Wounds

Question 1

wound documentation

Answer 1

-assess for: overall appearance, color, drainage, size, depth, undermining and or tunneling, swelling, pain

Question 2

Assess the closed wound for

Answer 2

overall appearance, skin edges well-approximated, closure (staples, sutures, steri-strips), drainage, swelling, pain

Question 3

Factors influencing wound healing

Answer 3

-age, diet, obesity, chronic disease, smoking, tissue perfusion, mediations, *wound stress

Question 4

Pressure Injury: Bottom up (assessing, staging

Answer 4

A pressure injury is “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 and may be painful
-the injury occurs as a result of intense and or prolonged pressure

Question 5

Pressure injury stage 1

Answer 5

-not blanchable; pressure injury lightly pigmented

Question 6

Pressure Injury Stage 2

Answer 6

-damage to the top layer of skin (top layer of skin rubbed off or looks like a clear blister)

Question 7

Pressure injury stage 3

Answer 7

• down into vascular tissue, becomes painful for patient
• Scooped out area (very shallow tho)
• tissue bed looks granular

Question 8

Pressure Injury Stage 4

Answer 8

-Hitting muscle, tendon, ligament or bone exposed

Question 9

Unstageable pressure injury

Answer 9

• Wound over bony prominence but can’t see the bottom of wound; so we don’t know whats under
• necrotizing tissue or dead tissue
• We don’t know what it is - don’t call it anything unless you KNOW what it is

Question 10

Deep tissue injury

Answer 10

discoloration of tissue (purple blue) over bony area, could look like a blood filled blister

Question 11

Mucosal Pressure injuries

Answer 11

• inside of nare, lip, tongue, rectum, penis, vagina
• can’t stage them
• Patient had a mucosal pressure injury

Question 12

Device related pressure ulcer

Answer 12

• Pressure injuries resulting from a medical device creating localized tissue compression
• Key interventions:
  1. Secure devices with minimal pressure against underlying tissue
  2. Use soft dressings or foam around rigid edges
  3. If possible, remove / reposition devices daily and assess skin underneath

Question 13

Nursing Interventions

Answer 13

• pressure ulcer intervention: reposition!
  1. every 2 hours while in bed / every 1 hour while in chair
  2. use pillows or wedges
  3. Use static air boots and or cushions
• Perform routine and PRN skin care
  1. Routine peri care
  2. May require condom catheter or fecal management device
  3. Moisture barrier ointment or paste
  4. Assess skin folds for moisture
• decrease friction and shear
  1. use lifting devices to move patients
  2. Keep head of the bed at 30 degrees or less
• nutrition: encourage a protein rich diet and hydration; consult dietician
• mobility: encourage frequent movement