, legs, ankles, and heels, areas under the breasts, between skin folds, and between toes.
T or F
False
Apply a moisturizer on dry areas—hands, elbows, legs, ankles, and heels—but NOT on the areas under the breasts, between skin folds, and between toes.
A metal frame placed on the bed and over the client.
A bed cradle (Anderson frame)
Venous ulcers may “weep” fluid.
T or F
True
Scratching is not a common cause of venous ulcers.
T or F
False
Scratching is also a common cause of venous ulcers.
Some ulcers occur spontaneously, without any specific cause.
T or F
True
To prevent venous ulcers :
- Apply elastic stockings or elastic wraps, according to the care plan and if you are allowed to do so.
- Remind the client not to sit with the legs crossed.
- Do not use elastic or rubber-band type garters to hold socks or hose in place.
- Provide good skin care daily. Clean and dry between the toes. • Avoid injury to client’s legs and feet. • Keep linens clean, dry, and wrinkle-free. • Follow the care plan for walking and exercise, as movement increases venous blood flow.
- Reposition the client at least every 2 hours. Follow the care plan.
- Elevate the client’s legs, according to the care plan.
- Have the client wear comfortable socks and shoes.
- Do not do anything that may irritate the skin. Avoid scrubbing or rubbing when bathing or drying the client.
- Avoid massaging over the pressure point. Never rub or massage reddened areas.
- Keep the heels off the bed. Use pillows or other devices, as instructed by your supervisor. Place the pillows or devices under the lower legs from mid-calf to the ankles.
- Use protective devices, as directed by your supervisor and the care plan.
- Report signs of skin breakdown, venous
