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37 Cards in this Set
- Front
- Back
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Discus the risk factors that contribute to pressure ulcer formation |
impaired sensory perception impaired mobility alteration in level of consciousness shear friction moisture |
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Pressure ulcer staging system |
Stage I: nonblanchable redness of intact skin Stage II: partial-thickness skin loss Stage III: full-thickness skin loss (fat visible) Stage IV: full-thickness tissue loss Unstageable: depth cannot be determined |
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Normal process of wound healing |
1 Hemostasis phase - platelets form clots 2 Inflammatory phase - leukocytes gather at the wound 3 Proliferation phase - epithelialization 4 Remodeling phase - maturation |
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Primary intention vs Secondary intention |
Primary: the skin edges are approximated Secondary: wound is left open to fill with scar tissue |
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Complications of wound healing |
Hemorrhage - bleeding from a wound site Infection - invasion of body by pathogens Dehiscence - total separation of wound layers Evisceration - protrusion of visceral organs through a wound |
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Acute vs Chronic wounds |
Acute: Wound that proceeds through an orderly and timely reparative process that results in sustained restoration of anatomical and functional integrity Chronic: Wound that fails to proceed through an orderly and timely process to produce anatomical and functional integrity |
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Pathogenesis of Pressure Ulcers |
pressure intensity pressure duration tissue tolerance |
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Wound Repair |
hemostasis inflammatory repsonse epithelial proliferation reestablishment of the epidermal layers |
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Factors that impede or promote wound healing |
nutrition: physiological processes of wound healing depend on the availability of protein, vitamins, and the trace minerals zinc and copper tissue perfusion: ability to perfuse the tissues with adequate amounts of oxygenated blood infection: prolongs the inflammatory phase; delays collagen synthesis; prevents epithelialization age: increased age affects all phases of wound healing psychosocial impact of wounds: psychological response to any wound is part of the nurse's assessment |
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Assessment for pressure ulcer risk |
mobility nutrition presence of body fluids comfort level |
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Nursing Diagnoses associated with impaired skin integrity |
risk for infection imbalanced nutrition acute or chronic pain impaired physical mobility impaired skin integrity risk for impaired skin integrity ineffective peripheral tissue perfusion impaired tissue integrity |
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Assessment for skin integrity |
sensation mobility continence presence of wound |
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Assessment for wounds |
emergency setting: inspect the wound for bleeding stable setting:determine progress toward healing wound appearance: edges open or closed character of wound drainage: amount, color, odor, and consistency drains: quantity, placement, character of drainage, and condition of collecting equipment wound closures: staples, suture, wound closures palpation of wound: wound edges would cultures: obtain a specimen |
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Acute Care - Wound Management |
debridement: removal of nonviable, necrotic tissue education: education of the patient and caregivers nutritional status: nutrition is fundamental to normal cellular integrity and tissue repair protein status: need enhanced caloric and protein supplementation hemoglobin: low hemoglobin level decreases delivery of oxygen to the tissues |
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Acute Care - First Aid for Wounds |
Hemostasis: control bleeding / bandage Cleaning: gentle / normal saline Protection: applying sterile or clean dressings and immobilizing the body part |
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Purposes of Dressings |
1 Protect a wound from microorganism contamination 2 Aid in hemostasis 3 Promote healing by absorbing drainage and debriding a wound 4 Supporting/splint the wound site 5 Protect patients from seeing the wound 6 Promote thermal insulation of the wound surface |
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Types of Dressings |
Dry or Moist Transparent film dressing Hydrocolloid: protects the wound from surface contamination Hydrogel: maintains a moist surface to support healing |
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To change a dressing you must know... |
the type of dressing the presence of underlying drains or tubing the type of supplies needed for wound care |
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Prepare for a dressing change |
evaluate patient pain describe procedure steps to patient gather supplies recognize normal signs of healing answer patient's questions about procedure |
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During dressing change |
Assess the skin beneath the tape Perform thorough hand hygiene (before and after) Wear sterile gloves before directly touching an open or fresh wound Change dressings if they become wet or if patient shows signs of infection
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Cleaning skin and Drain Sites |
Cleaning - apply noncytotoxic solution Irrigation - to remove exudates Suture Care - removal and maintenance Drainage Evacuators - port units that remove and collect drainage |
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Functions of Bandages and Binders |
create pressure immobilize and/or support a wound reduce or prevent edema secure a splint secure dressings
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Heat and Cold Therapy |
assessment for temperature tolerance bodily responses to heat and cold local effects of heat and cold factors influencing heat and cold tolerance application of heat and cold therapies |
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Cold is contraindicated if.... |
the site of injury is edematous in the presence of neuropathy the patient is shiver the patient has impaired circulation |
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Heat is contraindicated... |
For areas of active bleeding For an acute localized inflammation Over a large area if a patient has cardiovascular problems |
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What is indicated when a reddened area blanches on fingertip touch? |
Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode. |
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When obtaining a wound culture to determine the presence of a wound infection, from where should the specimen be taken? |
Wound after it has first been cleaned with normal saline Drainage that has been present on the wound surface can contain bacteria from the skin, and the culture may not contain the true causative organisms of a wound infection. By cleaning the area before obtaining the culture, the skin flora is removed. |
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When the nurse examines the surgical wound site, the sutures are open, and pieces of small bowel are noted at the bottom of the now-opened wound. Which corrective intervention should the nurse do first? |
Cover the area with sterile, saline-soaked towels and immediately notify the surgical team; this is likely to indicate a wound evisceration If a patient has an opening in the surgical incision and a portion of the small bowel is noted, the small bowel must be protected until an emergency surgical repair can be done. The small bowel and abdominal cavity should be maintained in a sterile environment; thus sterile towels that are moistened with sterile saline should be used over the exposed bowel for protection and to keep the bowel moist. |
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Which description best fits that of serous drainage from a wound? |
Clear, watery plasma Serous fluid generally is serum and presents as light red, almost clear fluid. |
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For a patient who has a muscle sprain, localized hemorrhage, or hematoma, which wound care product helps prevent edema formation, control bleeding, and anesthetize the body part? |
An ice bag helps to constrict excess fluid in tissues, which prevents edema. The blood vessels become constricted, help to control bleeding, and can decrease pain where the ice bag is placed. |
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Which skin care measures are used to manage a patient who is experiencing fecal and urinary incontinence? |
Using an incontinence cleaner, followed by application of a moisture-barrier ointment Skin that is in contact with stool and urine can become moist and soft, allowing it to become damaged. The stool contains bacteria and in some cases enzymes that can harm the skin if in contact for a prolonged period of time. The use of an incontinence cleaner provides a gentle removal of stool and urine, and the use of the moisture-barrier ointment provides a protective layer between the skin and the next incontinence episode. |
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Hydrocolloid dressing? |
A dressing that forms a gel that interacts with the wound surface Since moisture enhances wound healing, the gel that forms places the wound in the proper environment for healing. |
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Indication for a binder to be placed around a surgical patient with a new abdominal wound? |
Reduction of stress on the abdominal incision A binder placed over the abdomen can provide protection to the abdominal incision by offering support and decreasing stress from coughing and movement. |
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When is an application of a warm compress indicated? |
To relieve edema / to improve blood flow to an injured part Warm compresses can improve circulation by dilating blood vessels, and they reduce edema. The moisture of the compress conducts heat. |
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What is the removal of devitalized tissue from a wound called? |
Debridement is the removal of nonliving tissue, cleaning the wound to move toward healing. |
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What does the Braden Scale evaluate? |
Six risk factors that place the patient at risk for skin breakdown It does not assess skin or wounds. 1. Sensory Perception 2. Moisture 3. Activity 4. Mobility 5. Nutrition 6. Friction and Shear |
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On assessing your patient's sacral pressure ulcer, you note that the tissue over the sacrum is dark, hard, and adherent to the wound edge. What stage? |
Unstageable Since the pressure ulcer assessed was covered with necrotic tissue, the depth could not be determined.
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