Wound management Flashcards
Name the absorbent dressing types
- calcium alginates
- hydrofibers (aquacel), silver impregnated hydrofiber
- silicone foam
- hydrocolloids
- antimicrobial dressing
- crystalline sodium chloride impregnated nonwoven gauze
- hydrogel
What dressing is this?
non-adherent gauze with bizmuth
What are the side effects of Dakin’s?
- Redness
- irritation
- swelling
- pain
What stage of injury is this?
Unstageable pressure injury
What are the side effects of nystatin?
burning, itching, redness, stinging
What are non-modifiable risk factors for pressure injury?
older than 65
history of pressure injury
What are the interventions for candidiasis?
- keep skin dry
- treat with nystatin
- treat Fluconazole PO or IV for widespread rash
What are the dressings used for stage 2 pressure injury?
- silicone foam to absorb moisture and reduce friction
- hydrocolloid for moderate drainage, change every 3 to 5 days
- non-adherent dressing covered with dry gauze and tape (cloth or silicone tape on fragile skin)
- hydrogel with gauze and tape to add moisture to the wound
What are the guidelines for administering Flagyl?
- PO = empty stomach preferred
- IV = infuse over 30 to 60 minutes
topical = cleanse area first, apply in thin layer
What are the contraindication for compression wrap therapy?
- poor result on ankle-brachial index study
- presence of arterial disease
- decompensated heart failure
- actue SOB
What are personal risk factors for arterial ulcers?
- smoking
- advanced age
- diabetes
- HTN
- hyperlipidemia
- family history
- ethnicity
What is important patient teaching for Flagyl?
- do not drink alcohol for 3 days after treatment ends (risk for disulfram-like reaction)
- avoid driving if feeling drowsy
- possible metallic taste
- may have a dry mouth
- urine may turn dark
What interventions for dry, flaky skin?
- petrolatum ointment (avoid between the toes)
- eucerin emollient after bathing
- lacHydrin
- triamcinolone
What stage injury is this?
Stage 3 pressure injury
Name the pressure points on the body
- back of head
- back of shoulders
- elbows
- lower back and buttocks
- hips
- inner knees
- heels
What are the pharmacokinetics of mupirocin?
metabolized in skin, minimal systemic absorption
What steps can be taken to prevent skin tears?
- do not drag patient, use a lift device
- do not use tape or adhesives on sensitive skin
- maximize nutrition and hydration
- do not pull skin when giving care
- moisturize skin with a low pH product
What are the signs a wound is infected?
- pus
- foul odor
- pain
- swelling
- redness
- heat
- fever
- chills
What is the nursing assessment for Flagyl?
- assess for infection (vitals, wound, sputum, urine, stool, WBCs)
- get cultures before starting therapy
- monitor neuro status with IV admin
- monitor liver function tests
What type of wound is this?
Arterial ulcer
What therapeutic class is fluconazole?
systemic antifungal
What are the nursing interventions for peristomal MASD?
- assess for proper stomal appliance placement
- correct and educate on stoma appliance
- crust skin with pectin based powder and then no sting protectant
- use zinc oxide if paste won’t adhere
What is a stage 2 pressure injury?
- partial thickness loss of skin with exposed dermis or
- serum filled blister
- wound bed pink or red and moist
- no slough or eschar present, no granulation tissue
What are some cardiovascular diseases that increase risk for pressure injury?
impaired circulation
peripheral vascular disease, either venous or arterial
edema
MI
GI bleed
What are the s/s of peristomal MASD?
- maceration
- redness
- denuding of skin
What are the contraindications for topical triamcinolone ?
- untreated bacterial or viral infections
- hypersensitivity to corticosteroids
- use cautiously with hepatic dysfunction, diabetes, cateracts, glaucoma, TB, skin atrophy
What is this wound?
Neuropathic (diabetic) lower extremity wound
What are the interventions for deep tissue injury?
- do not place a dressing
- relieve pressure at all times
- monitor for 7 days
What are the uses of Santyl?
- removal of dead skin and tissue from a wound, esp. ulcer
- uses enzyme collagenase
- works with antibiotics
What dressing is this?
non-adherent gauze with petroleum
What causes arterial ulcers?
decreased blood flow to the lower extremity
What are some nursing interventions for intertrigo?
- keep skin folds dry
- reduce friction
- use pH balanced cleanser and wipes
- textile wicking product in skin folds
What are 3 aggravating factors for MASD?
- friction
- irritants
- microbes
What is the time/action profile for fluconazole?
PO:
- unknown onset, 2 to 4 hour peak, 24 hr duration
IV
- rapid onset
- peaks at end of infusion
- 24 hr duration
What are the side effects of Santyl?
- burning sensation that should subside
- risk for systemic infection
What dressings are appropriate for treating skin tears?
- non-adherent gauze with bizmuth
- non-adherent gauze with petroleum
- silicone foam or non-adherent dressing covered with gauze
What are the types of autolytic debridement?
- hydrocolloid dressing
- crystalline sodium chloride dressing
- very slow method
What is the therapeutic class for Flagyl (metronidazole)?
anti-infectives, antiprotozoals, antiucler agents
anaerobic infections caused by Bacteroides, Clostridium
other: Trichomonas vaginalis, Entamoeba histolytica, Giardia lamblia, H. pylori, C. Difficile
What are dressings used for venous stasis ulcers?
- bismuth gauze covered by dry gauze and tape
- silver impregnated hydrofiber covered with dry gauze
- foam dressing covered with dry gauze (for drainage)
- wicking textile covered with dry gauze (for drainage)
- cadexomer iodine dressing for wound with biofilm
What solution is used for chemical debridement?
Dakin’s moistened gauze
What is stage 1 of a pressure injury?
- intact skin
- non-blancheable redness (not purple)
- possilbe changes in skin temp, changes in firmness, changes in sensation
What are the pharmacokinetics for Flagyl?
- widely distributed
- excretion by liver and feces
What are the indications for Flagyl?
- anaerobic infections (intra-abdominal, gynecologic, skin, lower respiratory, bone, joint, CNS, septicemia, endocarditis)
- Amebicide (amebic dysentery, trichomoniasis)
- PUD caused by H. pylori
- bacterial vaginosis
What are the indications for lidocaine patch?
local anesthetic
What are the components of a nursing assessment for skin?
- wound description
- nutrition status
- blood glucose levels
- signs of infection
- head to toe skin assessment
What are the indications for fluconazole?
Fungal infections causing the following conditions:
oropharyngeal or esophageal candidiasis
systemic candidiasis
UTI
peritonitis
cryptococcal meningitis
prevention in bone marrow transplant patients
What is Metrogel?
Topical Flagyl
What is MASD?
Moisture associated skin damage
What therapeutic class is nystatin?
Topical antifungal
What are some labs and tests that indicate risk for pressure injury?
braden score under 19
BMI over 30
albumin under 3.5
prealbumin under 20
What is an unstageable pressure injury?
- full thickness skin and tissue loss
- dark wound bed or blood filled blister
- pain and temperature changes to wound
- may degrade in several days to stage 4
What causes skin tears?
external friction or shearing
What are the s/s of incontinence associated skin damage?
- red, inflamed skin, hyperpigmentation in dark skin
- glistening skin
- islands of eroded skin
- complications such as full thickness wound and yeast infection
What are nursing interventions for periwound MASD?
- absorbent dressings
- wound vac
- pouching system
- barrier cream or film on periwound area
What is this wound?
Venous stasis ulcer
What are the indications and uses for nystatin?
- candidiasis (of skin)
- athlete’s foot
- jock itch
- ringworm
- seborrheic dermatitis
- dandruff
- onychomycosis of nails
- tinea versicolor
What are the uses for Dakin’s solution?
- prevent and treat skin and tissue infections that could result from cuts, scrapes and pressure sores
- before and after surgery to prevent surgical wound infections.
How is venous return promoted?
- elevate feet above heart
- avoid sitting or standing for long periods
- promote ankle flexion
What are the indications for topical triamcinolone?
To treat itching and inflammation caused by allergies or an immune response.
What skin condition is this?
candidiasis (yeast rash)
Name medical devices associated with pressure injury
- pulse ox
- tubing
- tracheostomies
- splints/braces
- SCDs
- venous access sites
- catheters
- drains
- NG tubes
- ETT tubes
What are the pharmacokinetics for fluconazole?
- widely distributed
- mostly excreted by kidneys
- 30 hr half life
How to apply silvadene cream?
- sterile technique
- make sure wound is covered at all times with cream
- apply medium thickness
What are risk factors for yeast rash?
- recent antibiotic therapy
- immunocompromised
- protein malnutrition
- obesity
- stool or urinary incontinence
- perspiration
- chemotherapy
- diabetes
- hot or humind environment
What are the s/s of arterial ulcers?
- punched out shape, demarcated edges
- small and deep
- usually found on toes, ankle bones (malleolus), top of foot
- pale gray wound bed with no granulation
- necrosis
- minimal drainage
- infection or gangrene
- painful, especially with movement or at night
- prolonged cap refill
- diminished or absent pedal pulses
- ankle brachial indices less than 0.9
What dressing is this?
silicone foam dressing
What is a stage 3 pressure injury?
- full thickness loss of skin
- slough, eschar and granulation tissue may be present
- adipose tissue visible
- may be shallow or deep
- may have undermining or tunneling
What are the precautions with Dakin’s?
- chlorine allergy
- do not swallow or use near face
What are some s/s of intertrigo?
- pinkish, red
- partial thickness lesions
- linear fissures
- pain
- itching
- burning
- odor
- found in skin folds
- incontinence
What class is Dakin’s and how is it ordered?
- anti-infective
- once daily or twice daily for more serious wounds
- apply on gauze or spray into wound
- protect periwound with petroleum jelly
What are sources of moisture for MASD?
- urine
- stool
- sweat
- wound drainage
- saliva
- mucus
What are the components of a wound assessmentl?
- size (length, width and depth)
- redness
- odor
- color of wound bed
- drainage
- presence of necrotic tissue
- undermining or tunneling
What is the assessment for pressure injury?
- daily assessment
- color of wound bed and periwound
- odor
- location
- size
- undermining/tunneling
- signs of infection
- pain, temp, firmness
What are the s/s of periwound MASD?
- maceration from heavy exudate (white or gray skin)
- inflammation
- friction
- redness
- denuding
Where is the cause of the venous stasis ulcer?
- venous insufficiency
- valve reflux
- blockage of veins
- lack of calf muscle pumping
(pathogenesis not well understood)
What are the nursing interventions for lidocaine topical?
- assess for open wounds. Only apply to intact skin
- apply 1 hour before procedure
- wipe clean before procedure
- teach patient to avoid trauma to the area as there is no sensation to the skin for several hours
What therapeutic class is silvadene cream?
- anti-infectives
- sulfa antibiotics
What is a skin tear?
separation of epidermis from the dermis or dermis from underlying structures
What is action of nystatin?
disrupts the synthesis of the fungal cell wall
What are nursing interventions for pressure injuries in general?
use the skin care protocol
use specialized sleep surface
nutrition consult for all pressure injuries
What are the side effects of silvadene cream?
- skin irritation
- blue/gray skin or gums
- anemia
- kidney problems
- liver problems
What drugs are risk factors for pressure injury?
vasoconstricting drugs
immunosuppressive drugs
steroids
cancer drugs
What are the side effects of mupirocin?
skin irritation
What are the nursing interventions for nystatin?
- monitor for improvement (slight improvement over 3 days, may take several weeks for full improvement)
- instruct patients to continue full course of treatment even when better
- keep skin clean and dry, change socks daily
What is the classification for lidocaine topical?
Therapeutic: anesthetic
What are the causes of neuropathic wounds?
- usually diabetes
- Hansen’s disease
- familial neuropathy
- spinal cord injury
- alcoholism
What stage of injury is this?
Suspected deep tissue injury (purple discoloration)
What are the interventions for arterial ulcers?
- protect wound and keep it dry
- dress with iodine and cover with gauze
- monitor and treat infections
- consult surgery for revascularization
- proper foot care
- promote cardiovascular and diabetic health (meds, controlled blood sugars, diet)
What are the nursing interventions for triamcinolone topical?
- monitor skin for response
- monitor for infection and notifiy provider (pain, redness, exudate)
- possible adrenal function test for large doses or long term treatment
What solution is used for enzymatic debridement?
Santyl collagenese
What is the classification for topical triamcinolone?
Therapeutic: anti-inflammatories (steroidal)
Pharmacologic: corticosteroids (topical)
What are the indications and uses of mupirocin?
- topical treatment of impetigo
- skin lesions infected with staph or strep
- nasal colonization with MRSA
What is the main risk factor for neuropathic wounds?
trauma on lower extremity and uncontrolled diabetes
What stage injury is this?
Stage 3 pressure injury
What is the time and action of Flagyl?
- PO = rapid onset, peak at 2 hours, duration 8 hours
- IV = rapid onset, peaks at end of infusion, lasts 8 hours
- Topical = 3 week onset, 9 week peak, lasts 12 hours
- vaginal = unknown onset, 8 hour peak, lasts 12 hours
What are the s/s of a venous stasis ulcer?
- shallow
- irregular borders
- found between ankle and mid calf
- aching in calf (often relieved by walking)
- red wound bed
- warm to the touch
- swelling
- pulses present
- some drainage
What are adverse reactions of Flagyl (PO or IV included)?
- dizziness, HA
- abdominal pain, anorexia, nausea
- stevens-johnson syndrome
What are appropriate dressings for neuropathic wounds?
- silver hydrofiber
- bismuth impregnated gauze and cover with gauze
- foam
- gentamicin moistened gauze covered with dry gauze
- crystalline sodium chloride for drainage
- calcium alginate for drainage
- saline moistened gauze
- hydrogel covered with dry gauze
- dakin’s
- silvadene
- mupirocin
- cadexomer iodine based dressing for chronic wounds with biofilm
Where is yeast rash typically found?
- groin
- perineum
- buttocks
- underarm
- under breasts
- pannus
What are the indications for topical gentamicin?
localized infection caused by susceptible organisms (primarily gram negative bacillary or enterococcal infections)
What are nursing interventions for incontinence related MASD?
- no adult diapers (exceptions for transportation)
- do not scrub area
- use pH balanced skin cleanser and wipes
- protect skin with barrier cream such as petroleum or zinc oxide
- use incontinence appliances (condom catheter, retracted penis pouch, fecal incontinence collector pouch)
What are contraindications for fluconazole?
- concurrent use with pimozide
- use caution with renal patients, liver issues, elderly
What dressings should be used for stage 3 pressure injury?
- absorbent dressing for wounds with drainage
- gauze dressings with ordered medications
- santyl debriding ointment covered with dry gauze, kerlix and taped
- crushed Flagyl on necrotic wounds. cover with non-adherent gauze and then dry gauze and tape.
- metrogel for necrotic wounds with odor and in need of moisture. cover with non-adherent gauze and then dry gauze and tape.
- cadexomer for chronic wounds with biofilm. cover with non-adherent dressing, then dry gauze.
What are the nursing interventions for stage 2 pressure injury?
- protect from further injury (reduce friction and shear)
- maintain a moist wound bed
- place dressings
What spectrum is mupirocin?
- gram positive, esp. staph and beta hemolytic strep
What are the side effects of fluconazole?
- increased side effects with HIV patients
Severe
- hepatotoxicity
- stevens-johnson syndrome
mild to moderate:
- HA, dizziness, nausea, hypokalemia, hypertriglyceridemia
What are risk factors for intertrigo?
- exposure to moisture
- friction
- reduced perfusion
- adipose tissue
- diabetes
- steroid and antibiotics at the same time
- obesity
What is granulation tissue?
new vascular tissue on a healing wound
What therapeutic class is mupirocin (Bactroban)?
anti-infective
What are some risk factors for venous stasis ulcers?
- venous reflux
- DVT
- reduced mobility, leg weakness
- fractures
- varicosities
- standing occupation
- family history
- CHF
- pregnancy
- obesity
- advanced age
What are some neuro diseases that increase risk for pressure injury?
CVA
spinal cord injury
cognitive dysfunction
decreased sensory perception
What is a pressure injury?
- localized area of injury to skin and underlying tissue and
- found over a bony prominence or related to a medical device and
- caused by pressure or shear
What stage is this injury?
Stage 4 pressure injury
What are the nursing interventions for mupirocin?
- assess lesions before treatment and daily. Improvement should be seen in 3 to 5 days.
- wash affected area with soap and water, and dry
- apply thin layer
- may be covered with gauze
What are the s/s of neuropathic wounds?
- wounds on plantar aspect of foot, metatarsal heads, heels, other pressure points
- smooth wound edges
- pink, pale or necrotic wound bed
- small drainage
- periwound calloused, red or macerated
- hypertrophic nails
- insensate
What dressing is this?
silicone dressing (no foam)
Name the 11 risk factors for skin tears
- old age
- history of skin tears
- steroid use
- dehydration
- bruising
- purpura
- edema
- poor nutrition
- cognitive impairment
- dry skin
- impaired mobility
What are the interventions for venous stasis ulcer?
- control edema
- controle drainage
- protect skin
- promote venous return
- stimulate granulation tissue growth
- place dressing
What are lower extremity wounds typically caused by?
- venous stasis
- blockage of veins
- arterial insufficiency
- immobility
- neuropathic factors
What are the indications and uses for silvadene cream?
- help prevent and treat wound infections, especially burns
What is the brand name for fluconazole?
Diflucan
What is a stage 4 pressure injury?
- full thickness loss of skin and tissue loss
- exposed fascia, muscle, tendon, ligament, bone or cartilage
- may have slough or eschar
- rolled edges, undermining, tunneling may be visible
- may be shallow or deep
When should you notify the provider about a wound or skin issue?
- increase in wound size
- deterioration in nutrition status
- deterioration in hydration status
- increasing bowel or bladder incontinence
- decrease in mobility
- deteriorating skin around wound
- signs of infection
What are the nursing interventions for tube site MASD?
- assess for sources of leaking such as constipation, ileus
- check for balloon inflation and bumper placement
- replace tube
- tape tube
- clean insertion site with soap and water or diluted hydrogen peroxide
- barrier cream
- nystatin powder
What is the patient teaching for fluconazole?
- continue taking medication until course is completed, even if feeling better
- notify provider if signs of liver damage occur (fatigue, poor appetite, nausea, jaundice, dark urine, pale stools)
- notify provider if there is no sign of improvement
What are the nursing interventions for stage 4 pressure injury?
- protect from further injury
- turns
- moist wound bed
- debridement
- absorption of exudate
- wound filler
- treatment of infection
What is the time and action profile for topical lidocaine?
Local = rapid onset, unknown peak, 2 hour duration
What is this dressing?
non adherent dressing (adaptic)
What are the nursing interventions for skin tears?
- control bleeding with pressure
- attempt to approximate flap with steristrips
- apply a dressing
What are the side effects for topical triamcinolone ?
- irritation of skin
- atrophy of skin
- hypopigmentation
- maceration
- secondary infection
What are risk factors for incontinence related MASD?
- urinary incontinence
- fecal incontinence
- immobility
What rate is safe for IV fluconazole?
administer over 1 to 2 hours, do not exceed 200 mg/hr
What are the side effects of topical lidocaine?
- stinging, burning, contact dermatitis
- erythema
What diseases are associated with arterial ulcers?
- atherosclerosis
- collagen abnormalities
- vasculitis
- rheumatoid arthritis
- Lupus
- Buerger’s disease
- Raynaud’s disease
- Protein C deficiencies
What are the dressings used for stage 1 pressure injury?
- silicone foam
- hydrocolloid
What are the nursing interventions for Stage 1 pressure injury?
- place dressings (silicone foam, hydrocolloid)
- protect from further injury (do not use tape)
- use moisturizer, socks, elbow padding to reduce friction
- use zinc oxide for stool barrier
-
What are the risk factors for tube site skin irritation?
- gastroparesis
- constipation
- ileus
- fungal infection/yeast infection
What are the interventions for neuropathic wound?
- dressings as ordered
- debridement (surgical or enzymatic)
- control blood sugars
- no bare feet, shoes that fit well
- hyperbaric oxygen therapy
What are the types of MASD?
- incontinence associated skin damage
- intertriginous dermatitis
- periwound moisture associated skin damage
- peristomal moisture associated skin damage
- tube site skin irritation
What stage is this injury?
Stage 1 pressure injury
What are the interventions for unstageable pressure injuries?
- do not debride stable, hard, dry eschar in ischemic limbs or heel
- use 10% povidone iodine solution
- cover with dry gauze
What are the types of debridement?
- autolytic debridment
- mechanical (pulsatile lavage)
- chemical
- enzymatic
- surgical
What are the s/s of tube site irriation?
- inflammation, redness around feeding tube
- rash
- denuding
What classification is gentamicin topical?
Pharmacologic: aminoglycosides
Therapeutic: anti-infective
What is focused nursing assessment for fluconazole?
- obtain cultures from infected area before administration, including CSF
- monitor BUN and creatinine
- monitor liver function tests (AST, ALT, serum alkaline phosphate, bilirubin)
What are the nursing interventions for stage 3 and stage 4 pressure injury?
- protection from further injury
- turns
- maintenance of moist wound bed
- debridement
- absorption of exudate
- wound filler
- treatment of infection
