Shared Flashcard Set

Details

Unit 17 - Skin Integrity and Wound Healing
Test 3
138
Nursing
Undergraduate 3
04/07/2014

Additional Nursing Flashcards

 


 

Cards

Term
What are the 2 layers of the epidermis?
Definition
Stratum corneum
Stratum germinativum
Term
What 3 layers make up the skin?
Definition
-Epidermis
-Dermis
-Subcutaneous
Term
How does age effect skin integrity?
Definition
older adult skin: less elastic, drier, reduced collagen, areas of hyperpigmentation, more prone to injury, chronic disease
Term
How does mobility status effect skin integrity?
Definition
increased pressure, shearing, and friction can lead to breakdown
Term
How does nutrition effect skin integrity?
Definition
Poor nutrition, less regeneration
Dehydration = poor turgor
Term
How does sensation level effect skin integrity?
Definition
Diminished sensation leads to increased risk for pressure and breakdown
Term
How does impaired circulation effect skin integrity?
Definition
negatively affects tissue metabolism, main cause of chronic wounds; arterial, venous, DM
Term
How do medications effect skin integrity?
Definition
side effects: itching, rashes
Term
How does moisture effect skin integrity?
Definition
Leads to maceration
Ex: incontinent bowel/ bladder
Term
How does fever effect skin integrity?
Definition
Depletes moisture, sweating= moisture on skin
Increases metabolic rate
Term
How does infection effect skin integrity?
Definition
Infection
Impedes healing
S&S: erythema, edema, fever, pain, drainage, odor, color chg, tunneling, absent granulation
Term
How does lifestyle effect skin integrity?
Definition
Tanning, bathing, piercings, tattoos: 20% risk for infection; sepsis, endocarditis, hepatitis
Term
Of the following factors, which would put a client at greatest risk for impaired skin integrity?

-digoxin
-moisture
-decreased sensation
-dehydration
Definition
Decreased sensation

This could lead to a delay in seeking treatment due to lack of awareness.
Term
What are the classifications of wounds?
Definition
- Open/Closed
- Acute/Chronic
- Arterial/Venous
- DM ulcer
- Pressure Ulcer
- Superficial or Partial/Full-Thickness
Term
What is a penetrating wound?
Definition
Involves an organ
Term
What is serous exudate?
Definition
straw-colored
Clean wounds
Term
What is sanguineous?
Definition
bloody drainage
Deep wounds
Term
What is serosanguineous?
Definition
mix of bloody and
straw-colored fluid
New wounds
Term
What is purulent drainage?
Definition
yellow, contains pus
Infected wounds
Term
What is regeneration?
Definition
HEALING.

Only occurs in epidermal/partial thickness wounds
NO SCAR
Term
What is primary intention?
Definition
A Clean surgical incision/edges approximated
Minimal scarring
Term
What is secondary intention?
Definition
Wound edges not approximated
Tissue loss is extensive
Heals from inner layer to surface, slowly, beafy red granulating tissue fills in
Ex: pressure ulcer, infected wounds
Term
What is tertiary intention?
Definition
Granulating tissue brought together if there is no infection present
Delayed closure of wound edges
Term
What are the complications of wound healing?
Definition
Hemorrhage
Infection
Dehiscence
Evisceration
Fistula
Term
What is infection?
Definition
bacteria count above 100,000 organisms/gram of tissue, exception- beta-hemolytic streptococci
Term
What is dehiscence?
Definition
one or more layers, infammatory phase, obese clients
Term
What is evisceration?
Definition
Total separation MEDICAL EMERGENCY-Know tx!
Term
What is a fistula?
Definition
abnormal passage, from infection
Term
How do you treat evisceration?
Definition
The wound is managed in the prehospital setting by covering the eviscerated contents with a moist, sterile gauze or trauma dressing to prevent further contamination and drying. No attempt should be made to replace eviscerated organs into the peritoneal cavity
Term
The client calls the nurse to the room and states, “Look, my incision is popping open where they did my hip surgery!” The nurse notes that the wound edges have separated 1 cm at the center and there is straw-colored fluid leaking from one end. The nurse’s best action is to
Definition
Place a clean, sterile 4 x 4 over the incision and monitor the drainage.

A 1 cm separation of wound edges only in the center of a surgical incision on the hip is too small to truly be termed dehiscence. Even if there were a large separation, there are no “internal viscera” to protrude.
Term
What is the braden scale?
Definition
scale (based on sensory perception, moisture, activity, mobility, nutrition, and friction or shear)
Numeric value for 6 risk factors related to impaired skin integrity
Term
What is an at risk score?
Definition
<18
Term
What should be noted when assessing a wound?
Definition
Location
Size
Appearance
Drainage
Redness
Swelling
Term
What are the nursing interventions related to wound care?
Definition
Cleansing/irrigating
Caring for a drainage device
Debrieding a wound
Applying negative pressure wound therapy
Dressing a wound
Supporting/immoblizing a wound
Applying heat cold
Term
How can you debride a wound?
Definition
Sharp
Mechanical
Chemical
Enzymatic
Autolysis
Term
What is a Jackson-Pratt drain?
Definition
The JP drain removes fluids by creating suction in the tube. The bulb is squeezed flat and connected to the tube that sticks out of your body. The bulb expands as it fills with fluid.
Term
What is a hemovac?
Definition
Works the same way as JP - just larger container
Term
What does a wound vac provide?
Definition
Negative pressure
Term
What is used to dress a wound?
Definition
gauze/transparent film
Hydrocolloids/hydrogels
Term
What are the supporting/binding materials?
Definition
Binders/bandages
Term
What intrinsic factors lead to pressure ulcers?
Definition
Immobility
Impaired sensation
Malnourishment
Aging
Fever
Term
What extrinsic factors lead to pressure ulcers?
Definition
Friction
Pressure
Shearing
Exposure to moisture
Term
What is a stage 1 pressure ulcer?
Definition
Non-blanchable erythema
Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category I may be difficult to detect in individuals with dark skin tones. May indicate “at risk” persons.
Term
What is a stage 2 pressure ulcer?
Definition
Partial thickness
Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or sero-sanginous filled blister.Presents as a shiny or dry shallow ulcer without slough or bruising*. This category should not be used to describe skin tears, tape burns, incontinence associated dermatitis, maceration or excoriation.
*Bruising indicates deep tissue injury.
Term
What is a stage 3 pressure ulcer?
Definition
Full thickness skin loss
Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/Stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and Category/Stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage III pressure ulcers. Bone/tendon is not visible or directly palpable.
Term
What is a stage 4 pressure ulcer?
Definition
Full thickness tissue loss
Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling. The depth of a Category/Stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and these ulcers can be shallow. Category/Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteomyelitis or osteitis likely to occur. Exposed bone/muscle is visible or directly palpable.
Term
What are the nursing diagnoses related to pressure ulcers?
Definition
Risk for Impaired Skin Integrity- one or more risk factor; use Braden scale
Impaired skin Integrity- damage to epidermis or dermis
Impaired Tissue Integrity-extends to subcutaneous tissue, muscle, or bone.
Risk for Impaired Tissue Integrity-risk for delayed healing/further progression of wound r/t age, nutrition, other wounds.
Term
What interventions can be done by a nurse for a patient at risk for pressure ulcers?
Definition
Prevention- Braden scale, inspect daily, turning
Meticulous skin care and moisture control-moisture barrier
Bathe gently-mild soap, rinse, dry
Adequate nutrition- calories, protein, etc.
Frequent repositioning
Therapeutic mattresses- specialty mattress, float heels, NO donuts
Term
Who can do an initial assessment of a wound?
Definition
A nurse
Term
Who can do wound care?
Definition
A nurse
Term
Who can inspect skin during AM care?
Definition
Nursing assistant personelle
Term
Who can report redness, warmth, drainage to a nurse?
Definition
NAP
Term
Who can turn/position patients?
Definition
NAP
Term
What is a penrose drain?
Definition
usually not sutured, advance as ordered
Term
What are the collection drains?
Definition
-JP
-Hemovac
Term
What should you do for a collection drain?
Definition
Compress device to create suction
Avoid dislodging
Monitor amt. and character of drainage, record output
Report to MD change in amt. or character
Empty to maintain suction
Term
What labs are important for wound care?
Definition
Prealbumin-protein levels
CBC- luekocytes=infection
Erythrocyte Sedimentation Rate-inflammatory/necrotic process
Glucose-increases with infection
Coagulation studies- hemorrhage
Wound cultures-swab, needle, biopsy
Term
What causes partial thickness?
Definition
Abrasions
Friction rubs
Superficial shear force
Term
What are the types of skin tears associated with parietal thickness?
Definition
Skin tears
Linear
Flap
No, minimal, complete tissue loss
Term
What is full thickness?
Definition
Destruction of all skin layers
May expose subcutaneous tissue, fascia, muscle, or bone
Scar formation
Term
What are the 4 phases of wound healing?
Definition
Hemostasis
Inflammation
Granulation
Maturation
Term
What is hemostasis? What kind of wound does it occur in?
Definition
Blood comes in contact with collagen which activates clotting pathways
Platelet aggregation and fibrin clot forms
Seals vessel
Bleeding stops

ONLY ACUTE
Term
What is the inflammation phase?
Definition
Injury causes vasodilation and increase blood flow to the area
Term
What is released during inflammation?
Definition
Growth factors
Term
When does the first WBC arrive at the injury site?
Definition
2 mins - NEUTROPHILS
Term
What happens at day 3 of the inflammation phase?
Definition
Day 3 the macrophage arrives to eliminate necrotic tissue and release growth factors
Term
How does the inflammation phase present itself?
Definition
as slight erythema, warmth, and induration
Term
What is granulation phase?
Definition
Neoangiogenesis
Fibroblast synthesize collagen and other structural tissue proteins
Term
What is needed for granulation?
Definition
Must have protein, energy, ascorbic acid, zinc, iron, and oxygen
Term
When does the granulation phase begin?
Definition
Usually begins around day 5 with peak between 5-15 days
Palpate healing ridge postop day 5-9
Term
When does contraction happen?
Definition
In the granulation phase.

Mobilization of wound edges for wound size reduction
Occurs in open wound only
Term
What is epithelialization?
Definition
Resurfacing.
Term
When are acute wounds resurfaced?
Definition
In 3 days
Term
When are chronic wounds resurfaced?
Definition
Migration from the edges only
Term
What is the maturation phase?
Definition
Scar tissue modification
Lysis of collagen fibers with new synthesis
Time frame: 1-2 years
Term
When is the wound 50% tensile strength?
Definition
2 weeks
Term
When is the wound 80% tensile strength?
Definition
3 months
Term
What are the elements of the braden scale?
Definition
Sensory perception
Moisture
Activity
Mobility
Nutrition
Friction and shear
Term
What are the elements of the norton scale?
Definition
Physical condition
Mental condition
Activity
Mobility
Incontinent
Term
What factors affect healing?
Definition
Perfusion/Oxygenation
Nutritional status
Infection
Corticosteroids
Aging
Diabetes
Term
What is perfusion/oxygenation essential for?
Definition
Essential for fibroblast proliferation and collagen synthesis, leukocyte activity and phagocytosis , and re-epithelialization
Term
What diseases effect perfusion/oxygenation?
Definition
Pressure, vascular disease, anemia, diabetes, edema, smoking, etc
Smoking: vasoconstrictive effect that last hours
Term
What is necessary for repair?
Definition
Positve nitrogen balance
Term
What does a positive nitrogen balance indicate?
Definition
Indicates adequate protein stores to support collagen synthesis and immune functions
Term
What is the CBC level for women?
Definition
12-16
Term
What is the CBC level for men?
Definition
13-18
Term
What is the normal WBC range?
Definition
5-11
Term
What does an albumin level of <2.8 indicate?
Definition
Gut wall edema
Term
What does a pre albumin level of < 10 indicate?
Definition
Depletion
Term
What does infection do?
Definition
Prolongs the inflammatory phase and causes additional damage
Term
All wounds are __________ NOT _________.
Definition
Contaminated.
infected
Term
What do corticosteroids effect?
Definition
adverse effect on neoangiogenesis, inflammation, contraction, and epithelialization
Term
What is aging effect on skin?
Definition
Delay in epithelial turnover as we age
Reduce blood supply to the skin
Reduce rates of collagen synthesis
Compromised inflammatory response
Term
How does elevated glucose effect the skin?
Definition
compromises fibroblast and leukocyte activity
Term
What is the ideal level for glucose AT THE LEAST?
Definition
Should aim for levels below 200 (at the least)
Term
What complications arise from diabetes?
Definition
Potential impaired circulation
Possible neuropathy
Motor
Autonomic
Sensory
Term
What is DIWAMOPI?
Definition
Debridement
Infection
Wick
Absorb Exudate
Moist wound healing
Open wound edges
Protect
Insulate
Term
What is debridement?
Definition
Remove necrotic tissue
Remove medium for bacterial growth
Progress wound from inflammatory phase to proliferative phase
Term
What is autolytic debridement?
Definition
Body takes care of itself; have to have adequate WBCs
Term
What is enzymatic debrideemnt?
Definition
Enzyme removes necrotic tissue
Term
What is chemical debridement?
Definition
Good for necrotic tissue and heavy bacterial load
Term
What should you do for infection?
Definition
Identify and treat: are there any lifted tabs
Term
What does infection do to the inflammatory phase?
Definition
Lengthens it.

Inhibits all aspects of the repair process
Term
What does wick mean?
Definition
fill dead space: any innies or outies
Term
What does premature closing of superficial wounds cause?
Definition
abscess formation and wound breakdown
Term
What does exudate contains?
Definition
contains bacterial toxins that can impair wound repair
Term
What can exudate cause?
Definition
maceration of intact skin
Term
What does moist wound healing promote?
Definition
Circular cellular migration. Prevents cell death.
Term
Why do you need open wound edges?
Definition
Closed wound edges are nonproliferative and prevent re-epithelialization
Term
What do you protect a wound from?
Definition
From infection
From trauma
Term
What is insulation?
Definition
Maintain normal temperature at wound surface
Term
What does insulation do?
Definition
Reduces vasoconstriction
Enhances cellular activity
Term
What else needs to be considered?
Definition
The cause of the wound
-pressure
-trauma
-venous
-arterial
-diabetes
Term
How do you treat a pressure related wound?
Definition
Relieve the pressure
Offloading devices
Boots
Pillows
Support surface to include bed and/or wheelchair
Term
What areas are high at risk for a pressure wound?
Definition
Heels
Sacrum
Ischial tuberosities
Term
What is DTI?
Definition
purple or maroon localized area of intact skin or blood filled blister due to damage of underlying soft tissue from pressure or shear
Term
How do you treat a trauma related wound?
Definition
Remove the trauma
Avoid future injury
Term
Where are venous diseases located?
Definition
Medial malleolous
Term
What does a venous ulcer look like?
Definition
Dark red/thin layer of adherent slough with a lot of exudate.

Pain improves with elevation
Term
How do you treat a venous disease?
Definition
Reduce the venous hypertension
Elevation
Compression therapy unless contraindicated
Absorptive dressing
Protect periwound skin
Monitor infection
Manage venous dermatitis
Term
What is the location of arterial disease?
Definition
: distal foot and toe
Term
What does an arterial ulcer look like?
Definition
Necrotic wound base or viable but pale
Punched out appearance
Low exudate
Dependant rubor
Term
What makes an arterial ulcer better?
Definition
Pain that worsens with activity or elevation but improves with dependency and rest
Term
How do you treat an arterial ulcer?
Definition
Vascular consult
Enhance perfusion
Dependant or neutral position
Nonadherent dressing if open lesion
Necrotic and infected prompt MD consult
Necrotic and not infected; protection
Watch closely for infection
Term
Where are diabetes ulcers located?
Definition
plantar surface or toes
Term
What do diabetes ulcers look like?
Definition
Red ulcer unless exist with arterial disease
Exudative
Term
How do you treat an arterial ulcer?
Definition
Control blood sugars
Offloading
Paring of corn and calluses
Assess for occult signs of infection
Dressing selection based on depth and exudate quantity
Term
What other diseases are associated with wounds?
Definition
Rheumatoid arthritis
Cancer
Scleraderma
Pyoderma gangrenosum
Vasculitic
Calciphylaxis
Term
When culturing, where should your sample be from?
Definition
Culture viable wound beds only!
Term
What are the advanced therapies used to wound care?
Definition
Negative pressure wound therapy
Foam
Gauze
Skin substitutes
Contact casting
Hyperbaric oxygen therapy
Term
What is the foam used to treat wounds?
Definition
Foam cut to fit wound that is covered with a film dressing connected to bedside suction for negative pressure
Term
What are the benefits of the foam?
Definition
Control exudate
Reduce edema
Promote neoangiogenesis
Term
What are the skin substitutes?
Definition
Dermal replacement
Mesh populated with dermal fibroblast


Dermal-epidermal replacement
Type 1 bovine collagen with human fibroblast with epidermal layer of keratinocytes
Term
What is contract casting used for?
Definition
Gold standard for offloading wounds; especially diabetic foot ulcers on the first metatarsal head
Term
What is hyperbaric oxygen therapy?
Definition
Hyperbaric chamber or room
Patient breaths 100% oxygen while exposed to 1-2 atmospheres of pressure
Term
What does hyperbaric oxygen do?
Definition
Increases the amount of oxygen dissolved in the plasma
Increases amount of oxygen available to tissue
Term
What does hyperbaric oxygen cause?
Definition
Vasoconstriction
Enhanced leukocyte function
Support for collagen synthesis and neovascularization
Increased diffusion distance
The distance that oxygen molecules can diffuse from the vessel into the tissue
Term
What are the different team members of wound care?
Definition
WOC nurse
Physical therapy
Occupational therapy
Diabetes educator
Dietician
Primary care physician
Vascular surgeon
Orthopedic surgeon
Plastic surgeon
Supporting users have an ad free experience!