Term
| Your client has a Braden scale score of 17. The appropriate nursing action is |
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Definition
| Implement a turning schedule |
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Term
| Proper technique for performing a wound culture includes which of the following? |
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Definition
Cleansing the wound prior to obtaining the specimen.
Rationale: Wound culture specimens should be obtained from a cleaned area of the wound. Microbes responsible for the infection are more likely to be found in viable tissue. Collected drainage contains old and mixed organisms. |
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Term
| A client has a pressure ulcer with a shallow, partial skin thickness, eroded area but no necrotic areas. The nurse would treat the area with which of the following dressings? |
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Definition
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Term
| What type of dressings are used for wounds with significant drainage? |
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Definition
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Term
| Thirty (30) minutes after application is initiated, the client requests that the nurse leave the heating pad in place. The nurse explains to the client that |
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Definition
Heat application for longer than 30 minutes can actually cause the opposite effect (constriction) of the one desired (dilation).
Rationale: The heating pad needs to be removed. After 30 minutes of heat application, the blood vessels in the area will begin to exhibit the rebound effect resulting in vasoconstriction. Lowering the temperature, but still delivering heat—dry or moist—will not prevent the rebound effect. The visual appearance of the site on inspection does not indicate if rebound is occurring. |
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Term
| Which statement, if made by the client or family member, would indicate the need for further teaching? |
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Definition
If a person cannot turn himself or herself in bed, someone should help the person change position every 4 hours.
Rationale: Immobile and dependent persons should be repositioned at least every 2 hours, not every 4 |
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Term
| An appropriate nursing diagnosis for a client with large areas of skin excoriation resulting from scratching an allergic rash is |
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Definition
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Term
| Which of the following are primary risk factors for pressure ulcers? Select all that apply. |
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Definition
-Low-protein diet
-Lengthy surgical procedures
-Fever |
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Term
| Which of the following items are used to perform wound irrigation? Select all that apply. |
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Definition
Clean gloves
Sterile gloves
60-mL syringe |
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Term
| Which of the following indicates proper use of a triangle arm sling? |
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Definition
| The knot is placed on either side of the vertebrae of the neck. |
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Term
|
Definition
| growing only in the presence of oxygen |
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Term
|
Definition
| growing only in the absence of oxygen |
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Term
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Definition
|
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Term
|
Definition
| a strip of cloth used to wrap some part of the body |
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Term
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Definition
| a type of bandage applied to large body areas (abdomen or chest) that are designed for a specific body part (arm sling) |
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Term
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Definition
| a protein found in connective tissue |
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Term
|
Definition
| a moist gauze dressing applied frequently to an open wound, sometimes medicated |
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Term
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Definition
| removal of infected and necrotic material |
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Term
|
Definition
|
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Term
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Definition
| the partial or total rupturing of a sutured wound |
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Term
|
Definition
|
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Term
|
Definition
| extrusion of the internal organs |
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Term
|
Definition
| loss of the superficial layers of the skin |
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Term
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Definition
|
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Term
|
Definition
| an insoluble protein formed from fibrinogen during the clotting of blood |
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Term
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Definition
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Term
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Definition
| young connective tissue with new capillaries formed in the wound healing process |
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Term
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Definition
| a contusion or "black eye" resulting from injury |
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Term
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Definition
| excessive loss of blood from the vascular system |
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Term
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Definition
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Term
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Definition
| prescribed or unavoidable restriction of movement in any area of a person's life |
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Term
|
Definition
| deficiency of blood supply caused by obstruction of circulation to the body part |
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Term
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Definition
| a hypertrophic scar containing an abnormal amount of collagen |
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Term
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Definition
| the wasting away or softening of a solid as if by the action of soaking |
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Term
|
Definition
| filling an open wound or cavity with a material such as gauze |
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Term
|
Definition
| reddened areas, sores, or ulcers of the skin occurring over bony prominences |
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Term
| Primary intention healing |
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Definition
| tissue surfaces are approximated (closed) and there is minimal or no tissue loss, formation of minimal granulation tissue and scarring |
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Term
|
Definition
| an exudate consisting of leukocytes, liquefied dead tissue debris, and dead and living bacteria |
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Term
|
Definition
|
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Term
|
Definition
| a bright red flush on the skin occurring after pressure is relieved |
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Term
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Definition
| renewal, regrowth, the replacement of destroyed tissue cells by cells that are identical or similar in structure and function |
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Term
|
Definition
| an exudate containing large amounts of red blood cells |
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Term
| Secondary intention healing |
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Definition
| wound in which the tissue surfaces are not approximated and there is extensive tissue loss |
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Term
|
Definition
| inflammatory material consisting of a combination of clear and blood-tinged drainage |
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Term
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Definition
| inflammatory material composed of serum (clear portion of blood) derived from the blood and serous membranes of the body such as the peritoneum, pleura, pericardium, and meninges |
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Term
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Definition
| a combination of friction and pressure that, when applied to the skin, results in damage to the blood vessels and tissues |
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Term
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Definition
| a bath in which the client sits in warm water to help soothe and heal the perineum |
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Term
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Definition
|
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Term
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Definition
| healing that occurs in wounds left open for 3 to 5 days and then closed with sutures, staples, or adhesive skin closures |
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Term
|
Definition
| constricted blood vessels |
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Term
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Definition
| an increase in the diameter of blood vessels |
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Term
| An adolescent client who has diabetes mellitus is 2 days postoperative following an appendectomy. The client is tolerating a regular diet well. He has ambulated successfully around the unit with assistance and requests pain medication every 6-8 hr while reporting pain at 2 on a scale of 0 to 10 after the medication is given. his incision is approximated and free of redness with scant serous drainage noted on the dressing. Which of the following risk factors for poor healing does this client have (select all) |
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Definition
impaired circulation
impaired/suppressed immune system |
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Term
| an entry in a clients chart states that the wound drainage is "sanguineous". this means it is what? |
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Definition
|
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Term
| what is an example of a wound or injury healing by secondary intention? |
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Definition
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Term
Scenario: an older adult woman is 6 days postoperative following surgery for a bowel obstruction. during the last 24 hours she has reported nausea and she vomited small amounts of clear liquid 3 times in the last 8 hours. currently, her incision is well approximated and free of redness, tenderness and swelling.
which finding would indicate development of a wound infection? |
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Definition
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Term
Scenario: an older adult woman is 6 days postoperative following surgery for a bowel obstruction. during the last 24 hours she has reported nausea and she vomited small amounts of clear liquid 3 times in the last 8 hours. currently, her incision is well approximated and free of redness, tenderness and swelling.
later that day, the client becomes confused and pulls off her surgical dressing. The nurse enters the room and finds the clients wound separated with viscera protruding. which of the following nursing interventions are most appropriate? (select all) |
|
Definition
-call for help
-cover the wound with a sterile dressing moistened with .9% sodium chloride
-stay with the client
-DO NOT attempt to repack wound or reinsert organs.
-The nurse should have the client lie supine with her hips and knees bent |
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Term
Scenario: An older adult client who has diabetes mellitus must now use a wheelchair after a cerebrovascular accident (CVA) 2 years ago that affected her right side. She doesn't respond to pain on the right side of her body. Her fluid and food intake is good, but she needs help with eating.
Which risk factors for developing pressure ulcers does this client have? |
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Definition
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Term
Scenario: An older adult client who has diabetes mellitus must now use a wheelchair after a cerebrovascular accident (CVA) 2 years ago that affected her right side. She doesn't respond to pain on the right side of her body. Her fluid and food intake is good, but she needs help with eating.
What can the nurse to to prevent skin breakdown? |
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Definition
| Encourage repositioning every 15 minutes while the client is in the wheelchair. |
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Term
| True or false: the skin is the largest organ in the body and serves a variety of important functions in maintaining health and protecting the individual from injury. |
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Definition
|
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Term
| true or False: hypoproteinemia is an abnormally high protein content in the blood |
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Definition
False.
It is an abnormally low level of protein in the blood |
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Term
| What can hypoproteinemia indicate? |
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Definition
| Can indicate inadequate diet or intestinal or renal disorders |
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Term
| True or False: Wound beds that are too dry or disturbed too often fail to heal |
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Definition
|
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Term
| Should nutritional supplements be considered for nutritionally compromised wound care clients? |
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Definition
| Yes, an inadequate intake of calories, protein, vitamins and iron is believe to be a risk factor for pressure ulcer development. |
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Term
| the nurse is assessing a wound and notes that the exudate is puruent. What would you expect the exudate to look like? |
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Definition
| The exudate is thick with the presence of pus and is yellow in color. |
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Term
| During Discharge planning, the nurse is teaching a client how to apply an electric heat pad to his back. What is important for the nurse to know? |
|
Definition
-Do not insert sharp objects into pad as this may damage wiring and cause an electric shock
-ensure body area is dry unless there is a waterproof cover on pad
-use pads with a preset switch so clients can cant turn up the heat
-do not place the pad under the client. Heat will not dissipate and client may be burned. |
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Term
| what action taken by a client while administering a hot water bottle would indicate a need for further teaching? |
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Definition
| The client fills the bag with water at a temp of 135F |
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Term
| What water bad temps are considered safe for normal adults and children over 2 years? |
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Definition
|
|
Term
| What water bad temps are considered safe for debilitated or unconscious adults and children under 2 years? |
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Definition
|
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Term
|
Definition
| Sharp instrument ''open, deep or shallow'‘. |
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Term
|
Definition
| blow from a blunt instrument '' closed, skin appears ecchymosed (bruised)''. |
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Term
|
Definition
| Surface scrape ''open, involving the skin''. |
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Term
|
Definition
| penetration of the skin and often the underlying tissues by a sharp instrument, either intentional or unintentional ''open wounds''. |
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Term
|
Definition
| tissue torn apart, often from accident ''open, edges are often jagged''. |
|
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Term
| Describe a penetrating wound |
|
Definition
| penetrating the skin and underlying tissues. '' Open wound ''. |
|
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Term
| What are the risk factors for pressure ulcers? |
|
Definition
-Friction and shearing
-immobility
-inadequate nutrition
-fecal and urinary incontinence
-decreased mental status
-diminished sensation
-excessive body heat
-advanced age
-chronic medical conditions
- |
|
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Term
| Describe stage I of Pressure ulcers |
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Definition
| red color and the skin don’t return to normal color even the pressure is released. |
|
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Term
| Describe stage II of Pressure ulcers |
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Definition
| redness accompanied by blisters or shallow break in the skin |
|
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Term
| Describe stage III of Pressure ulcers |
|
Definition
| break in the skin extending to the subcutaneous tissue |
|
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Term
| Describe stage IV of Pressure ulcers |
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Definition
| ulcer involves loss of all skin layers exposing muscle and bone. |
|
|
Term
| what are effects of wounds? |
|
Definition
Loss of all or part of organ functioning
Sympathetic stress response
Hemorrhage and blood clotting
Bacterial contamination
Death of cells |
|
|
Term
| when is a wound considered "open"? |
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Definition
| when the skin or mucous membrane surface is broken. |
|
|
Term
| What is intentional trauma? |
|
Definition
| trauma occuring during therapy e.g., operations or venipuncture, removing tumor. |
|
|
Term
| what is unintentional trauma? |
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Definition
|
|
Term
| When can Shearing forces occur? |
|
Definition
| when a patient is moved carelessly or slides down in bed. |
|
|
Term
| what is reactive hyperthermia? |
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Definition
| the bright red flush the skin takes on after pressure is relieved. |
|
|
Term
| what is the cause of pressure ulcers? |
|
Definition
| localized ischemia, a deficiency in the blood supply to the tissue |
|
|
Term
| What is the physiology behind pressure ulcer occurrence? |
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Definition
| The tissue is compressed between two hard surfaces, usually the surface between the bed and the skeleton, when the blood cannot reach the tissue, the cells are deprived of oxygen and nutrients, waste products of metabolism accumulate in the cells, and the tissue consequently dies. Prolonged, unrelieved pressure also damages the small blood vessels. |
|
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Term
| what are other names for pressure ulcers? |
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Definition
| decubitus ulcers, pressure sores, or bedsores |
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Term
|
Definition
| uninfected wounds in which minimal inflammation is encountered. |
|
|
Term
| what is a clean-contaminated wound? |
|
Definition
| surgical wounds in which the respiratory, alimentary, genital or urinary tract has been entered. No evidence of infection. |
|
|
Term
| What is a Contaminated wound? |
|
Definition
| open, fresh, accidental wounds and surgical wounds involving a major break in sterile technique or a large amount of spillage from the gastrointestinal tract. Show evidence of inflammation. |
|
|
Term
| What is a Dirty or infected wound? |
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Definition
| containing dead tissue and wounds with evidence of a clinical infection, such as purulent drainage. |
|
|
Term
| What is Primary intention healing |
|
Definition
| Occurs where the tissue surfaces have been approximated (closed) and there is minimal or no tissue loss |
|
|
Term
| What is Secondary intention healing |
|
Definition
| It is extensive and involves considerable tissue loss, and in which the edges cannot or should not be approximated. e.g., pressure ulcer. |
|
|
Term
| How does secondary intention healing differ from primary intention healing? |
|
Definition
1- The repair time is longer
2- Scarring is greater
3- Susceptibility to infection is greater |
|
|
Term
|
Definition
is initiated immediately after injury and last 3 to 6 days. This phase include mildly elevated temperature, leukocytosis, and generalized malaise. Two major processes occur during this phase:
Hemostasis
Phagocytosis |
|
|
Term
|
Definition
| extends from day 3 or 4 to about day 21 postinjury. Fibroblasts (connective tissue cells), which migrate into the wound begin to synthesize collagen (whitish protein), these substance adds tensile strength, this decreases the chance that wound open again. Capillaries grow across the wound, ↑ the blood supply. Fibroblasts move from the bloodstream into wound, depositing fibrin , the tissue becomes a translucent red color. This tissue , called granulation tissues , is fragile and bleeds easily |
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|
Term
| Maturation (Remodeling phase): |
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Definition
| ): begins about day 21 and can extend 1 or 2 years after the injury. During maturation, the wound is remodeled and contracted. The scar becomes stronger but the repaired area is never as strong as the original tissue. |
|
|
Term
| time of inflammatory phase |
|
Definition
| initiated immediately after injury and last 3 to 6 days |
|
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Term
|
Definition
| day 3 or 4 to about day 21 postinjury. |
|
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Term
|
Definition
| day 21 and can extend 1 or 2 years after the injury. |
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Term
|
Definition
| bacteria that produce pus |
|
|
Term
|
Definition
| consisting of pus and blood |
|
|
Term
|
Definition
| consisting of clear and blood tinged drainage |
|
|
Term
|
Definition
| abnormal massive bleeding |
|
|
Term
|
Definition
| The temperature and pulse increase, wound become tender, swollen, and warm. |
|
|
Term
| when is wound dehiscence most likely to occur? |
|
Definition
| 4 to 5 days postoperatively |
|
|
Term
| what are factors affecting wound healing? |
|
Definition
-Developmental considerations
-Nutrition
-Wound condition
-Lifestyle
-Medications |
|
|
Term
| Nursing intervention for maintaining skin integrity and wound care involve: |
|
Definition
1- Supporting wound healing
2- Preventing pressure ulcers
3- Treating Pressure ulcers
4- Dressing and cleaning wounds
5- Supporting and immobilizing wounds
6- Heat and cold applications |
|
|
Term
| Nursing intervention: Moist wound healing |
|
Definition
| The dressing and frequency of change should support moist wound bed conditions. Wound beds that are too dry or disturbed too often fail to heal. |
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|
Term
| Nursing intervention: nutrition and fluids |
|
Definition
| Clients should be assisted to take in at least 2500ml of fluids a day unless it is contraindication, also the nurse should ensure that clients receive sufficient protein, vitamins C,A,B1 and B5, and Zinc. |
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Term
|
Definition
| a scalpel or scissors is used to separate and remove dead tissue. |
|
|
Term
|
Definition
| scrubbing force or moist to moist dressings. |
|
|
Term
|
Definition
| collagenase enzyme agents such as papain – urea |
|
|
Term
|
Definition
| dressing that contain wound moisture, such as hydrocolloid and clear absorbent dressings. |
|
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Term
|
Definition
-Sedative effect to relief pain and aches
-Vasodilatation and increase blood flow to the affected area
-Bringing oxygen and nutrients, antibodies, and leukocytes
-Promote soft tissue healing
-It is often used for clients with musculoskeletal problems such as arthritis. |
|
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Term
|
Definition
Disadvantages:
Increase capillary permeability which cause edema |
|
|
Term
|
Definition
Vasoconstriction, which decrease the blood supply and nutrients to the affected area.
Decrease cellular metabolism
Decrease removal of wastes
Prolonged exposure to cold results impaired circulation, cell deprivation, and subsequent cell damage |
|
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Term
|
Definition
| to flush out the wound, remove foreign particles |
|
|
Term
|
Definition
type of healing that occurs with wounds that are left open for 3-5 days to allow for edema or infection to resolve or exudate to drain. They are then closed.
Also called delayed primary intervention |
|
|
Term
| how do you know healing has occurred? |
|
Definition
wound site is smaller
exudates are decreasing, no fresh blood |
|
|
Term
| Meaning of Braden scale score 18-23 |
|
Definition
| no risk for pressure ulcers |
|
|
Term
| Meaning of Braden scale score 15-16 |
|
Definition
| low risk, but implement preventative measures |
|
|
Term
| Meaning of Braden scale score 13-14 |
|
Definition
moderate risk
likely showing stage I signs if not sate II |
|
|
Term
| Meaning of Braden scale score 12 or less |
|
Definition
| high risk- likely has stage III or IV |
|
|
Term
|
Definition
| confined to the skin, that is, the dermis and epidermis |
|
|
Term
|
Definition
| involving the dermis, epidermis, subcutaneous tissue, and possibly muscle and bone |
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|
