Wound/skin care Flashcards
1
Q
Debridement
A
Removal of devitalized tissue, foreign matter, infected tissue
2
Q
Desiccation
A
dehydration; drying up of skin cells and can cause cell death/delay wound healing
3
Q
Maceration
A
Softening or break down of skin from exposure to excess moisture
(Urinary or bowel incontinence can cause this)
4
Q
Primary healing intention
A
Approximated edges, sutures or staples, small amounts of tissue loss, minimal scarring,
5
Q
Secondary healing intention
A
Edges not approximated, granulation tissue, packed with gauze, drainage systems, longer healing, more scar tissue
6
Q
Serous drainage and time frame
A
Clear serous portion of blood
Watery, yellowish/pinkish/ clear
Up to 3 days post op
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)
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
9
Q
Should volume of drainage increase or decrease after surgery?
A
Decrease
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
11
Q
Scant
A
Wound moist but no measurable amount exeduate on dressing
12
Q
Copious
A
Large amount of lolllll wound has fluid
Covers 75% of bandage
13
Q
Small amount of exeduate
A
<25% exeduate
14
Q
None (exeduate)
A
Too dry
15
Q
Moderate amount of exeduate
A
25-75 %
16
Q
Signs of local infection
A
Heat Puss Increased pain Increased inflammation Redness Tenderness
17
Q
Systemic infection symptoms
A
Fever Chills Malaise Tachycardia Decreased BP Increased WBC
18
Q
Hemorrhage
A
Excessive bleeding (can be internal or external)
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
20
Q
Evisceration
A
Complication from dehiscence where organs come out of wound (protrusion)
21
Q
3 factors contributing to pressure ulcers
A
External pressure (prolonged)
Friction
Sheer
22
Q
Friction
A
Rubbing together of surfaces causes skin break down and can damage bvs
23
Q
Sheer
A
Tissue layers sliding over each other and cause micro tears(damages bvs so decreased perfusion)
24
Q
Poor nutrition and wound healing
A
If nutrition is not good, wound healing takes longer
25
How does DM increase chance of infection
High sugar content in blood (bacteria loves sugar) and poor circulation
26
Why do we consider fecal and urinary incontinence with wound healing
Excess moisture = skin break down
| Fecal matter/urine bacteria can also increase chance infection
27
Why do we pack wounds with moist NS gauze
Prevent tissue damage when removing gauze later
| We don’t want to remove granulated tissue
28
Why to assess pain when performing wound care
Pain is likely to occur when changing wound dressings, so we want to alleviate the pain before starting
29
When to empty JP drain
1/2 or 1/3 full
30
What to monitor with dilaudid
RR, O2, sedation level
31
Expected signs of primary wound healing
```
No signs dehiscence
Dry blood
Slight swelling
Slightly warm
Reddened edges
```
32
Expected healing secondary wound
```
Small amounts fat visible
Shininess
Red (healthy tissue)
Reddened edges
No drainage
```
33
1 most likely complication of surgical wound
Bleeding (hemorrhage)
34
What type of hemorrhage is more likely (internal or external)
External in first 24 hours
35
#2 most likely complication of wound
Infection
36
How to prevent wound infections
Broad spectrums
Dry and clean dressing
Change dressing at appropriate intervals
Standard precautions
37
Why would WBC be high post op?
Inflammation: first 24 hours
Infections:2-7 days
38
Eschar
Black/grey non-viable tissue
39
Slough
Yellow/green non-viable tissue
40
How does eschar/slough effect wound healing
Impedes cell growth; needs to be removed to allow for growth
41
SxS internal hemorrhage
```
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
What will nurse monitor if internal hemorrhage is suspected
RR, O2, BP, HR,
43
How to treat hemorrhage
Isotonic solutions
Fresh plasma
Blood
44
Nurse action for dehiscence
Cleanse with NS
45
Who is at risk for dehiscence
Obese, diabetics, hx of infection, poor perfusion
46
Nursing interventions to prevent dehiscence
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
What to do if dehiscence or evisceration occurs
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
What are some ways IAP is increased
```
Getting up
Coughing
Sneezing
Bending
Lifting > 10 lbs
```
49
What are the four phases of wound healing
Hemostasis, inflammation, proliferation, maturation
50
Hemostasis
First step in healing phase
| Blood clots form
51
Inflammatory
Second step in healing phase,
Phagocytosis and epithelial tissue forms
On day 0-6
52
Proliferation
Third step of healing phase
Fibroblasts form new tissue
Revascularization and granulation
Wound looks lighter
53
Maturation
4th phase of healing phase
Day 21-2 years
Collagen formation and scar tissue smaller
54
Tertiary intention
Wound purposely left open, cleaned, debrided
55
Best defense against microbes
Intact skin and mucous membranes
56
Basophils percent and function
1%
| Allergic reactions
57
Eosinophils percent and function
3%
| Allergic reaction
58
Monocytes percent and function
6 %
Phagocytosis large particles
bacterial infection
59
Lymphocytes percent and function
30%
Acute viral
Chronic bacterial
60
Neutrophils percent and function
60%
| Fight acute bacterial infxn
61
Systemic factors that effect wound healing
Age, circulation, wound condition, meds (corticosteroids), immunosuppression, nutrition, BMI
62
Stage 1 PU
Non-Blanchard redness, superficial skin break down, blisters may occur
63
Stage 2 PU
Thick skin loss (epidermis, dermis, or both)
| Shallow crater
64
Stage 3 PU
Full thickness skin loss
Adipose tissue visible
Extend down to fascia
65
Stage 4 PU
Full thickness skin loss
| Destruction of muscle, bone, tendons, joints
66
Stage 4 PU treatment
skin grafts, debridment,, turning grew, pressure relief, protect from moisture, wound dressing
67
Stage 3 PU treatment
debridement, turn freq, moisture protect, wound dressing, presssure relief
68
Stage 2 PU treatment
Turning frequent, pressure relief, protect moisture, wound dressings,
69
Stage 1 PU treatment
Freq turning, pressure relief, moisture protect, wound dressing
70
What do you use to clean PU stages 2,3,4
NS
71
Unstageable PU
Covered in slough/eschar.
| Tissue must be removed to determine PU stage
72
How does heat therapy work to benefit pain
Dilation of vessels to increase circulation(more nutrients and cap permeability) to decrease pain/tension
Relaxes joints, stimulates nerves
73
How long to apply heat therapy
20-30 min
74
Educate patient for heat therapy on…
Do not increase temperature
| Do not increase time
75
Why do patients need to be precautious with heat therapy?
1. Burn risk
| 2. Rebound effect: longer than 45 min vasoconstriction (incr HR, incr BP)
76
What to assess in wound assessment
Location, size, tunneling, undermining, approximation of edges, signs dehiscence, SxS expected hearing, appearance of slough/ eschar, granulation tissue, drainage
77
How does cold therapy work? What does it help with?
Vasoconstriction of bvs decreases inflammation and cap permeability
Helps with blood coagulation and decrease bleeding
78
How long to apply cold therapy
20-30 min
79
Why should patients avoid prolonging cold therapy
1. Tissue ischemia
| 2. Rebound effect: vasodilation (decr. BP, incr HR)
80
What can sepsis cause (complication)?
Multi organ failure
81
Sepsis
Infection in blood triggers inflammation all over body
82
What survey commonly causes infection?
GI surgery bc abdomen close to peri area
| Feces and urine can contaminate wound easily
83
Why are GI surgery patients put on antibiotics? How long?
High chance infection
| They are on antibiotics for 48 hours post op
84
Why can’t we count on fever for elderly
Their immune system function is low so their body may not respond with a fever
85
Why take two separate swabs when performing culture swab on wound
We take two swabs on two diff spots on the wound to decrease chance of contamination
Both have to come back positive
86
Nursing interventions for sepsis
```
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
Why monitor lactic acid levels during sepsis
Can cause multiple organ damage
| Lactic acid keeps O2 from entering cells bc high acidity of blood
88
Why monitor urine output when someone is septic
Antibiotics affect kidney function
| Also dropped BP affects kidney function (less blood flow)
89
MOA of cephalosporin(cefazolin)
Inhibit cell wall synthesis (bactericidal)
90
Is cephalasporin broad or narrow spectrum?
Broad spectrum
91
Adverse effects of cephalasporin
N/V
Diarrhea
(Cdiff likely— opportunist organism bc antibiotic kills normal flora)
92
Nursing considerations when pt is on cephalasporin
```
Check culture results
Ask re allergies (foods/meds)
Interference with anticoagulants
Monitor infection site
Monitor SxS of infection
```
93
What can increase risk of infection
Multiple wounds, poor nutrition, poor hydration, >65 y.o., urinary incontinence, drains, poor immunity from chronic ailments (HTN, DM2), hospitalization
94
Why does hospitalization increase risk of infection
Around ill people
Stress
Lack of sleep
Seeing multiple HCPs
95
How do we know an antibiotic will kill a bacterium (regarding susceptibility)
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
What is a significant PU score
Less than 18 we need to implement measures to prevent PUs
97
Things that increase chance of PU
```
Decreased mobility
Altered peripheral senses
Hydration status
Incontinence
Poor nutrition
```
98
Interventions for PU
```
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
What are the most common regions for PUs?
```
#1 coccyx
#2 heels
```
