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
|
|
Term
|
Definition
straw-colored
Clean wounds |
|
|
Term
|
Definition
bloody drainage
Deep wounds |
|
|
Term
|
Definition
mix of bloody and
straw-colored fluid
New wounds |
|
|
Term
| What is purulent drainage? |
|
Definition
yellow, contains pus
Infected wounds |
|
|
Term
|
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
|
Definition
| bacteria count above 100,000 organisms/gram of tissue, exception- beta-hemolytic streptococci |
|
|
Term
|
Definition
| one or more layers, infammatory phase, obese clients |
|
|
Term
|
Definition
| Total separation MEDICAL EMERGENCY-Know tx! |
|
|
Term
|
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
|
|
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
|
Definition
| Works the same way as JP - just larger container |
|
|
Term
| What does a wound vac provide? |
|
Definition
|
|
Term
| What is used to dress a wound? |
|
Definition
gauze/transparent film
Hydrocolloids/hydrogels |
|
|
Term
| What are the supporting/binding materials? |
|
Definition
|
|
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
|
|
Term
|
Definition
|
|
Term
| Who can inspect skin during AM care? |
|
Definition
| Nursing assistant personelle |
|
|
Term
| Who can report redness, warmth, drainage to a nurse? |
|
Definition
|
|
Term
| Who can turn/position patients? |
|
Definition
|
|
Term
|
Definition
| usually not sutured, advance as ordered |
|
|
Term
| What are the collection drains? |
|
Definition
|
|
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
|
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
|
|
Term
| When does the first WBC arrive at the injury site? |
|
Definition
|
|
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
|
|
Term
| When are acute wounds resurfaced? |
|
Definition
|
|
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
|
|
Term
| When is the wound 80% tensile strength? |
|
Definition
|
|
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
|
|
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
|
|
Term
| What is the CBC level for men? |
|
Definition
|
|
Term
| What is the normal WBC range? |
|
Definition
|
|
Term
| What does an albumin level of <2.8 indicate? |
|
Definition
|
|
Term
| What does a pre albumin level of < 10 indicate? |
|
Definition
|
|
Term
|
Definition
| Prolongs the inflammatory phase and causes additional damage |
|
|
Term
| All wounds are __________ NOT _________. |
|
Definition
|
|
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
|
Definition
Debridement
Infection
Wick
Absorb Exudate
Moist wound healing
Open wound edges
Protect
Insulate |
|
|
Term
|
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
|
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
|
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
|
Definition
| Maintain normal temperature at wound surface |
|
|
Term
|
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
|
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
|
|
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
|
|
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
|
|
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 |
|
|
