Skin Integrity & Wound Care

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Skin Integrity & Wound Care
2011-03-07 00:30:25

Ch. 48 Integumentary
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  1. A __________is a localized injury to the skin and other ynderlying tissue, usually over a bony prominence, as a result of pressure or pressure in combination w/shear and/or friction
    pressure ulcer
  2. Age related changes, such as:
    cause the older adults skin to be easily torn in response to mechanical trauma, especially shearing forces
    • reduced skin elasticity
    • decreased collagen
    • thinning of undrelying muscle and tissues
  3. ________ & _______, which are common in the older adult, are factors that interfere w/wound healing
    • concomitant medical conditions
    • polypharmacy
  4. Name some factors that put a client at risk for pressure ulcer development...(4)
    • decreased mobility
    • decreased sensory perception
    • fecal or urinary incontinence
    • poor nutrition
  5. Prolonged, intense pressure affects cellular metabolism by decreasing or obliterating blood flow, resulting in tissue _______ & ultimately tissue death
  6. The three pressure related factors that contribute to pressure ulcer development are:
    • pressure intensity-how much pressure is applied
    • pressure duration-how long is pressure applied
    • tissue tolerance-ability of tissue to redistribute weight
  7. A nurse can quote pressure ulcer stage if it has been established by a wound care specialist but nurses can not diagnose stages of pressure ulcers

    *Once you have staged a ulcer, this stage endures een as the ulcer heals ex: healing stage III pressure ulcer
  8. This is the minimal amount of pressure required to collapse a capillary
    capillary closing pressure
  9. If the hyperemia area blanches and the erythema returns when you remove your finger, the hyperemia is transient and is an attempt to overcome the ischemic episode, thus called _____________
    blanching hypermia
  10. Dark skinned ppl do not blanch. How do you assess for possible skin breakdown?
    • use natural or halogen light source
    • avoid fluorescent light source, it casts a bluish hue making assessment difficult
    • color appears darker than surrounding skin
    • has purplish/bluish hue
    • initial warmth when compaired to surrounding skin
  11. The extrensic factors of ____,____ and _____affect the ability of the skin to tolerate pressure.
    • shear
    • friction
    • moisture
    • The greater the degree of these things being present, the more suseptible skin will be to damage
  12. A factor related to tissue tolerance pertains to the ability of the underlying skin structures to assist in redistributing pressure. Systemic factors such as: (3) affect the tissue's tolerance to externally applied pressure
    • poor nutrition
    • increased aging
    • low blood pressure
  13. When ____ is present, the skin and subcutaneous layers adhere to the surface of the bed and the layers of muscle and the bones slide in the direction of body movement
    shear-this involves the underlying tissue capillaries and necrosis occurs deep w/in the tissue layers
  14. Mechanical force excerted when skin is dragged across a coarse surface such as bed linens
    friction-affects the epidermis
  15. Pressure ulcer assessment includes (5)
    • depth of tissue involvement (staging)
    • type & approximate % of tissue in wound bed
    • wound dimensions
    • exudate description
    • condition of surrounding skin
  16. List the decubitus stage:
    Intact skin w/nonblanchable redness of a localized area
    Stage I
  17. List the decubitis stage:
    Partial-thickness skin loss involving epidermis, dermis or both. The ulcer is superficial and presents clinicall as an abrasion, blister or shallow crater.
    Stage II
  18. List the decubitis stage:
    Full-thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed. May include undermining or tunneling
    Stage III
  19. List the decubitis stage:
    Full-thickness tissue loss w/exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound. Often includes undermining & tunneling
    Stage IV
  20. The NPUAP has developed a definition for an ulcer in which the base of the wound cannot be visualized. An _______ ulcer is a full-thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, black) in the wound bed
    unstageable ulcer
  21. ________is red moist tissue composed of new blood vessls, the presence of which indicates progression toward healing
    granulation tissue
  22. soft yellow or white tisue is characteristic of ________(stringy substance attached to the wound bed)
  23. Wound _______ describes the amount, color, consistency and odor of wound drainage and is part of the wound assessment
    exudate-excessive indicates infection
  24. Wound classification system describes:5
    • describe the status of skin integrity
    • cause of the wound
    • severity or extent of tissue injury/damage
    • cleanliness of the wound
    • descriptive qualities of the wound tissue such as color
  25. Process of wound healing with little tissue loss. The skin edges are approximated or closed and the risk for infection is low
    primary intention
  26. Process of wound healing involving loss of tissue such as a burn, pressure ulcer or sever laceration. The wound is left open until it becomes filled w/scar tissue.
    secondary intention-it takes longer for this wound to heal thus the risk for infection is greater
  27. This wound is left open for several days, then the wound edges are approximated. The closure of wound is delayed until risk of infection is resolved
    tertiary intention
  28. Wound that proceeds through an orderly and timely reparative process that results in sustained restoration of anatomical & functional integrity
  29. Wound that fails to proceed through an orderly & timely process to produce anatomical & functional integrity
  30. There are three components involved in the healing process of a partial-thickness wound:
    • inflammatory response
    • epithelial proliferation (reproduction) & migration
    • reestablishment of the epidermal layers
  31. A wound left open to air can resurface in 6-7 days whereas a wound that is kept moist can resurface in 4 days. The difference in the healing rate is related to the fact that epidermal cells _________________
    only migrate across a moist surface
  32. The three phases involved in the healing process of a full-thickness wound are:
    • inflammatory-reaction to wounding & lasts approx 3 days
    • proliferative-filling of wound w/granulation tissue 4-21 days
    • remodeling-maturation 3-4 weeks
  33. Leukocytes reach wound w/in a few hours. The primary WBC is the neutrophil, which begins to injest bacteria. The 2nd important leukocyte is the monocyte which transforms into macrophages "garbage cells" and clean a wound of bacteria, dead cells and debris by way of phagocytosis
  34. Impairment of healing during the proliferative phase usually results from systemic factors such as age, anemia, hypoproteinemia and zinc deficiency
  35. Complications of wound healing:
    Internal bleeding from a hemorrage is detected by:
    • looking for distention or swelling of the affected body part
    • a change in the type & amount of drainage from drain
    • signs of hypovolemic shock
  36. _____is a localized collection of blood underneath the tissues that appears as a swelling, change in color, sensation or warmth or mass that often takes on a bluish discoloration
  37. True or false:
    If a wound culture is taken and has negative results, if purulent material drains from the wound, it is considered infected
  38. A surgical wound infection usually does not develop until the ___ or ____ postoperative day.
    4th or 5th
  39. _________is the partial or total seperation of wound layers.
    Clients often report that it feels as something has "given way".
    • Dehiscence-3-11 days after injury
    • Although poor nutritional status, infection and obesity are at risk for dehiscence, obese clients have a >risk bc of the constant strain placed on their wounds
  40. With total separation of wound layers, ___________ is a protrusion of visceral organs through a wound opening
    Evisceration-This is an emergency situation. The nurse places sterile towels soaked in sterile saline over the tissues to reduce bacterial in invasion & drying. NPO
  41. A _______ is an abnormal passage between two organs or between an organ and the outside of the body. Most result from poor wound healing or a complication of disease such as Crohn's
  42. Types of wound drainage:
    Clear, watery plasma
  43. Types of wound drainage:
    Thick, yellow, green, tan, or brown
  44. Types of wound drainage:
    Pale, red, waters: mixture of clear and red fluid
  45. Types of wound drainage:
    Bright red: indicates active bleeding
  46. Name 2 common scales for predicting pressure ulcer risk:
    • Norton Scale
    • Braden scale
  47. Your patient returns from surgery and after a few hours you notice the surgical dressing is soaked w/blood. What would be your course of action?
    Do not remove or replace the dressing. Add more dressing to the current dressing. The 1st dressing is usually changed by the physician/team.
  48. Pressure ulcers usually develop w/in the _________of hospitalization
    first 2 weeks
  49. Physiological processes of wound healing depend on the availability of ____, vitamins __ & ___ and the trace minerals ____ & ______.
    A well nourished surgical pt still requires at least _____kcal/day for nutritional maintenance
    • protein
    • vitamins A
    • vitamin C
    • zinc
    • copper
    • 1500 kcal/day
  50. ______proteins are biochemical indicators of malnutrition
    serum proteins
  51. An _______ is superficial w/little bleeding and is considered a partial-thickness wound. The wound appears "weepy" because of plasma leakage from damaged capillaries.
  52. A _______sometimes bleeds more profusely, depending on the wound's depth and location
  53. _________wounds bleed in relation to the depth and size of the wound.
    • puncture:
    • the primary dangers of punctures wounds are internal bleeding & infection
  54. Frequent skin assessment should be performed at least ______/day.
    High-risk clients will need more frequent shik assessments, such as _______
    • once
    • every shift
  55. Elevating the head of the bed to 30 degrees or less will decrease the chance of pressure ulcer development from shearing forces
    • Make sure to reposition clients at least every 2 hours on a schedule
    • limit the amount of time client sits to 2 hrs or less
    • inform client to shift weight every 15 min
  56. You clean pressure unlcers with _______ or ____________
    • noncytotoxic wound cleaners such as normal saline or
    • commercial wound cleansers
  57. Wound irrigation (high-pressure irrigation and pulsatile high pressure lavage) and whirlpool treatments are all methods of _______debridement
  58. _________debridement uses synthetic dressings over a wound to allow the eschar to be self-digested by the action of enzymes that are present in wound fluids
    autolytic debridement
  59. You can accomplish _____debridement with the use of a topical enzyme preparation, Dakin's solution or sterile maggots
  60. _______debridement is the removal of devitalized tissue by using a scalpel, scissors, or other sharp instrument
    • surgical
    • It is the quickest method of debridement and is indicated when the client has signs of cellulitis or sepsis
  61. A friction injury occurs in clients who are:
    • restless
    • have spastic conditions
    • skin is dragged rather than lifted when repositioned
  62. Observing all surgical wounds closely withing the _________to______hrs, when risk of hemorrhage is the greatest
    first 24 to 48 hours