Wounds Flashcards
Wound
Injury that’s results in a disruption in the normal continuity
INCISIONS
Cutting or sharp instrument; wound edges in close approximation and aligned
Contusion
Blunt instrument, overlying skin remains intact, with injury to underlying soft tissue; possible resultant bruising and/or hematoma
Abrasion
Friction; rubbing or scraping epidermal layers of skin; top layer of skin abraded
Laceration
Tearing of skin and tissue with blunt or irregular instrument; tissue not aligned, often with loose flaps of skin and tissue
Puncture
Blunt or sharp instrument puncturing the skin; intentional (such as venipuncture) or accidental
Penetrating
Foreign object entering the skin or mucous membrane and lodging in underlying tissue; fragments possibly scattering throughout tissues
Avulsion
Tearing a structure from normal anatomic position; possible damage to blood vessels, nerves, and other structures
Chemical
Toxic agents such as drugs, acids, alcohols, metals, and substances released from cellular necrosis
Thermal
High or low temperatures; cellular necrosis as a possible result
Irradiation
UV light or radiation exposure
Pressure ulcers
Compromised circulation secondary to pressure or pressure combined with friction
Venous ulcers
Injury and poor venous return, resulting from underlying conditions, such as incompetent valves or obstruction
Arterial ulcers
Injury and underlying ischemia, resulting from underlying conditions, such as atherosclerosis or thrombosis
Diabetic ulcers
Injury and underlying diabetic neuropathy, peripheral arterial disease, diabetic foot structure
Desiccation
Localized wound dehydration
Maceration
Localized wound over-hydration or excess moisture
Necrosis
is death of tissue in the wound.
Evisceration
is complete separation of the wound, with protrusion of viscera through the incisional area.
Bandages and binders are
used to secure dressings, apply pressure, and support the wound.
A roller bandage is
a continuous strip of material wound on itself to form a cylinder or roll and is applied using a circular turn, spiral turn, or figure-of-eight turn. It is effective for use around joints, such as the knee, elbow, ankle, and wrist
Stage III wounds
have full-thickness tissue loss. Subcutaneous tissue may be visible but no bone, tendons, or muscle should be seen.
Stage I involves
intact skin with nonblanchable redness.
Stage II involves
a partial tissue loss such as a blister.
Stage IV involves
full-thickness tissue loss with exposed bone, tendon, or muscles
Undermining is
the term for a hollow area between the outer wound and the wound bed. It resembles a cave.
Eschar is a
leathery covering that is dead tissue and is usually removed by debridement.
Tunneling is
a cavity or channel formed from a wound.
Dehiscence
is the opening of a previously closed surgical wound.
Risk of pressure ulcers albumin level Hemoglobin A1C Glucose Body weight Total lymphocyte count
Albumin of less than 3.2 mg/dL . Hemoglobin A1C levels greater than 8% due to prolonged high glucose levels. Glucose levels greater than 120 mg/dL Body weight decrease 5%-10% TLC <1,800/mm3
Primary intention
Wounds healed by primary intention are well approximated (skin edges tightly together).
Intentional wounds
minimal tissue loss,
such as those made by a surgical incision with sutured approximated edges, usually heal by primary intention.
Secondary intention
Wounds healed by secondary intention have edges that are not well approximated.
Large, open wounds, such as from burns or major trauma, require more tissue replacement
often contaminated,
take longer to heal
form more scar tissue.
If a wound that is healing by primary intention becomes infected, it will heal by secondary intention.
Tertiary or delay primary closure
are those wounds left open for several days to allow edema or infection to resolve or fluid to drain, and then are closed
OpSite
The nurse would place an OpSite over a central venous access device insertion site. An OpSite helps to secure the device and is appropriate for a site with little drainage. The nurse would use appropriate aseptic techniques when changing a dressing.
Sof-wik
The nurse would place a Sof-Wick around a drain insertion site.
The Sof-Wick absorbs drainage and protects the wound from contamination or injury.
Tefla
purpose of a Telfa is to not adhere to the wound, and allows drainage to pass through to a secondary dressing.
When applying a negative pressure dressing,
a piece of foam is cut to the shape of the wound and placed in the wound bed.
Irrigation requires sterile, not clean, technique
and the pressure setting of the V.A.C. Therapy Unit is specified by the physician rather than increased until drainage is visible.
Suction is always provided by the V.A.C. Therapy Unit, not by attaching the tubing to wall suction.
Biosurgical debridement
Autolytic debridement
Enzymatic debridement
Mechanical debridement
Biosurgical debridementuses fly larvae to clear the wound of necrotic tissue. This is accomplished through an enzyme the larvae releases.
Autolytic debridement involves using the client?s own body to break down the necrotic tissue.
Enzymatic debridement involves the use of synthetic enzymes that break down necrotic tissue when applied to the wound bed.
Mechanical debridement involves physically removing the necrotic tissue, such as surgical debridement.
Penrose drain
Provides sinus tract
Ex. After incision and drainage of abscess, in abdominal surgery
T-tube
For bike drainage
Ex. After gallbladder surgery
Jackson-Pratt
Decreases dead space by collecting drainage
Ex. After breast removal abdominal surgery
Drainage for after breast removal abdominal surgery
Jackson-Pratt
Decreases dead space by collecting drainage
Hemovac
Decreases dead space by collecting drainage
Ex. After abdominal surgery orthopedic surgery
Gauze, iodoform gauze, NuGauze
Allow healing from base of wound
Ex. Infected wounds after removal of hemorrhoid
Normal albumin level
3.5-5 mg/dL
<3.2 risk
Normal total lymphocytes count
1000-4000/mm3
<1800@risk
Normal hemoglobin A1C
<6%
Greater then 8 % @risk
Normal Glucose
70-120 mg/dL
Greater then 120 @risk
Skin assessment for pressure ulcers includes inspection of
Location of any lesion or ulcer
Identification of the stage
Size of the ulcer: length, width, depth; presence of undermining, a hollow between the skin surface and the wound bed, resulting from death of the underlying tissue
Color and type of wound tissue
Presence of any abnormal pathways in the wound, such as a sinus tract (a cavity or channel underneath the wound that has the potential for infection) or tunneling (a passageway or opening that may be visible at skin level, but with most of the tunnel under the surface of the skin).
Visible necrotic tissue; necrotic tissue that is in the process of separating from viable portions of the body is referred to as slough.
Presence of an exudate or drainage (amount and type)
Presence of odor
Presence or absence of granulation tissue
Visible evidence of epithelialization
Periwound skin condition
Preventing pressure ulcers
Assess the skin of patients at risk on a daily basis. Pay particular attention to bony prominences.
Cleanse the skin routinely and whenever any soiling occurs. Use a mild cleansing agent, minimal friction, and avoid hot water.
Maintain higher humidity in the environment and use skin moisturizers for dry skin.
Avoid massage over bony prominences.
Protect the skin from moisture associated with episodes of incontinence or exposure to wound drainage.
Minimize skin injury from friction and shearing forces by using proper positioning, turning, and transferring techniques. Use lubricants, protective films, dressings, and padding to diminish the effects of friction on the skin.
Use appropriate support surfaces (tissue load management surfaces).
Investigate reasons for inadequate dietary intake of protein and calories. Administer nutritional supplements or more aggressive nutritional intervention as needed.
Continue efforts to improve mobility and activity. If this is unrealistic, attempt to maintain current level of activity, mobility, and range of motion.
Document measures used to prevent pressure ulcers and the results of these interventions
General purpose of dressing
Provide physical, psychological, and aesthetic comfort Prevent, eliminate, or control infection Absorb drainage Maintain a moist wound environment Protect the wound from further injury Protect the skin surrounding the wound Remove necrotic tissue, if appropriate
Dressing : Purpose Transparent films, such as: Bioclusive DermaView Mefilm Polyskin Uniflex OpSite Tegaderm
Allow exchange of oxygen between wound and environment
Are self-adhesive
Protect against contamination; waterproof
Prevent loss of wound fluid
Maintain a moist wound environment
Facilitate autolytic débridement
No absorption of drainage
Allow visualization of wound
May remain in place for 24 to 72 hours, resulting in less interference with healing
Dressing : USE Transparent films, such as: Bioclusive DermaView Mefilm Polyskin Uniflex OpSite Tegaderm
Wounds with minimal drainage
Wounds that are small; partial-thickness
Stage I pressure ulcers
Cover dressings for gels, foams, and gauze
Secure intravenous catheters, nasal cannulas, chest tube dressing, central venous access devices
PURPOSE The Hydrocolloid dressings, such as: DuoDerm Comfeel PrimaCol Ultec Exuderm
Are occlusive or semi-occlusive, limiting exchange of oxygen between wound and environment
Minimal to moderate absorption of drainage
Maintain a moist wound environment
Are self-adhesive
Provide cushioning
Facilitate autolytic débridement
Protect against contamination
May be left in place for 3 to 7 days, resulting in less interference with healing
USE The Hydrocolloid dressings, such as: DuoDerm Comfeel PrimaCol Ultec Exuderm
Partial- and full-thickness wounds
Wounds with light to moderate drainage
Wounds with necrosis or slough
Not for use with wounds that are infected
Ischemia
Blanching of skin over an area under pressure results from ischemia. When pressure is relieved, reactive hyperemia follows and the skin is red and feels warm. Reactive hyperemia is not a stage I pressure ulcer.
CBT
Cognitive behavior therapy (CBT) requires a therapist to work through any maladaptive sleep beliefs. CBT can be very successful is used with other complementary therapies. CBT can include progressive muscle relaxation measures, stimulus control, and sleep restriction therapy. Sedatives and hypnotics would not be used in conjunction with CBT. Pharmacological approaches do not have to be attempted prior to CBT initiation. A client undergoing CBT is not asked to stay in bed during normal sleep hours if the client is not able to sleep.
Red wounds are in what stage and intervention needed
Proliferation stage
Gentle cleansing and change of dressing
Need protection
Which color wounds need cleansing and irrigating
Yellow
occlusive or semiocclusive dressings that limit exchange of oxygen between wound and environment, provide minimal to moderate absorption of drainage, maintain a moist wound environment, and may be left in place for 3 to 7 days, resulting in less interference with healing.
Hydrocolloids
maintain a moist wound environment and are best for partial or full-thickness wounds.
Hydrogel
absorb exudate and maintain a moist wound environment. They are best for wounds with heavy exudate.
Alginates
allow exchange of oxygen between wound and environment. They are best for small, partial-thickness wounds with minimal drainage
Transfer films
