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skills exam 3 > Wounds > Flashcards

Wounds Flashcards

1
Q

What are the risk factors for pressure ulcer development

A
  • impaired sensory perception
  • moisture
  • alterations in consciousness
  • impaired mobility
  • shear
  • friction
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2
Q

Pressure Ulcer Stages 1-4

A 
1= intact skin with non blanchable redness, usually over bony prominence. May have warmth, edema, hardness, pain. 
2= partial skin-thickening loss, involving epidermis, dermis, or both. Red/pink wound, no slough. Blister may be present. 
3= full thickness tissue loss, with visible fat. May include tunneling or undermining. Some slough may be present. 
4= full tissue thickness is lost, exposed bone, muscle or tendon. Eschar or slough may be present.
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3
Q

What is granulation tissue?

A
  • red, moist tissue composed of new blood vessels. Indicates progression towards healing.
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4
Q

What is Slough?

A
  • soft, yellow, white tissue. Appears stringy and attached to wound bed.
  • must be removed by skilled clinician before the wound can heal
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5
Q

What is eschar

A
  • black or brown necrotic tissue. Needs to be removed before healing can begin.
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6
Q

What is primary intention wound healing

A
  • example is surgical incision. Little tissue is lost.
  • Edges approximate, or are closed. Low risk of infection.
  • quick healing. Minimal scarring.
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7
Q

What is secondary intention wound healing?

A
  • Wound is open until it fills with scar tissue. Edges don’t approximate
  • greater chance of infection
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8
Q

What is hemorrhage and hematoma?

A

Hemorrhage= bleeding from wound site that is normal during and immediately after trauma. Can be internal or external

  • locate internal by looking for distention and swelling of the affected body part, or signs of hypovolemic shock.
  • Hematoma is localized collection of blood under tissues. Swelling, change in color, sensation, and warmth occur.
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9
Q

Infection in wounds

A
  • infected wounds have purulent draining (yellow, green, or brown), even if its culture is negative it is still considered infection.
  • A positive culture does not always mean its infected.
  • all dermal wounds are considered contaminated with bacteria. The amount of bacteria present is what differentiated contaminated from infected
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10
Q

Signs of infected wound

A
  • a surgical wound infection doesn’t appear till 3-5 days after surgery
  • fever, tenderness, pain at site.
  • edges of wound are inflamed
  • drainage is odorous and purulent
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11
Q

What is dehiscence

A
  • Wound fails to heal properly, so tissues separate.
  • Partial or total separation of wound layers
  • patients at risk for poor wound healing is at risk for dehiscence
  • Occurs from strain too (coughing, vomiting)
  • when there is an increase in serosanguinous drainage, be alert for potential dehiscence
  • prevent by placing folded blanket or pillow over abdominal wound when patient is coughing.
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12
Q

what is evisceration?

A

Total separation of wound layers

  • Protrusion of visceral organs through a wound opening
  • emergency
  • nurse needs to place sterile towels soaked in saline over tissues to reduce chances of bacteria and drying of the tisue
  • patient is NPO
  • notify surgical team immediately, emergency.
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13
Q

How does a nurse asses pressure ulcer risks

A
  • Braden Scale
  • ranges from 6-23. lower score=higher risk
  • assesses sensory perception, nutrition, moisture, activity, mobility, and friction/shear
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14
Q

What is the nursing intervention for a patient with risk factor of decreased sensory perception

A
  • Asses pressure points for signs of non-blanching reacting hyperemia
  • provide pressure-redistribution surface
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15
Q

What is the nursing intervention for a patient with moisture as a risk factor?

A
  • Assess need for incontinence management
  • following each incontinent episode, clean area with no-rinse perineal cleaner or nonionic and protect skin with moisture barrier ointment
  • frequently assess at a minimum of once a day, or once per shift for a high risk patient
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16
Q

nursing intervention for a patient at risk for friction and shearing?

A
  • reposition patient using drawsheet and lifting off surface
  • provode trapeze to facilitate movement
  • position patient at 30 degree lateral turn and limit head elevation to 30 degrees
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17
Q

nursing intervention or a patient at risk for decreased activity?

A
  • Establish a post individualized turning schedule at least every 2 hours
  • pad bony prominences
  • dont let them sit in a chair for longer than 2 hours. if sitting in chair, have them shift weight every 15 min
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18
Q

nursing intervention for a patient at risk for poor nutrition?

A
  • Provide adequate nutritional and fluid intake, assist as necessary
  • consult dietician
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19
Q

What is mechanical debridement

A
  • wet-to-dry saline gauze dressings. Place moistened gauze into wound and allow dressings to dry thoroughly before removing gauze that adheres to tissue.
  • removed both viable and dead tissues so its is not used often
  • never use this method in a clean granulating wound.
  • other type is Wound Irrigation (high pressure irrigation, or pulsitile, and whirlpool)
20
Q

What is Autolytic debridement

A
  • synthetic dressings oer a wound that allow eschar to be self digested by the action on enzymes that are present in wound fluids
  • examples are transparent film and hydocolloid dresings
21
Q

What is chemical debridement?

A
  • use of topical enzyme preparation
  • Dakins solution or sterile maggots (EWWWWWW)
  • ## enzymes help break down necrotic tissue
22
Q

What is surgical debridement

A
  • removal of vitalized tissue by a scalpel, scissors, or other sharp instrument.
  • some states require an advanced practicing nurse of HCP to do the procedure- check hospital policy
  • usually done for cellulitis or sepsis
23
Q

What are some essential factors for managing wounds

A
  • educating patient and family
  • support nutritional status
  • patients with pressure ulcers need increased caloric intake and protein intake. Increase protein to 1.8 g/kg/day to help build epidermal tissue. Increase calories to build subcut tissue
  • increase vitamin C for collagen synthesis, capillary wall integrity, fibroblast fx
  • Maintain hemoglobin level to 12 g/100ml
24
Q

What should you do immediately for a puncture wound?

A
  • allow it to bleed (ex-dog bite, letting it bleed lets the dogs saliva, bacteria, etc. drain out)
  • if puncture is sharp object like knife, leave the object in place, do not remove it until patient is at emergency facility.
25
Q

How should you clean a minor laceration, or abrasion, small wound? how should you care for a laceration that is bleeding profusely?

A

Small wounds- use NS and lighting cover with dressing
Large, bleeding wounds- brush away surface contaminants and concentrate on hemostasis until patient can be cared for in a hospital setting.

26
Q

What are the purposes of wound dressings

A
  • protects from M.O.
  • aids in hemostasis
  • promotes healing by absorbing drainage and debriding wound
  • supports or splints the wound site
  • protects patient from seeing wound
  • thermal insulation of wound surface
  • moist environment
27
Q

What are pressure dressings used for?

A

they promote hemostasis byt exerting pressure on the bleeding site

28
Q

dressings for pressure ulcers

A
  • continously provides moist environment
  • clean wouns and periwound area at each dressing change
  • keep surrounding skin dry, but wound moist
  • may need to change the type of dressing over time as the ulcer heals. Assess it regularly to determine if modifications are necessary
  • consider caregiver time, ease of use, availability, and cost of dressing when selecting it.
29
Q

For “clean” wounds, what dressing should be used?

A
  • non-adherent gauze (Tefla) is used on wounds with little or no drainage
  • wont stick to wound
30
Q

When should you use a self-adhesive transparent film dressing?

A
  • they trap moisture over wound and provide moist environment
  • idea for small, superficial wounds, partial thickness wounds, or used to protect high risk skin* (dont use if a lot of moisture)
  • allows surface to breath, but provides barrier to bacteria
  • moist environment speeds epithelial growth
  • can view wound
  • does not require secondary dressing
31
Q

When should you use hydrocolloid dressings?

A
  • use on shallow to moderately deep dermal ulcers
  • contain complex formulations of colloids, elastomeric and adhesive components
  • adhesive and non occlusive
  • max wear time is 7 days
  • support healing in clean granulating wounds
  • debride necrotic wounds autolytically
  • absorbs drainage through use of exudate absorbers in the dressing
  • maintains wound moisture
  • impermeable to bacteria
  • preventative for high risk infections
  • can be left in place for 3-5 days
32
Q

When/why to use hydrogel dressings?

A
  • hydrates and absorbs smaller amounts of exudate/moisture
  • used for partial thickness and full thickness wounds, deep wounds with some exudate, necrotic wounds, burns, radiation damaged skin.
  • Useful in painful wounds, very soothing
  • disadvantage- require secondary dressing
33
Q

When to use calcium alginate dressings

A
  • NEVER use on dry wound.

- good for significant exudate. Requires secondary dressing

34
Q

Wounds covered with eschar are…

A

unstagable

35
Q

Steps in packing a wound

A
  • assess size, depth, shape (to determine dressing needed)
  • entire wound surface must be in contact with dressing/gauze
  • ## dont pack too tightly, and it should not extend over wound surface
36
Q

What is a VAC

A
  • vacuum-assisted closure (or negative pressure wound therapy)
  • facilitated healing and collects wound fluid
    negative pressure draws edges of wound together.
  • reduces edema, removes fluid, helps granulation tissue form, etc.
37
Q

Describe wound irrigation

A
  • require sterile tech.
  • use 35 mL syringe with 19 G needle
  • doesnt damage healed tissue
  • never occlude wound opening with syringe and make sure fluid flows directly into wound, and not over surrounding site before it gets to wound.
38
Q

When is the application of heat contraindicated?

A
  • area of bleeding
  • acute localized inflammation (appedicitis)
  • CV problems
39
Q

When is cold application contraindicated?

A
  • if site is edematous
  • impaired circulation
  • neuropathy
  • if patient is shivering
40
Q

Conditions that increase risk of injury from hot/cold applications

A
  • very young or old patients= thin skin, reduced sensitivity
  • open sounds, broken skin, stomas= subcut and visceral tissues are more sensitive to pressure and temp. fewer pain receptors
  • areas of edema and scar formation= reduced sensation
  • peripheral vascular disease= diabetes, arteriosclerosis. Extremities are less sensitive to temp due to circulatory impairments. Cold application further constricts blood flow
  • Confusion/unconsciousness= perception of sensory or painful stim is reduced
  • spinal cord injury= alterations in nerve pathways prevent reception of sensory or painful stim
  • Abcessed tooth or appendix= infection is highly localized, heat can cause rupture
41
Q

What is the physiological response to heat and its therapeutic benefits?

A
  • Vasodilation–> improves blood flow, delivery of nutrients, removal of wastes, lessens venous congestion
  • Reduced viscosity–> improves delivery of leukocytes and antibiotics
  • Increases tissue metabolism–> increases blood flow, provides local warmth
  • increase capillary perm–> promotes movement of waste products and nutrients
42
Q

What conditions would be improved by heat application

A
  • open wounds, rectal surgery, episiotomy, painful hemorrhoids, muscle tension, vag inflammation, wound debridement
43
Q

What is the physiological response to cold and its theraputic benefits?

A
  • Vasoconstriction–> reduced blood flow, prevents edema, reduces inflammation
  • Local anesthesia–> reduced pain
  • Increased viscosity–> promotes coagulation
  • Decrease muscle tension–> relieves pain
44
Q

What conditions are improved by applying cold?

A
  • direct trauma (sprain, strain, fracture, muscle spasm), superficial laceration, puncture wound, minor burn, injection, joint trauma
45
Q

What are some safety suggestions for applying heat/cold therapy?

A
  • explain to patient what will be felt
  • instruct patient to report changes or discomfort
  • timer or clock to time the application
  • call light within reach
  • refer to hospital policy for safe temps
  • do not allow patient to adjust temp
  • do not allow patient to move an application
  • do not place patient in position that prevents them from moving away from the temp. source
  • do not leave a patient who is unable to sense temp changes or move away from the temp source

skills exam 3 (7 decks)

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