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Fundamentals of nursing > Wounds > Flashcards

Wounds Flashcards

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1
Q

Thermoregulation skin?

A

vasoconstriction
vasodilatation
perspiration

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2
Q

Elimination done by skin?

A

through sweat
certain byproducts
electrolytes
water

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3
Q

Storage a function of skin?

A

stores 15% body’s water
stores 1/3 of the body’s blood supply

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4
Q

Synthesis of Vitamin D

A

when exposed to UV sunlight

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5
Q

Absorption?

A

of certain drugs

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6
Q

Sensation?

A

(pain, pressure, temperature)

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7
Q

Definition of wound:

A

any break in the normal integrity of the skin and tissues

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8
Q

Classifications of wounds?

A

Intentional vs Unintentional
Closed vs Open
Acute vs Chronic
Pressure injury stages

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9
Q

Intentional wounds: Planned procedures

A

Surgeries, interventional radiology therapies, paracentesis, etc.
Done under sterile field
Wound edges clean and bleeding usually under control
Infection minimal and healing facilitated

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10
Q

Acute wounds?

A

Heal within days to a week
Progresses through the normal healing process Ex: surgical inc
Risk of infection < chronic

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10
Q

Chronic wounds?

A

Healing is delayed >30 days
Healing stalled d/t infection, ischemia, continued pressure, or edema
Ex: diabetes ulcers, PVD, PI
The wound remains in the inflammatory phase of healing

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10
Q

Phases of wound healing?

A

Hemostasis
Inflammation (2-3 days)
Proliferation (Granulation, fibroblastic, connective tissue)
Maturation (Remodeling)

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10
Q

Hemostasis?

A

Occurs immediately after tissue injury
Vasoconstriction and blood clotting via platelet and fibrin aggregation

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11
Q

Level of contamination

A

contamination does not equal infection

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12
Q

Clean wound

A

Uninfected wound with minimal inflammation
Respiratory, GI, GU tracts not involved

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13
Q

Clean-contaminated wound

A

Surgical incisions that are madein the respiratory, GI, or GU tract
Higher risk of infection but no obvious infection

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14
Q

Contaminated wound

A

Open, traumatic wounds or surgical incision in which there is a bridge in asepsis
High risk of infection

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15
Q

Infected wounds

A

> 100,000 organisms per gram of tissue
Organisms present BEFORE procedure

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16
Q

*Beta-hemolytic strep presence in any number indicates and infected wound

A

*Beta-hemolytic strep presence

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17
Q

*Beta-hemolytic strep presence in any number indicates and infected wound

A

*Beta-hemolytic strep presence

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18
Q

When do Signs of Infection appear

A

Usually occurs 2-7 days after injury or surgery
Contaminated wounds more likely to get infected

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19
Q

PRESSURE INJURY?

A

“A PRESSURE INJURY is a localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device”
The injury can present as intact skin or an open ulcer.

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21
Q

STAGES OF PRESSURE INJURY?

A

STAGE 1
STAGE 2
STAGE 3
STAGE 4
SUSPECTED DEEP TISSUE INJURY
UNSTAGEABLE PRESSURE INJURY

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22
Q

DEVICE RELATED PI

A

Mucosal Membrane Pressure Injury:
Found on mucous membranes with a history of medical device at location of injury
Due to the anatomy of the tissue these injuries cannot be stage

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23
Q

Other Device Related PI That Can Be Staged

A

Behind ears from nasal cannula
Nasogastric tubes
Endotracheal tubes

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24
Q

PRESSURE INJURY stage 2

A

Partial thickness skin loss with exposed dermis
Wound bed viable, shallow, pink or red and moist
Intact serum filled or ruptured blister
No adipose tissue, granulation tissue, slough or eschar
May be mistakenly used to describe skin tears, burns, maceration, excoriation, incontinence associated dermatitis or, abrasions

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25
Q

How does infection affect wound healing?

A

Bacteria invades tissue → systemic response

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25
Q

How does infection affect wound healing?

A

Bacteria invades tissue → systemic response

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25
Q

What is undermining? Wound Assessment

A

Erosion under the wound edges, resulting in a large wound with a small opening
May have multiple directions

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26
Q

What is Tunneling? Wound Assessment

A

Destruction of the fascial planes which results in a narrow passageway
Potential for abscess formation
Usually one direction

*Use the clock face to describe direction of wound

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27
Q

Location. Wound Assessment

A

Describe location using anatomical terms
Non-healing wounds on feet usually d/t diabetes or PVD (peripheral vascular disease)

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28
Q

Jackson Pratt (JP)

A

Placed during surgery or interventional radiology to remove fluid collection
Can help in healing process and remove infected pockets of fluid

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29
Q

Flaps?

A

Blood supply stays attached to flap
Grafts don’t work well over hard structures like bones or very complex wounds

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30
Q

What is Regenerative/Epithelial Healing?

A

Wound only involves epidermis and dermis
New tissue cannot be distinguished from intact skin
No scar formation
E.g. Partial-thickness wounds

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31
Q

What are Langerhan cells? what are they made of? found ?

A

They phagocytize foreign material and trigger an immune response. they are on the epidermis

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32
Q

What tissue is the epidermis made of?

A

Thin, barrier layer
Made of by epithelial cells

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33
Q

What are keratinocytes? what do they provide ?

A

Found in epidermis. Keratinocytes provide strength and elasticity

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34
Q

What are Melanocytes? what do they provide ? found in ?

A

Epidermis. Melanocytes give skin pigment

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35
Q

What are Langerhan cells? what do they provide ? found in?

A

phagocytize foreign material and trigger an immune response

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36
Q

What layer is the dermis? What does it contain?

A

Second. Contains collagen: elastic connective tissue to provide structural integrity
Blood vessels
Sweat and oil glands, hair follicles, sensory receptor

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37
Q

Does the skin act as a physical barrier ?

A

YES

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38
Q

What is the ph on the skin?

A

Low pH (4-6.8), inhibits microbes
Acidic environment.

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39
Q

what does the sebum on the skin contain?

A

Sebum on the skin contains antimicrobials

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40
Q

How does the skin provide immunity?

A

Provides immunity
Epidermis: Langerhan cells
Dermis: macrophages and mast cell

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41
Q

Does the skin prevent excess fluid loss?

A

YES

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42
Q

Does the skin synthesis Vitamin D?

A

when exposed to UV sunlight

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43
Q

does the skin absorb certain drugs ?

A

Yes

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44
Q

what sensations are transmitted through the skin ?

A

pain, pressure, temperature

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45
Q

Another function of the skin is body image?

A

yes

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46
Q

What are the 4 wound classifications and their subcategories?

A

Intentional vs Unintentional
Closed vs Open
Acute vs Chronic
Pressure injury stages

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47
Q

What are the characteristics of intentional wounds ?

A

They are Planned procedures such as :
Surgeries, interventional radiology therapies, paracentesis, etc.
Done under sterile field
Wound edges are clean and bleeding is usually under control
Infection is minimal and healing is facilitated

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48
Q

What are the characteristics of unintentional wounds?

A

They are accidental such as :
Unexpected trauma (accidental cuts, stabbing, gunshot, burns)
Contamination of wound likely d/t unsterile environment
Bleeding may be uncontrolled
High risk of infection and longer healing time

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49
Q

What are the characteristics of open wounds through intentional or unintentional means?

A

well: The risk of infection is dependent on the intention.
If intentional = lower risk
If unintentional = higher risk

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49
Q

What are the characteristics of open wounds through intentional or unintentional means?

A

well: The risk of infection is dependent on the intention.
If intentional = lower risk
If unintentional = higher risk

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50
Q

What are the characteristics of closed wounds, meaning wounds where the skin stays intact?

A

Blunt force trauma: Falls, internal injury from a car accident, assault
Contusion, hematomas, ecchymosis

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51
Q

What are the characteristics of Acute wounds?
?

A

Heal within days to weeks
Progresses through the normal healing process Ex: surgical inc
Risk of infection < than chronic

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52
Q

What are the characteristics of chronic wounds?

A

Healing is delayed >30 days
Healing stalled d/t infection, ischemia, continued pressure, or edema
Ex: diabetes ulcers, PVD, PI
The wound remains in the inflammatory phase of healing

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53
Q

what are the 4 stages of healing?

A

Hemostasis (Bleeding)
inflammation
proliferative
remodeling

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53
Q

what are the 4 stages of healing?

A

Hemostasis (Bleeding)
inflammation
proliferative
remodeling

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54
Q

is inflammation a specific reaction ?

A

No

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55
Q

is inflammation the same as infection ?

A

Not the same as infection; although infections may trigger inflammation

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56
Q

is inflammation the same as infection ?

A

Not the same as infection; although infections may trigger inflammation

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57
Q

when does hemostasis occur and what happens during this stage?

A

Occurs immediately after tissue injury
Vasoconstriction and blood clotting via platelet and fibrin aggregation

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58
Q

What is inflammation intended for? where does it occur? which is the second phase of wound healing

A

Intended to neutralize, control or eliminate offending agent
Occurs at tissue level on skin : e.g. result of trauma, surgery, insect bites, sore throat
Occurs at cellular level inside body : e.g. stroke, DVT, myocardial infarctions

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58
Q

What is the chemical response during inflammation and what are the local symptoms? which is the second phase of wound healing

A

Chemicals mediators such as histamine, kinins, prostaglandins released at site of injury also responsible for early stage vasodilation
Kinins attract neutrophils to area

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58
Q

What is the chemical response during inflammation and what are the local symptoms? which is the second phase of wound healing

A

Chemicals mediators such as histamine, kinins, prostaglandins released at site of injury also responsible for early stage vasodilation
Kinins attract neutrophils to area

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58
Q

What is the systemic response during inflammation ? which is the second phase of wound healing

A

Fever caused by endogenous pyrogens released by neutrophils and macrophages
Chills occur in fevers d/t resetting of hypothalamic thermostat control

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59
Q

what is contusion?

A

A contusion is any injury that causes blood to collect under the skin

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60
Q

Echymosis

A

bruising

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61
Q

what is exudate?

A

a mass of cells and fluid that has seeped out of blood vessels or an organ, especially in inflammation.

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62
Q

Parasentesis

A

Perforation of a cyst. Intentional wound

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63
Q

echhymosis

A

bruising

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64
Q

5 cardinal signs of inflammaton

A

redness
warmth
swelling
pain
loss of function

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64
Q

what provides immunity in the dermis?

A

macrophages and mast cells

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64
Q

what provides immunity in the dermis?

A

macrophages and mast cells

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65
Q

Hematoma

A

blood clot .A pool of mostly clotted blood that forms in an organ, tissue, or body space

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66
Q

chronic healing lasts ?

A

more than 30 days

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67
Q

kenin and prostaglandins.

A

Chemical response during innflammation. any of a group of substances formed in body tissue in response to injury. They are polypeptides and cause vasodilation and smooth muscle contraction.

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67
Q

kenins

A

attract neutrofils to the area of inflammation.

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68
Q

what causes fever during inflammation ?

A

endogennous pyrogens released by neutrophils and macrophages to rest highpothalamic temp

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68
Q

what causes fever during inflammation ?

A

endogennous pyrogens released by neutrophils and macrophages to rest highpothalamic temp

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69
Q

histamines and prostaglandins during inflammation ?

A

they cause vasodilation for wbc etc to come and help

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70
Q

what do fibroblasts do ?

A

fibro = cell blast= make.
They form collagen and produce growth factors to form BV. all of this results in granulation and tissue formation. it is highly vascular and bleeds easily though

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71
Q

Granulation tissue is

A

the foundation for scar formation

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72
Q

Granulation tissue is

A

the foundation for scar formation

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73
Q

Clean wound

A

Uninfected wound with minimal inflammation
Respiratory, GI, and GU tracts not involved

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73
Q

Clean wound

A

Uninfected wound with minimal inflammation
Respiratory, GI, and GU tracts not involved

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74
Q

Clean-contaminated

A

Surgical incisions that enter the respiratory, GI, or GU tract
Higher risk of infection but no obvious infection

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75
Q

Contaminated

A

Open, traumatic wounds or surgical incisions in which there is a breach in asepsis
High risk of infection

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76
Q

Infected wounds

A

> 100,000 organisms per gram of tissue
Organisms present BEFORE the procedure

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77
Q

Beta-hemolytic strep presence

A

*Beta-hemolytic strep presence in any number indicates and infected wound

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78
Q

When do signs of infecction occur in injury

A

2 to 7 days after

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78
Q

When do signs of infecction occur in injury

A

2 to 7 days after

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79
Q

ulcer

A

an open sore on an external or internal surface of the body, caused by a break in the skin or mucous membrane that fails to heal.

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80
Q

wher si the wound bed viable shallow and pink or red ?

A

stage 2 pressure injury

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81
Q

intact serum or reptured blister

A

stage 2

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82
Q

what is excoriation ?

A

excessive skin scratching

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83
Q

contamination does not equal infecction

A

yes

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84
Q

List 12 areas of bony prominance

A

Occiput
ear
scapula
elbow
sacrum
ischial tuberosities
greater trochanter
medial condyle of tibia
fibular head
medial mallelous
lateral malleolus
heel

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85
Q

how much is capillary pressure that causes low pressure ?

A

20mm hg ver low

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86
Q

ischimia

A

inadecuate blood supply to tissue
especially the heart
isch=to stop/slow
emia=blood

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87
Q

how long can tissue tolerate ischemia ?

A

2h only

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88
Q

mucosal membrane pi can’t be staged due to their anatomy and location?

A

true

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89
Q

where does a non blanchable erythema occur?

A

stage 1 PI

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90
Q

pressure injury is how in color ?

A

not marron or purpula because that is a feature of deep tissue injury

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91
Q

is stage 1 pressure injury difficult to asses in people with dark skin?

A

yes

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92
Q

what layer of skin can be seen with stage 2 PI

A

the dermis because there is a partial loss of skin

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93
Q

can we see adipose tissue, granulation, slough or eschar during a stage 2 pressure injury ?

A

hell no

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94
Q

what can a stage 2 PI mistake for?

A

skin tears, burns,maceration , excoriation, incontinence associated dermatitis and abrasions

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95
Q

is the skin intact in a stage 1 PI?

A

yes

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96
Q

warmth and firmness compared to adjacent tissue ?

A

stage 1

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97
Q

stage 3 and 4 PI are full thickness tissue loss

A

true

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98
Q

is adipose and granulation visible in the ulcer during stage 3 ?

A

yes

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99
Q

Is epibole (center ) visible during stage 3 PI?

A

yes

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100
Q

Slough and or eschar may be visible during a stage 3 PI

A

yes

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101
Q

what happens if Slough and or eschar obscure a 3 stage injury ?

A

the wound can’t be staged

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102
Q

Can undermining and tunneling occur in stage 3 injury ?

A

yes it may but not 100%

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103
Q

Is facia and bone and tendon visible in stage 3 injury?

A

no they are not

104
Q

CERTAIN AREAS: NOSE, EARS, OCCIPUT ARE SHALLOW ULCERS BUT CAN BE STAGE III OR WORSE
?

A

true

105
Q

Can we see Exposed bone, tendon, muscle, tendons, ligaments
in a stage 4 injury?

A

yes

106
Q

is Epibole, undermining and/or tunneling common
in a stage 4 injury ?

A

yes

107
Q

Slough or eschar may be present in a stage 4 pi but does not completely obscure the wound bed

A

true

108
Q

can a stage 4 pi cause osteomyelitis?

A

yes

109
Q

what is the healing scar tissue of stage 4 pi made of ?

A

made of protein/collagen tightly woven together

110
Q

the new ly regenerated tissue from stage 4 pi is always gonna be stage 4 even if it looks like stage 2 because we can’t reverse staging

A

true

111
Q

if a stage 4 injury is reopened we call it stage 4 even if it looks like stage 2

A

true

112
Q

what is an unstageable pressure injury?

A

it is when Extent of tissue damage cannot be terminated d/t obscurity from slough or eschar

113
Q

what happens of we remove eschar or slough from a stage 3 or 4 injury ?

A

it can be staged

114
Q

can we remove eschar from a stable wound?

A

Stable eschar (dry, adherent, intact without erythema) on heel or limb should not be softened or removed. Provides natural barrier to cover wound

115
Q

what is a deep pressure injury DTPI ? and what color is it ?

A

Persistent nonblanchable deep red, maroon, or purple discoloration

116
Q

what is a serum filled blister ?

A

a stage 2 pi

117
Q

what is a blister filled with blood ?

A

DTPI

118
Q

is DTPI difficult to detect in dark people?

A

yes

119
Q

DTPI

A

can resolve without tissue loss pr it can open and reveal the extent of tissue injury

120
Q

shear is when?

A

One layer of tissue slides over another layer of tissue. Ex epidermis over dermis. This causes the 2 layers to separate from each other. due to this separation Blood vessels and capillaries damaged → impaired circulation

121
Q

what is an example of shearing?

A

When a patient partially sitting up in bed and person sliding down toward foot of bed; skin sticks to sheet

122
Q

does an edema and pressure interfere with blood flow ?

A

yes

123
Q

do dehydrated cells die
?

A

yes dissecation kills cells

124
Q

does moist environment promote epithelialization?

A

oui

125
Q

does maceration caused by overhydration cause changes pH of skin and promotes bacterial growth and therefore causing infection?

A

yes

126
Q

can epithelization occur over dead tissue ?

A

Necrosis - Epithelialization cannot occur over dead tissue (slough or eschar); must be debrided

127
Q

what is a biofilm in a wound? and what does it do ?

A

A protective matrix of bacterial that ↓ the effectiveness of abx and normal immune response

128
Q

does a biofilm contain multiple species of bacteria?

A

Biofilm may contain multiple species of bacteria that shield against the immune system and antimicrobial agents

129
Q

can a biofilm healing through chronic inflammation, delayed granulation tissue formation, and delayed epithelial migration

A

yes

130
Q

can a biofilm healing through chronic inflammation, delayed granulation tissue formation, and delayed epithelial migration

A

yes

131
Q

biofilm Impairs migration and proliferation of keratinocytes
?

A

oui

132
Q

Is a biofilm a reservoir for infection?

A

yes

133
Q

what is the percentage of biofilm in chronic wounds ?

A

60%

134
Q

what is the PRIMARY CAUSE OF WOUND CHRONICITY

A

biofilm

135
Q

Adequate circulation importanat in wound healing ?

A

yes , to carry oxygen and nutrients to wound

136
Q

Nutrition - wound healing requires adequate protein, carbohydrates, fats, vitamins and minerals, fluid intake

A

yes

137
Q

does bacteria compete with granulation tissue for nutrition?

A

oui

138
Q

Vit…. and …. essential for epithelialization and collagen synthesis

A

A and C

139
Q

what does zinc do to cells ?

A

Zinc promotes proliferation of cells

139
Q

what does zinc do to cells ?

A

Zinc promotes proliferation of cells

140
Q

Is protein essential for cell and tissue growth? What is the recommended amount?

A

yes . 1-2.5 g/kg/day of protein to prevent tissue catabolism)

140
Q

Is protein essential for cell and tissue growth? What is the recommended amount?

A

yes . 1-2.5 g/kg/day of protein to prevent tissue catabolism)

141
Q

why is it important to make 50% of our diet carbs ?

A

cellular metabolism; protein sparing
30-45 kcal/kg/day to maintain (+ positive )nitrogen balance

142
Q

how much fat should we intake for wound healing ?

A

20 to 30% of what we eat has to come from fat. It provides energy, protein sparing, vit A absorption

143
Q

does fat help with vit A absorption ?

A

yes

144
Q

HOw much fluid should we intake a day ?

A
  • Maintain fluid intake to 1ml/Kcal/day (ex: 2500 Kcal =2500mL/day)
    2.5 L
145
Q

why does fever affect BMR and why is it used during wound healing?

A

fever regulates your temp and to carry this out you need more energy and therefore more oxygen to meet the BMR

146
Q

what is diaphoresis? and what does it cause on the skin in excess?

A

masceration

147
Q

what is a normal albumin level? what is its half life

A

3.2g to 5g /dl and its half-life is 20 to 22 days

148
Q

what is normal prealbumin aka Transthyretin level? what is its half-life

A

(normal 2—42 g/DL)
Half life 2-4 days

149
Q

what is a better indicator of current nutrition albumin or prealbumin ?

A

prealbumin

150
Q

What is a normal level of transferrin and what does it do?

A

170 to 370 mg/dl
Transport protein to carry iron

151
Q

Overly thin and obese people more susceptible to skin irritation and injury

A

yes

152
Q

how do Corticosteroids affect wound healing?

A

decrease the inflammatory process

153
Q

Anemia?

A

affects negativly wound healing

154
Q

what does hypothermia cause in wound healing?

A

causes vasoconstriction

155
Q

Impaired immune function and chronic illnes slow wound healing

A

true

156
Q

chemotherapy agents, DM, prolonged abx, immunocompromised people have more difficulty healing

A

yes

157
Q

Higher risk for dehiscence d/t increased tension on skin

A

it occurs in obese people

158
Q

Wound tension in obese people increases tissue pressure-reduces microperfusion and O2 availability in obese people

A

oui

159
Q

what does adiponectin do in obese people?

A

Low adiponectin impairs angiogenesis leading to micro-abnormalities that cause a persistent state of mild inflammation

160
Q

Impaired keratinocyte proliferation and migration (critical step in re-epithelialization) is common in obese people

A

yes

161
Q

Hyperglycemia impairs wound healing and leads to higher risk of infection

A

yes because it does not let the inmune system work

162
Q

Stress of wound increases blood sugar level

A

oui

163
Q

what do excess sugars do?

A

Excess sugars increase glycation → inhibit collagen and elastin regeneration

164
Q

Impaired circulation in diabetes and perfusion lead to hypoxia (foot ulcers, chronic pressure-related wounds)
Free radicals from hypoxia further prolong injury

A

yes

165
Q

diabetes causes Impaired immune function-T cells, phagocytosis, bactericidal ability etc.

A

oui

166
Q

Vitamin A and C help with epithialization and collagen synthesis

A

oui

167
Q

zinc promotes the proliferation of cells

A

si

168
Q

dehiscence

A

In obese people Higher risk for dehiscence d/t increased tension on skin

169
Q

Wound tension increases tissue pressure-reduces microperfusion and O2 availability in obese people

A

yes

170
Q

Low adiponectin in obese people?

A

impairs angiogenesis leading to micro-abnormalities that causes a persistent state of mild inflammation

171
Q

Impaired keratinocyte proliferation and migration in obese people causes?

A

slow re-epithelialization

172
Q

obese pople are more prone to pressure ulcers

A

oui

173
Q

Venous insufficiency and cardiovascular disease in obese people make the healing of a wound harder.

A

yes

174
Q

Many obese people are actually malnourished despite their weight

A

True

175
Q

Hyperglycemia impairs wound healing and leads to a higher risk of infection

A

oui

176
Q

Hyperglycemia impairs wound healing and leads to a higher risk of infection

A

oui

177
Q

Stress of wound increases blood sugar level

A

oui

178
Q

Excess sugars increase glycation which in turn?

A

inhibit collagen and elastin regeneration

179
Q

Impaired circulation and perfusion leads to ?

A

hypoxia (foot ulcers, chronic pressure related wounds)
Free radicals from hypoxia further prolong injury

180
Q

diabetes impairs immune function-T cells, phagocytosis, bactericidal ability etc.

A

oui

181
Q

Peripheral arterial disease

A

Limits activity d/t pain and leads to muscle atrophy
Thin tissue that is prone to ischemia and necrosis
Need to restore arterial blood perfusion for wound healing

182
Q

Chronic venous disease

A

Results in engorged tissue with high levels of waste products resulting in edema, ulceration, and breakdown

183
Q

is there a higher risk for dehiscence d/t increased tension on skin with …?

A

Obese people yes

184
Q

what is adiponectin and what does it do?

A

Low adiponectin (protein) impairs angiogenesis leading to micro-abnormalities that cause a persistent state of mild inflammation

185
Q

what happens to your sugar levels when you are stressed over a wound?

A

Stress of wound increases blood sugar level

186
Q

what do free radicals from diabetes do

A

Impaired circulation and perfusion leads to hypoxia (foot ulcers, chronic pressure related wounds)
Free radicals from hypoxia further prolong injury

187
Q

Intermittent claudication is a characteristic of which condition?

A

PAD (peripheral arterial disease)

188
Q

No edema is a characteristic of which condition PAD or PVD?

A

PAD (peripheral arterial disease)

189
Q

no pulse or weak pulse is a characteristic of which condition PAD or PVD?

A

pad

190
Q

no drainage is a characteristic of which condition PAD or PVD?

A

PAD

191
Q

round smooth sores is a characteristic of which condition PAD or PVD?

A

PAD

192
Q

black eschar is a characteristic of which condition PAD or PVD?

A

PAD

193
Q

location of sores on toes and feet is a characteristic of which condition PAD or PVD?

A

PAD

194
Q

dull achy pain is a characteristic of which condition PAD or PVD?

A

PVD

195
Q

lower leg edema is a characteristic of which condition PAD or PVD?

A

PVD

196
Q

pulse and drainage present is a characteristic of which condition PAD or PVD?

A

PVD

197
Q

sores with irregular borders is a characteristic of which condition PAD or PVD?

A

PVD

198
Q

yellow slough or ruddy skin is a characteristic of which condition PAD or PVD?

A

PVD

199
Q

location of sores in ankles is a characteristic of which condition PAD or PVD?

A

PVD

200
Q

Wounds may get colonized from surrounding skin and local skin organisms but it does not mean that they are infected

A

yes

201
Q

Subtle signs of contamination (bacteria has not invaded tissue) include:

A

new foul odor, ↑drainage, new tunneling of wound, absent or friable granulation tissue, change in color of wound bed

202
Q

No active infection until critically colonized (>100K)

A

oui

203
Q

Infection
causes ?

A

Bacteria invades tissue → systemic response

204
Q

Diminished activity of sebaceous and sweat glands→xerosis (itchy, red, dry, cracked, or fissured skin)

A

age-related skin change

205
Q

Epidermis and dermis thins and atrophies

A

age related skin change

206
Q

Less effective thermoregulation d/t loss of lean body mass and subcutaneous tissue

A

age-related skin change

207
Q

Changes in collagen/elastin fibers decreases elasticity and integrity → prone to tearing
Regeneration of healthy skin takes twice as long in an 80 year old vs 30 year old
Impaired tactile sensitivity
Blood vessels thinner and more fragile-bruise easily

A

Age Related Skin Changes

208
Q

If wound present: appearance, drainage, size, closed or open, odor
MEASURE

A

oui

209
Q

M

A

Measure size of wound

210
Q

E

A

E=Exudate amount

211
Q

A

A

A=Appearance of base: necrotic (black), fibrin (firm yellow), slough (soft yellow – viscous and opaque), granulation tissue (beefy and healthy or red and friable-unhealthy), biofilm

212
Q

S

A

S=Suffering (Pain)

213
Q

U

A

U=Undermining

214
Q

R

A

R=Re-evaluate treatment

215
Q

E

A

E=Edges

216
Q

Measure dimensions

A

L X W X D
Assess for presence of tunneling/undermining using moistened Q-tip
Length-greatest length in cm (measure from head to toes)
Width-greatest width side to side
Depth-mark with Q-tip at deepest point and hold to ruler

217
Q

Undermining

A

Erosion under the wound edges, resulting in a large wound with a small opening
May have multiple directions

218
Q

Tunneling

A

Destruction of the fascial planes which results in a narrow passageway
Potential for abscess formation
Usually one direction

219
Q

BLACK APPERANCE OF WOUND ?

A

necrotic

220
Q

firm yellow APPERANCE OF WOUND ?

A

fibrin

221
Q

soft yellow – viscous and opaque

A

slough

222
Q

beefy and healthy or red and friable-unhealthy

A

granulation tissue

223
Q

Wound Assessment Edge/perimeter of wound

A

Approximated, rolled, calloused
Wound open vs closed (sutures, staples, surgical glue)
Periwound skin (indurated, erythematous, macerated, bruised, normal)

224
Q

Serous Exudate/drainage:

A

Serous-typical of clean wounds, clear and watery with little cells=straw colored serum

225
Q

Sanguineous Exudate/drainage:

A

Sanguineous-bloody; if BRB=bleeding active; if red-brown and darker probably indicates capillary damage

226
Q

Best practices for wound healing

A

Suspend heels – pressure off
Keep HOB at <30 degrees if no contraindication
Inspect skin every shift and at every turn
Nutrition and hydration
Apply moisture barrier if incontinent
Vigilant skin care and moisture
Encourage mobility
Reposition at least every 2 hours

227
Q

Moist environment provide optimal conditions for wound healing →

A

increases rate of epithelialization and proliferation. healing exudate-vital proteins, cytokines, and growth factors which facilitate autolytic debridement

227
Q

Inadequate moisture impedes cellular activities and promotes eschar formation → poor healing

A

yes

228
Q

Dry dressings may disrupt healing when removed; fresh tissue gets removed during dressing change

A

yes

229
Q

Excessive moisture leads to maceration and increases likelihood of skin breakdown
Creates supportive environment for bacterial growth

A

yes

230
Q

Excessive moisture leads to maceration and increases likelihood of skin breakdown
Creates supportive environment for bacterial growth

A

yes

231
Q

Wound care

A

Remove wound debris gently with normal saline
Maintain moist (not dry or wet) environment
Soften necrotic tissue with wet to damp dressing (autolytic debridement)
Always fluff gauze before packing wound
Use absorbing dressings to remove excess exudate
Protect peri-wound
Maintain an aseptic technique to reduce the risk of contamination and infection
Manage pain

232
Q

Medihoney

A

contains an osmotic agent to draw out moisture from deeper tissue
Helps to lower the pH of the wound

233
Q

Xeroform-

A

Xeroform-occlusive bacteriostatic

234
Q

Hydrogel

A

Moist environment
Enhances autolytic debridement

235
Q

Silver-based dressings

A

Antimicrobial

235
Q

Mepilex – foam dressing

A

pad

236
Q

Jackson Pratt (JP)

A

Placed during surgery or interventional radiology to remove fluid collection
Can help in healing process and remove infected pockets of fluid

237
Q

Debridement

A

Removal of non-viable
Eliminates source of infection
Helps to visualize wound bed
Promotes healthy tissue to regenerate

238
Q

Types of debridement

A

Autolytic
Enzymatic
Surgical
Mechanical
Maggot

239
Q

negative pressure therapy

A

Applies negative pressure to the wound to remove excessive drainage (blood, exudate and infectious materials)
Provides direct and complete wound bed contact
Reduces edema
Promotes perfusion and granulation tissue formation by facilitating cell migration and proliferation

240
Q

what is a Skin Graft:

A

Taking skin from another part of the body to protect/fill in defect

241
Q

full-thickness skin graft vs split partial skin graft?

A

full: includs dermis and epidermis
partial: epidermis and some dermis

242
Q

where are skin grafts usually taken from ?

A

areas with extra skin like buttocks, groin, thigh

243
Q

how long for skin graft to heal ?

A

This “donor site” heals in 7-10 days

244
Q

Split/Partial thickness skin graft
?

A

removes skin but leaves deeper structures with sweat glands and hair follicles

245
Q

Flaps?

A

The blood supply stays attached to the flap
Grafts don’t work well over hard structures like bones or very complex wounds

246
Q

Evaluation of wound ?

A

Assess the effectiveness of treatment at a minimum once per week with measurements/observations
Reevaluate treatment if not healing in timely manner
The expected trajectory/path for wound healing is that the wound should be 20% smaller at week 2 and 40-50% at week 4 to heal in 12 weeks

247
Q

what is Regenerative/Epithelial Healing?

A

Wound only involves the epidermis and dermis
New tissue cannot be distinguished from intact skin
No scar formation
E.g. Partial-thickness wounds

248
Q

Wound involves minimal or no tissue loss

A

1 intetntion

249
Q

Edges approximated (sutures, staples, or surgical glue touching/closed)

A

primary intention

250
Q

Minimal scarring (However scar tissue is still only 80% as strong as the original tissue)
Eg. Clean surgical incisions

A

primary intention

251
Q

Extensive tissue loss that prevents edges from approximating or because wound intentionally left open d/t contaminated/infected tissue/blood clot

A

Secondary Intention:

252
Q

Wound debrided or infection resolved then allowed to heal from inner layer to surface with beefy red granulation tissue (a type of connective tissue)

A

secondary

253
Q

Heals more slowly and more scarring

A

secondary

254
Q

Tertiary Intention aka

A

Delayed primary closure

255
Q

Initially wound healed by secondary intention

A

3

256
Q

When there is no evidence of edema or infection, granulation tissue pulled together and wound edges sutured

A

3

257
Q

Less scarring than secondary intention

A

3

258
Q

Requires strict aseptic technique to prevent infection

A

3

259
Q

Hypertrophic scar

A

small bump

260
Q

Keloid-scar

A

Keloid-scar outgrows border of injury; acts like a tumor

261
Q

Adhesions

A

Adhesions: bands of scar tissue that form between or around organs e.g intestinal adhesions may lead to bowel obstructions

262
Q

Excessive contraction results in

A

Excessive contraction results in deformity; shortens muscle or scar tissue, especially over joints, results from excessive fibrous tissue formation

263
Q

Hemorrhage

A

Result from ruptured suture, accidental arterial puncture, fistulas, dislodged clot
Monitor surgical wound and drains frequently for bleeding for the first 48hrs
Apply pressure dressing if needed
Report uncontrolled and excessive bleeding

264
Q

Hematomas:

A

type of hemmorage Hematomas: localized mass of blood that could cause tissue ischemia

265
Q

Dehiscence and Evisceration

A

Most serious post-op complication

266
Q

Dehiscence

A

Dehiscence - partial or total separation of a wound

267
Q

Evisceration

A

Complication of a dehisced wound with protrusion of viscera (internal organ)

268
Q

Prevention and nursing intervention:
in Dehiscence and Evisceration

A

Prevention and nursing intervention:
Splint wound when cough/sneezing, getting out of bed
Use abdominal binder
If evisceration occurs, place patient in low fowler and immediately cover exposed organ with moistened sterile saline gauze
Contact provider immediately and stay with patient

269
Q

Fistula

A

Abnormal passage of an organ or vessel to the outside of the body or from an internal organ or vessel to another

Examples:
Carotid-cavernous fistula - an abnormal connection between the carotid artery to a large vein
Rectovaginal fistula - an abnormal connection between the rectum and vaginal
enterocutaneous fistula - an abnormal connection between the intestine and skin

270
Q

Partial-thickness wounds?

A

Partial Thickness – A partial thickness wound is confined to the skin layers; damage does not penetrate below the dermis and may be limited to the epidermal layers only.

271
Q

concussion

A

A concussion is an injury resulting specifically from brain trauma

272
Q

Serosanguineous

A

most commonly seen in new wounds lighter pink, a combination of serous and sanguineous drainage

273
Q

Purulence

A

thick, often malodorous (Pus-WBC’s, bacteria, and cellular debris

274
Q

Purosanguineous

A

thick red-tinged pus indicating blood in an infected wound

Fundamentals of nursing (11 decks)

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