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121 Cards in this Set
- Front
- Back
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Abrasion( or loss of Dermis)
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Superficial with little bleeding but some weeping (plasma leakage from damage capillaries)
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Laceration
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Is damage to the dermis and epidermis and is a torn, jagged wound. the depth and location of the laceration affect the extent of bleeding, with serious bleeding possible in greater than 5 cm (2 inch) long or 2.5inc (1 ich) long
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Approximate
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wound edges come together
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Cachexia
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General poor health and malnutrition with weakness and emanciation
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Dehiscence
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Separation of skin and tissue layer
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Debridement
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Seperation of wound layers with protrusion of visceral organs
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Evisceration
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Localized collection of blood under the tissues
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Fistula
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Abnormal passage between two body organs or between an organ and the outside of the body
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Shearing force
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The force exerted against the body while the skin remains stationary and the bony structure move
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Sites of the body that are common for pressure ulcer
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Scapula, Spine, Elbow, Iliac crest, Sacrum, Ischium, Achilles tendon,Heels and Sole
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Stage I Pressure ulcer
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nonblanchable redness of a localized area, usually over a bony prominence. the are may be painful, firm, soft warmer or coler compared with adjacent tissue
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Stage II pressure ulcer
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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 blisters. This stage should not be use to describe skin tears, tape burns,perinael dermititis, maceration or excoriation
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Stage III Pressure Ulcer
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Full thickness tissue loss. Subcutaneos fat may be visible but bone, tendons, or muscle is not exposed.
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Stage IV Pressure Ulcer
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Full-thick tissue loss with exposed bone , tendon,pr muscle. Slough or eschar may be present on some parts of the wound bed. often include undermining and tunneling. Extend into muscle and/or supporting structure (eg fascia, tendon or joint capsule ), making osteomyelitis possible. Expojsed bone, tendon is visible or directly palpable.
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Unstageable
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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, or black) in the wound bed. until enough slough and/or eschar is removed to esposed the base of the wound, the true depth , and therefore stage cannot be determined
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Provide an example of a conntributing factor for pressure ulcer formation
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The following increase a patient’s risk for pressure ulcer development: Shear, friction, moisture on the skin, poor nutrition, cachexia, infection, impaired peripheral circulation, obesity, and advanced age.
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Patient in what age group are at the highest risk for sensitivity to heat and cold application.
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Infants, young children, and older adults are most susceptible to sensitivity to heat and cold therapy.
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The major changes in an adult's skin that contribute to pressure ulcer development is
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Dryness of the older adult’s skin makes it less tolerant to pressure, friction, and shearing forces
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Identify primary intention wound healing
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A clean surgical wound with little tissue loss heals by primary intention with no granulation
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Identify secondary intention wound healing
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A severe laceration or chronic wound heals by secondary intention
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TRUE/FALSE
Wound that are kept moist for several days hela faste than that are kept dry |
TRUE
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TRUE/FALSE
Reddened areas that are noted on the patients skin should be massage |
FALSE
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TRUE/FALSE
Use of a foam ring or "donut" is effective for pressure reduction for the patient sitting out of bed |
FALSE
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TRUE/FALSE
Specimen for aerobic wound cultures should be taken from wound areas with clean, healthy skin |
TRUE
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Which complication of wound healing is assess by nurse when separation of layers of the skin with serosanguineous drainage is noted
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DEHISCENCE
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Bluish swelling or mass at the sites
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HEMATOMA/BLEEDING
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Fver, general ,malaise, and increased WBC count
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INFECTION
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Green , odorous local drainage
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INFECTION
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Decreased blood pressure, increased pulse rate, increased respiration
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BLEEDING/SHOCK
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Visceral organs protruding through abdominal wall
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Evisceration
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Wound edges swollen, painful, with redness extending from the edges outward
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INFECTION
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Identify the methods or indicators that are used for assessing darkly pigmented skin:
LIGHT SOURCE |
Natural or halogen light, avoid fluorescent light
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Identify the methods or indicators that are used for assessing darkly pigmented skin:
UNEXPECTED CONSISTENCY |
Firm, taut (edema, induration), diminished turgor
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Identify the methods or indicators that are used for assessing darkly pigmented skin:
UNEXPECTED CHANGE IN COLOR |
Different from other skin tones, darker, purple or bluish
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Identify how AGE influence wound healing
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Infants and older adults may have decreased circulation, oxygen delivery, clotting, and inflammatory responses, with an increased risk of infection. Older adults have slower cell growth and differentiation, and scar tissue is less pliable.
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Identify how OBESITY influence wound healing
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Obese individuals have a decreased supply of blood vessels in fatty tissue (impaired delivery of nutrients to the site), and suturing of adipose tissue is more difficult.
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Identify how DIABETES influence wound healing
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Diabetes: Individuals with this condition have small blood vessel disease (reduced oxygen delivery), and elevated glucose levels impair macrophage function.
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Identify how IMMUNOSUPPRESSION influence wound healing
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Immunosuppression: A reduced immune response leads to poor healing. Steroids also mask signs of inflammation/infection, and chemotherapeutic agents interfere with leukocyte production.
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SEROUS
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CLEAR WATERY PLASMA
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SANQUINEOUS
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FRESH BLOOD
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SEROSANQUINEOUS
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PALE,MORE WATERY, WITH PLASMA AND RBC
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PURULENT
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THICK, YELLOW, GREEN, OR BROWN WITH ORGANISMS WITH WBC
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What Nursing intervetion should be implemented to prevent pressure ulcer formation specifically related to PRESSURE REDUCTION
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Use of a supportive surface, regular and frequent turning and repositioning in the bed (q2h) and chair (q1h)
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What Nursing intervetion should be implemented to prevent pressure ulcer formation specifically related to SKIN CARE
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Keep skin clean and dry after incontinence, use skin barriers/protectants, turn or lift sheets to reduce friction and shear, maintain head of the bed at 30 degrees or lower, avoid vigorous massage of bony prominences or areas of redness
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Steps to obtaining wound culture:
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1. Cleanse the wound and allow to dry
2. Moisten swab with normal saline 3. Swab wound and allow to dry 4. Apply pressure to express fluid from wound onto swab 5. Return the swab to the culture tube |
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Waht is the indication for Tetanous toxoid injection
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The patient who has a dirty, penetrating wound may require a tetanus toxoid injection.
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Identify how a nurse determine whether a wound is healing.
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The nurse determines wound healing by measuring the wound diameter and depth, assessing the wound tissue, checking the periwound skin condition, and observing for exudate.
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A patient who is sitting out of bed in a chair and requres assistance to move arround should be limited to -------- hours sitting and should be repositioned every--------- hour(s)
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26. A patient who is out of bed in a chair should be limited to 2 hours sitting and repositioned at least every 1 hour.
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Nursing care of an Abrasion or Laceration includes:
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Control of any bleeding,
rinsing of the wound under running water, gentle cleansing with mild soap, application of a prescribed or over-the-counter antiseptic, and protection with a bandage. |
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A nurse can reduce frition or shear by :
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The nurse reduces friction or shear by using a draw sheet, trapeze bar, and/or support when moving the patient and by providing skin care to maintain integrity.
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What is the purpose for a negative pressure wound therapy system:
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The purpose is to remove excess fluid, stimulate granulation tissue growth, and reduce wound bacteria.
The tube is attached to suction to provide negative pressure. The dressing that is used is either black or white foam that is cut to fit the wound. The transparent dressing should cover the wound, extend 3 to 5 cm beyond the wound edges, provide an occlusive seal, and be free of wrinkles. |
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For wound healing, identify the following that are considered as safe quidelines, syringe size, Needle guage, psi, The syringe should be held how far above the wound?
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For wound irrigation:
a. Syringe size: 35 mL b. Needle size: 19 gauge c. psi: 8 d. The syringe is held 1 inch (2.5 cm) above the wound. |
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During an irrigation , the Nurse notes sanquineous return. The nurse should :
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Reduce the irrigating pressure and notify the health care provider.
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During irrigation it is noticed that there is retained debris in the wound , the Nurse should :
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More fluid or pressure should be used.
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Correct Nursing intervention for elastic bandages
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Placing the body parts to be bandage in anatomical position
Overlapping turns by one-half to two-thirds the width of the bandage |
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Identify the steps in caring for a traumatic wound
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The steps in caring for a traumatic wound are:
Stabilize the patient’s cardiopulmonary function Promote hemostasis (stop any bleeding) Cleanse the wound Protect the site from further injury |
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Provide an instance in which the application of heat is contraindicated
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Application of heat is contraindicated in the presence of active bleeding or acute inflammation, and for patients with cardiovascular disease.
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Provide an instance in which the application of cool is contraindicated
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Application of cold is contraindicated in the presence of edema at the site, decreased circulation, and shivering.
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What is the usual duration of time for the application of heat or cold
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Heat and cold are usually applied for about 20 to 30 minutes.
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What are the correct intervention for the application of heat and cold?
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Providing a timer or clock so the patient may help time the application
Not placing the patient in a position that prevents movement away from the temperature setting Keeping the best of the patient draped or covered while receiving treatment |
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Nonblanching hyperemia is--
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Redness that persists after palpation and indicates tissue damage.
This signifies that deep tissue damage is present and is commonly the first stage of pressure ulcer development. |
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TRUE /FALSE
When nonblanching hyperemia is assessed, the stage is reversible if pressure is relieved |
TRUE: Damage can be reversed with the removal of pressure.
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Correct action for the a postoperative dressing include
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Reinforcing saturated dressing
Providing the patient with an analgesic 30 minutes before the dressing change Nothing the amount, color, consistency, and odor (COCA) of wound drainage Expecting that a primary intention wound with no drainage will have the dressing discontinued |
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Nursing assessment and evaluation for a patient who need to continue dressing when he his dicharge to his home
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Before the patient is discharged, the nurse will want to assess/evaluate the patient’s:
•Wound and overall health status •Ability to perform the dressing independently •Concerns over the care and the appearance of the wound •Recognition of signs and symptoms that will require notification of the physician •Ability to obtain necessary supplies |
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What are the types of dressing
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-Guage
-Transparent Film -Hydrocolloid -Hygrogel -Wound VAC |
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Best for normal moderate dainage, deep wounds underlaying layers an tunnel
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Guage dressing
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- Best for minimal tissue loss with very little wound darinage
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Transparent Film
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Protect the wound from surface contamination good for 3-7 days
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Hydrocolloid dressing
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Best for wounds that requires moisture with grannulation. Change every 1-3days
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Hygrogel dressing
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Uses negative pressure to assist wound healing, promote wound healing by evacuating wound fluid, stimulating grannulation tissue formation, reducing bacterial burden of a wound and maintain moist wound environmment
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Wound VAC
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To prepare for dressing change
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Know the type, drain placement and the equipment need for the dressing
Follow physian order for the type, frequency, solution or oitment and use STERILE Technique for surgical wound and CLEAN Technique for chronic wound dressing |
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what does "Reinforece dressing Prn" stands for?
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Add dressing without removing existing one as needed. HCP does not want sutures line distruption and Hemostasis not interrupted
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How to mainatain Physiological wound environment
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Prevent and manage infection
Clean wound Remove nonviable tissue (Debridement) Manage exudates Eliminate dead space Control odor Protect wound Provide a moist environment |
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How to promote Wound healing by Providing systematic support to reduce existing and potential cofactors
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-Nutritional and Fluid support
-Control of Systemic condition affecting wound healing such DM,CV and Pulmonary disease (adequate oxygen) |
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Control wound healing by elinating Causative Factors such as :
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Pressure, Shears, Friction, Moisture
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What is the Purpose of dressing:
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Discourages wound exposure to micro-organism
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A pressure dressing promotes Hemostasis by
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Exerting localized, downward pressure over an actual or potential blessing site and fosters normal healing by eliminating dead space in underlying tissue
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A dry dressing promote healing by
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Allowing the wound to heal by primary intention and absorbing minimal oozing of wound changes
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When a wound is healing by secondary intention?
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Use a dressing to provide moist environment
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What are nursing intervention to maximize oxygen level during wound healing(pressure Ulcer)
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Pulmonary hygiene
Monitor tissue oxygen level and low flow oxygen |
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Acute management for pressure ulcer
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Systemic support (tx disease that impair O2 supply)
Adequate nutrition Assess medication Maintain physiological wound environment(prevent infecton, exudate mgt,wound protection,debride wound) |
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Health Promotion
Topical Skin care |
Perform skin care daily pay special attn to bony promineneces
Do not massage reddened area Use moisturizer Keep skin clean and dry Use moisture barrier for incontinence |
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What is the nurse first priority when provided skin care to an incontinence patient with pressure ulcer
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Assess and treat the cause of the incontinence then decide upon protection and or collection interventions
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Assist or teach patient with the ability to shift weight on the chair to reposition every____ minutes
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15
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Positioning intervention reduces pressure ulcer and shear to the skin. Change the postion of immobilized patient by turning every ________ hours and head of the bed below _______ degree angle
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1-2 hours and 30 degree
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Intervention to support adequate nutrition include
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Nutritional referral and appropriate dietaey supplement
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Assess the patient with pressure ulcer for signs and symptoms of wound infection:
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Redness, warmth of surrounding tissue, odor and presence of exudates.
If present, consult with the health care team to determing if you should culture the wound and if systemic or topical antibiotic are indicated. |
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Patient educaton goals before discharge
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Patient able to change dressing independently or with assistance from a family member before discharge
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Precation taken with applying dressing
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Assess skin color, pulse in distal extremities,patients comfort and changes in sensation to ensure pressure dressing do not intervere with circulation
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When to change dressing?
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Change dressing when it is saturated or it begins to dry out. always cover moist dressing with a dry secondary dressing
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For comfort administer analgesic medications_____ minutes before dressing changes(depending on a drug's time of peak of action)
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30-60 minutes
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TRUE/FALSE
Do not use povidine-iodine(Betadine), hydrogen peroxide and acetic to irrigate a clean, granular wound |
TRUE
These soln are toxic to fibroblasts a key cellular components in wound healing |
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TRUE/ FALSE
When cleansing a wound clense in the direction from the least contaminated area to the most containated area |
TRUE
Such as from the wound or incision site to the the surrounding or from an isolated drain site to surrounding skin. |
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TRUE/FALSE
An example of a safe wound cleasing and irrgation system is a 35-mL syringe and a 19-guage needle which has a psi of 8 |
TRUE
This method provides and ideal soln pressure for cleansing wounds while minimizing tissue trauma |
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TRUE /FALSE
Wound irrigation is a sterile technique |
TRUE
AND Normal Saline is the ideal solution to ensure comfort |
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TRUE/FALSE
Sature care reduce the formation of scar tissue while minimizing truma and tension and controlling bleeding Wound can be |
TRUE
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A nurse need to apply what principles before applying dressing and binder to a wound
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1. Inspect the skin for abrasion, edema, discoloration, or esposed wound egdes.
2. Cover exposed wounds or open abrasions with a sterile dressing 3. Assess the condition of underlying dressing and change if they are soiled 4. Assess the skin of underlying body parts and parts that will be distal to the dressing for signs of circulatory impairment(coolness, pallor orcyanosis diminished or absence pulses, swelling, numbness and tingling) to provide a means of comparing circulation after the dressing is applied. |
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TRUE/FALSE
After applying the dressing, assess, document and immediately report any changes in circulation, comfort level, body function such as ventilation and skin intergrity. |
TRUE
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Alway seek an order before loosening or removing a dressing appied by the HCP
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TRUE
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Type of binder that provide support after breast surgery or exert pressure to reduce lactation after childbirth
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Breast Binder
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A type of binder that supports large incisions that are vulnerable to to stress when the patient moves or cough
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Abdominal Binder
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A type of binder that support arms with muscular sprains or fracture.
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Slings
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Before application of the Heat and cold therapy the nurese should do what?
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Assess the intergrity of the body part
Determine the patient's ability to sense temperature variations and Ensure proper operationof equipment |
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Nurse is legally responsible for the safe administration of all heat and cold appliance
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TRUE
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Continous exposure to heat may cuase
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Demage epithelial cells, causing gredness, localized tenderness, and even blistering of skin
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Effects Heat therapy
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Vasolidation,
Reduces viscosity Reduce muscles tension and, Increases capillary permeability |
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Effects Cold therapy
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Vasoconstriction
Local anesthesia Reduce cell mebolism Increase blood viscosity |
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Prolong skin exposure to cold results in
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Reflex vasolidation (the cell inability to receive adaquate blood flow and nutrient which results in tissue ischemia.
The cell initiallt becomes reddened, then bluish-purple mottling with numbness and a burning type of pain. Tissue will eventually freeze from exposure to extreme cold |
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If heat is applied for 1 hour or more result in
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Reflex vasoconstriction(reduces blood flow as the body attempts to control heat loss from the area
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Do not apply heat over an active area of bleeding
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Risk for continous bleeding
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Do not apply heat in an acute localized inflammation such as appendicitis
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Risk for Rupture
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Do not apply heat to lage portion of patient with Cardiovascular problems
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Becuase vasolilation will disrupt blood supply to vital organs
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Cold is contraindicated if the site of the injury is edematous or patient has impaired circulation or is shivering
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May intensify shivering and reduce blood flow
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Aquatherma (Water-Flow) Pads
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useful for the treating muscle sprains and area of mild inflammation or edema
Application last 20-30 minutes and the patient does not lie on the pad |
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Indation for Sitz Bath
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Patient who has had rectal surgery
Episiotomy during childbirth Painful hemorrhoids or vaginal inflammation. ONLY PELVIC AREA IMMERSE IN WARM SOLN---FOR 20 MINUTES |
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A nurse recognize that a binder placed around a surgical ptient with a new abdominal wound is indicated for:
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Reduction of stress on the abdominal incision
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The patient ask the nurse what a hydrocolloid dressing is. The best description provided by the nurse is that :
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A dressing that forms a large gel that interacts with the wound surface
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A topical management of a clean ,granular wound healing by secondary intension requires:
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A moist dressing
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When repositioning an immobile patient, the nurse noticed redness over the prominence. When the area is assessed, the spot blanches with finger tip pressure indicating:
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Pressure damage that will resolve upon redistribution of the pressure
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Pressure injury to the skin results from:
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Compression of the skin by two surfaces for a prolonged period of time
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When obtaining a wound culture specimen to determine the presence of a wound infection, the nurse correctly collects the specimen from:
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Clean, healthy-looking tissue
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