Wound Care

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Wound Care
2011-03-31 23:46:51
Wound Care

EXAM 4 Wound Care
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  1. Classify Ulcer: Non-blanchable redness of a localized area, usually on a bony prominence
    Stage 1 ulcer
  2. Classify Ulcer: partial-thickness skin loss involving epidermis, dermis, or both?
    Stage 2 pressure ulcer
  3. Classify Ulcer; full-thickness tissue loss
    Stage 3 pressure ulcer
  4. Classify ulcer: full-thickness tissue loss with exposed bone, tendon, or muscle, slough or eschar may be present
    Stage 4 pressure ulcer
  5. Definition:
    Red moist tissue composed of new blood vessles, the presence of which indicates progression toward healing?
    Granulation tissue
  6. Definition:
    Stringy substance attached to wound bed?
  7. Definition:
    Black or borwn necrotic tissue?
  8. Definition:
    The amount, color, consistency and odor of wound drainage and is part of wound assessment?
    Wound exudates
  9. Wound healing:
    surgical wound (a wound with little tissue loss, clean incision; skin edges are approximated/close/little risk for infection)?
    Primary intention wound healing
  10. Wound healing:
    burn, pressure ulcer, severe laceration (wound involving loss of tissue; left open until becomes filled with scar tissue. Skin edges not approximated/longer healing time/greater chance for infection)?
    Secondary intention wound healing
  11. Wound healing:
    contaminated wounds (wound left open for several days, then wound edges are approximated)?
    Tertiary intention wound healing
  12. Pressure ulcers are also known as:
    And defined....?
    • pressure sores
    • decubitus ulcers
    • bed sores
    • defined = impaired skin integrity due to unrelieved prolong pressure
  13. What can cause pressure ulcers? Risks?
    • age-related skin changes (reduced elasticity, decreased skin turgor...)
    • Medical conditions and polypharmacy
    • Flattened attachment between dermis and epidermis
    • Diminished inflammatory reponse, slow wound healing
    • Little subcutaneous padding over bony prominences
    • Reduced nutritional intake
  14. Factors that contribute to pressure ulcers include:
    • Pressure intensity
    • - pressure ischemia
    • -blanching
    • Pressure duration
    • -low pressure over prolonged time
    • high pressure over short time
    • Tissue tolerance
    • -shear/friction/moisture - brkdwn skin
    • -integrity of skin to start with
  15. Three phases to partial thickness wound repair are?
    • 1. Inflammatory response
    • -Hemostasis- blood vessels constrict
    • -Fibrin - clotting
    • 2. Epithelial proliferation
    • -wound fills with granulation tiss.
    • -Contraction of wound occurs
    • -REsurfacing of wound by fibroblasts
    • 3. Reestablishment of epidermal layers
    • -Remodeling; collagen scare continues to reorganize
  16. Three phases to full-thickness wound repair?
    • 1. Inflammatory
    • -begins w/in minutes and lasts approx. 3 days
    • 2. Proliferative
    • -lasts 3-24 days
    • -appearance of new blood vessels
    • fibroblasts and granulation begin
    • 3. Remodeling
    • -final stage
    • -can take more than a year sometimes
    • -collagen scar continues to reorganize
  17. Complications of wound healing: Definition:
    bleeding from a wound site; poor clotting factor so bleeding doesn’t stop?
  18. Complications of wound healing: Definition
    second most common healthcare issue/concern?
  19. Complications of wound healing: Definition:
    wound fails to heal properly; partial or total rupture (seperation) of a sutured wound usually with separatioin of underlying skin layers?
  20. Complications of wound healing: Definition
    protrusion of visceral organs through wound opening occurs?
  21. Complications of wound healing: Definition:
    abnormal passage between two organs or between an organ and the outside of the body?
  22. Wound drainage;
    Clear, watery plasma - normal?
    Serous fluid
  23. Wound drainage:
    thick, yellow, green, tan or brown fluid/appearance on wound?
  24. Wound drainage:
    Pale, red, watery - mixture of clear and red fluid?
  25. Wound drainage:
    bright red - indicates active bleeding/
  26. Definition:
    Superficial wound with little bleeding; considered partial-thickness wound?
  27. Definition:
    Wound bleeds more profusely depending on wound depth/location (e.g., head wound)?
  28. Definition:
    Wound bleeds in relation to the depth and size of the wound (nail puncture vs. knife wound)?
  29. Seperates the dermis (inner layer) and epidermis (top layer) of skin?
    dermal-epidermal junction
  30. Pathogenesis of pressure ulcers - cause of pressure ulcers may include?
    • pressure intensity of skin to causative agent
    • blanching of skin - red tones absent
    • pressure duration of skin to causative agent
    • Tolerance of skin tissue to causative agent
  31. Risk factors for pressure ulcer develpment include?
    • impaired skin integrity
    • impaired mobility
    • friction
    • shear
    • moisture
    • alterations in LOC
  32. What are things to consider/do to keep skin intact?
    • Hydration
    • Nutrition
    • Keep glucose levels at 70-110
    • Know what patient is at risk for
    • Know what kind of patient is at risk
    • Know how to prevent wound from further injury
  33. Factors influencing pressure ulcer formation and wound healing?
    • nutrition
    • tissue perfusion
    • infection
    • age
    • psychosocial impact of wounds
  34. What to assess for, related to wound(s), upon client enterance to hospital?
    • skin
    • presence of ulcers
    • mobility
    • nutrition and fluid status
    • pain
    • exisitng wounds, apearance, location, character
    • wound culture
  35. What are some health promotion techniques to implement to ensure proper wound healing and prevention from further injury?
    • topical skin care - barrier cream
    • change position every 1-2 hours
    • provide support surfaces
    • -get client off bony prominence
    • -tents to raise sheets
    • -special mattresses
    • -boots for feet
    • -increase circulation back to heart - SCD's
  36. Wound definition:
    Removal of non-vialbe necrotic tissue?
  37. A wound will not heal if you do not remove causative agents - list some?
    • Friction
    • Shearing
    • Pressure
    • Moisture
  38. Type of debridement (there are 4)

    Wound irrigation or whirl pool, wet to dry saline gauze dressing?
    Mechanical debridement
  39. Type of debridement (there are 4)

    Synthetic dressing over wound allow eschar to be self-digested by the action of enzymes that are present in wound fluids?
    Autolytic debridement
  40. Type of debridement (there are 4)

    Topical enzyme prep; dankins solution or maggots?
    Chemical debridement
  41. Type of debridement (there are 4)

    Removal of devitalized tissue w/scalpel, scissors, sharp instrument?
    Sharp/surgical debridement
  42. Acute care for wound management includes?
    • debridement
    • nutrition - I's and O's
    • client education
  43. Types of dressings:
    Absorbant and wicks away wound exudates? Oldest and most common dressing type.
    Gauze dressings
  44. Types of dressings:
    Does not stick to wound - Telfa?
    Non-adherent gauze
  45. Types of dressings:
    Traps wounds moisture over the wound providing appropriate mositure environment for the wound/
    Self-adhesive/transparent film
  46. Types of dressings
    Absorbs drainage through use of exudate absorbers in dressing? Protects wound from surface contamination?
    Hydrocolloid dressings
  47. Types of dressings:
    Maintains a moist surface to support healing; soothing and reduces pain in wound?
  48. Types of dressings:
    You should not use this dressing on dry wounds, requires a secondary dressing when using this form of dressing/
    Foam dressings
  49. Types of dressings:
    This dressing uses negative pressure to support healing/
    Wound V.A.C.
  50. When changing dressings, what should you know first?
    • Type of dressing that is on client
    • Whether this is first or second changing (surgeon likes to change first time)
    • Any drainage tubes present
    • type of supplies needed for wound care
    • always to use aseptic technique
    • providing comfort measures for client before doing ANY kind of care to wound - PRIORITY
  51. 1. When removing a dressing you use a clean OR sterile technique?

    2. When applying a dressing you use a clean OR sterile technique?

  52. When using heat/cold therapy what should you assess for?
    • observe area - any changes
    • tolerance for temp
    • condition(s) that may contraindicate therapy
    • edema
    • bleeding
    • LOC - inability to feel the temp
    • condition of heat/cold equipment
    • ** remember, RN responsible for safe administration of this therapy
  53. Name some types of wound binders?
    • Abdominal
    • slings
  54. When packing a wound you should assess for?
    • Size, depth, shape of wound
    • appropriate material being used for wound
    • not to pack to tightly
    • vacuum assisted closure is needed
  55. What should you know about wound irrigation? Why do you irrigate the wound?
    • Doctors/Wound care specialists orders
    • Irrigation is to cleanse, keep free from debris/infection, and prevent, manage infection (this is also why you irrigate)
    • pg. 1307 P&P
  56. What is blanching?
    it is when the normal red tones of a light-skinned client are absent. Blanching does not occur in dark-skinned clients - they are more at risk for pressure ulcers as they are harder to identify.