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Nursing Fundamentals > Wound/skin care > Flashcards

Wound/skin care Flashcards

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1
Q

Debridement

A

Removal of devitalized tissue, foreign matter, infected tissue

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2
Q

Desiccation

A

dehydration; drying up of skin cells and can cause cell death/delay wound healing

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3
Q

Maceration

A

Softening or break down of skin from exposure to excess moisture
(Urinary or bowel incontinence can cause this)

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4
Q

Primary healing intention

A

Approximated edges, sutures or staples, small amounts of tissue loss, minimal scarring,

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5
Q

Secondary healing intention

A

Edges not approximated, granulation tissue, packed with gauze, drainage systems, longer healing, more scar tissue

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6
Q

Serous drainage and time frame

A

Clear serous portion of blood
Watery, yellowish/pinkish/ clear
Up to 3 days post op

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7
Q

Sanguineous drainage and time frame

A

Many RBCs
Bright to dark red
First 24 hours post op during hemostasis (wound still trying to heal)

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8
Q

Serosanguineous description and time frame

A

Mix of RBCs and serum
Dark pink but able to see through
Up two 3 days post op

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9
Q

Should volume of drainage increase or decrease after surgery?

A

Decrease

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10
Q

Purulent drainage description and time frame

A

WBCs, dead tissue, bacteria
Foul smell, color varies
2-7 days post op wound infection likely

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11
Q

Scant

A

Wound moist but no measurable amount exeduate on dressing

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12
Q

Copious

A

Large amount of lolllll wound has fluid

Covers 75% of bandage

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13
Q

Small amount of exeduate

A

<25% exeduate

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14
Q

None (exeduate)

A

Too dry

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15
Q

Moderate amount of exeduate

A

25-75 %

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16
Q

Signs of local infection

A 
Heat 
Puss 
Increased pain
Increased inflammation 
Redness 
Tenderness
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17
Q

Systemic infection symptoms

A 
Fever 
Chills
Malaise 
Tachycardia
Decreased BP
Increased WBC
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18
Q

Hemorrhage

A

Excessive bleeding (can be internal or external)

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19
Q

Dehiscence

A 
Separation of wound from excess stress put in wound that hasn’t healed
Shiny/tight, redness 
Hot 
Swollen
May look infected
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20
Q

Evisceration

A

Complication from dehiscence where organs come out of wound (protrusion)

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21
Q

3 factors contributing to pressure ulcers

A

External pressure (prolonged)
Friction
Sheer

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22
Q

Friction

A

Rubbing together of surfaces causes skin break down and can damage bvs

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23
Q

Sheer

A

Tissue layers sliding over each other and cause micro tears(damages bvs so decreased perfusion)

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24
Q

Poor nutrition and wound healing

A

If nutrition is not good, wound healing takes longer

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25
Q

How does DM increase chance of infection

A

High sugar content in blood (bacteria loves sugar) and poor circulation

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26
Q

Why do we consider fecal and urinary incontinence with wound healing

A

Excess moisture = skin break down

Fecal matter/urine bacteria can also increase chance infection

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27
Q

Why do we pack wounds with moist NS gauze

A

Prevent tissue damage when removing gauze later

We don’t want to remove granulated tissue

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28
Q

Why to assess pain when performing wound care

A

Pain is likely to occur when changing wound dressings, so we want to alleviate the pain before starting

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29
Q

When to empty JP drain

A

1/2 or 1/3 full

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30
Q

What to monitor with dilaudid

A

RR, O2, sedation level

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31
Q

Expected signs of primary wound healing

A 
No signs dehiscence 
Dry blood
Slight swelling 
Slightly warm 
Reddened edges
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32
Q

Expected healing secondary wound

A 
Small amounts fat visible
Shininess 
Red (healthy tissue) 
Reddened edges 
No drainage
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33
Q

1 most likely complication of surgical wound

A

Bleeding (hemorrhage)

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34
Q

What type of hemorrhage is more likely (internal or external)

A

External in first 24 hours

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35
Q

2 most likely complication of wound

A

Infection

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36
Q

How to prevent wound infections

A

Broad spectrums
Dry and clean dressing
Change dressing at appropriate intervals
Standard precautions

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37
Q

Why would WBC be high post op?

A

Inflammation: first 24 hours
Infections:2-7 days

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38
Q

Eschar

A

Black/grey non-viable tissue

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39
Q

Slough

A

Yellow/green non-viable tissue

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40
Q

How does eschar/slough effect wound healing

A

Impedes cell growth; needs to be removed to allow for growth

41
Q

SxS internal hemorrhage

A 
Decrease BP 
Decreased urinary output 
Tachycardia 
Cyanosis, pale 
Poor cap refill 
Bruising 
Decreased H&H
Altered mental status 
Increased RR
Cool moist skin 
Distended abdomen
42
Q

What will nurse monitor if internal hemorrhage is suspected

A

RR, O2, BP, HR,

43
Q

How to treat hemorrhage

A

Isotonic solutions
Fresh plasma
Blood

44
Q

Nurse action for dehiscence

A

Cleanse with NS

45
Q

Who is at risk for dehiscence

A

Obese, diabetics, hx of infection, poor perfusion

46
Q

Nursing interventions to prevent dehiscence

A

Identify those at risk
Splint surgical site when coughing (pillow or abdomen binder)
Avoid straining
No lifting > 10 lbs
No bending
Teach wound care, nutrition, SxS infection
Stool softeners

47
Q

What to do if dehiscence or evisceration occurs

A

Low Fowler’s, knees slightly bent, cover wound with gauze + NS to avoid drying, abdominal binder (prevent eviscerating or to contain organs), notify MD, prep for surgery

48
Q

What are some ways IAP is increased

A 
Getting up 
Coughing 
Sneezing
Bending
Lifting > 10 lbs
49
Q

What are the four phases of wound healing

A

Hemostasis, inflammation, proliferation, maturation

50
Q

Hemostasis

A

First step in healing phase

Blood clots form

51
Q

Inflammatory

A

Second step in healing phase,
Phagocytosis and epithelial tissue forms
On day 0-6

52
Q

Proliferation

A

Third step of healing phase
Fibroblasts form new tissue
Revascularization and granulation
Wound looks lighter

53
Q

Maturation

A

4th phase of healing phase
Day 21-2 years
Collagen formation and scar tissue smaller

54
Q

Tertiary intention

A

Wound purposely left open, cleaned, debrided

55
Q

Best defense against microbes

A

Intact skin and mucous membranes

56
Q

Basophils percent and function

A

1%

Allergic reactions

57
Q

Eosinophils percent and function

A

3%

Allergic reaction

58
Q

Monocytes percent and function

A

6 %
Phagocytosis large particles
bacterial infection

59
Q

Lymphocytes percent and function

A

30%
Acute viral
Chronic bacterial

60
Q

Neutrophils percent and function

A

60%

Fight acute bacterial infxn

61
Q

Systemic factors that effect wound healing

A

Age, circulation, wound condition, meds (corticosteroids), immunosuppression, nutrition, BMI

62
Q

Stage 1 PU

A

Non-Blanchard redness, superficial skin break down, blisters may occur

63
Q

Stage 2 PU

A

Thick skin loss (epidermis, dermis, or both)

Shallow crater

64
Q

Stage 3 PU

A

Full thickness skin loss
Adipose tissue visible
Extend down to fascia

65
Q

Stage 4 PU

A

Full thickness skin loss

Destruction of muscle, bone, tendons, joints

66
Q

Stage 4 PU treatment

A

skin grafts, debridment,, turning grew, pressure relief, protect from moisture, wound dressing

67
Q

Stage 3 PU treatment

A

debridement, turn freq, moisture protect, wound dressing, presssure relief

68
Q

Stage 2 PU treatment

A

Turning frequent, pressure relief, protect moisture, wound dressings,

69
Q

Stage 1 PU treatment

A

Freq turning, pressure relief, moisture protect, wound dressing

70
Q

What do you use to clean PU stages 2,3,4

A

NS

71
Q

Unstageable PU

A

Covered in slough/eschar.

Tissue must be removed to determine PU stage

72
Q

How does heat therapy work to benefit pain

A

Dilation of vessels to increase circulation(more nutrients and cap permeability) to decrease pain/tension
Relaxes joints, stimulates nerves

73
Q

How long to apply heat therapy

A

20-30 min

74
Q

Educate patient for heat therapy on…

A

Do not increase temperature

Do not increase time

75
Q

Why do patients need to be precautious with heat therapy?

A
  1. Burn risk

2. Rebound effect: longer than 45 min vasoconstriction (incr HR, incr BP)

76
Q

What to assess in wound assessment

A

Location, size, tunneling, undermining, approximation of edges, signs dehiscence, SxS expected hearing, appearance of slough/ eschar, granulation tissue, drainage

77
Q

How does cold therapy work? What does it help with?

A

Vasoconstriction of bvs decreases inflammation and cap permeability
Helps with blood coagulation and decrease bleeding

78
Q

How long to apply cold therapy

A

20-30 min

79
Q

Why should patients avoid prolonging cold therapy

A
  1. Tissue ischemia

2. Rebound effect: vasodilation (decr. BP, incr HR)

80
Q

What can sepsis cause (complication)?

A

Multi organ failure

81
Q

Sepsis

A

Infection in blood triggers inflammation all over body

82
Q

What survey commonly causes infection?

A

GI surgery bc abdomen close to peri area

Feces and urine can contaminate wound easily

83
Q

Why are GI surgery patients put on antibiotics? How long?

A

High chance infection

They are on antibiotics for 48 hours post op

84
Q

Why can’t we count on fever for elderly

A

Their immune system function is low so their body may not respond with a fever

85
Q

Why take two separate swabs when performing culture swab on wound

A

We take two swabs on two diff spots on the wound to decrease chance of contamination
Both have to come back positive

86
Q

Nursing interventions for sepsis

A 
Monitor O2 sat, maintain <92%
Admin O2
Monitor lactic acid levels
Meds to increase BP (IV solution) 
Send for culture 
IV antibiotics 
Monitor urine output
87
Q

Why monitor lactic acid levels during sepsis

A

Can cause multiple organ damage

Lactic acid keeps O2 from entering cells bc high acidity of blood

88
Q

Why monitor urine output when someone is septic

A

Antibiotics affect kidney function

Also dropped BP affects kidney function (less blood flow)

89
Q

MOA of cephalosporin(cefazolin)

A

Inhibit cell wall synthesis (bactericidal)

90
Q

Is cephalasporin broad or narrow spectrum?

A

Broad spectrum

91
Q

Adverse effects of cephalasporin

A

N/V
Diarrhea
(Cdiff likely— opportunist organism bc antibiotic kills normal flora)

92
Q

Nursing considerations when pt is on cephalasporin

A 
Check culture results 
Ask re allergies (foods/meds) 
Interference with anticoagulants 
Monitor infection site 
Monitor SxS of infection
93
Q

What can increase risk of infection

A

Multiple wounds, poor nutrition, poor hydration, >65 y.o., urinary incontinence, drains, poor immunity from chronic ailments (HTN, DM2), hospitalization

94
Q

Why does hospitalization increase risk of infection

A

Around ill people
Stress
Lack of sleep
Seeing multiple HCPs

95
Q

How do we know an antibiotic will kill a bacterium (regarding susceptibility)

A

Culture indicates causative agent. Depending on antibiotics, only certain kind are suceptible to the antibiotic. If it is resistant, than the patient needs a different antibiotic

96
Q

What is a significant PU score

A

Less than 18 we need to implement measures to prevent PUs

97
Q

Things that increase chance of PU

A 
Decreased mobility 
Altered peripheral senses 
Hydration status 
Incontinence 
Poor nutrition
98
Q

Interventions for PU

A 
Focused skin assessment 
Turn Q2
Turn team schedule 
Ambulate patient 
Provide peri skin care to keep skin dry/intact 
Massage AROUND PU to increase circulation 
Air bed 
Boots 
Foot cradle 
Promote fluid intake (2L/day) 
HOB 30 degrees or less to relieve pressure 
Skin barriers 
Nutritional supps (protein, vitamin c) 
Lift patient vs sliding
Change out moist dressing/bedding
Foam on boney prominences 
Skin moisturizer prevent skin drying 
Smooth bedding
99
Q

What are the most common regions for PUs?

A 
#1 coccyx 
#2 heels

Nursing Fundamentals (8 decks)

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