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50 Cards in this Set
- Front
- Back
- 3rd side (hint)
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What are the functions of the skin?
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- protection: epidermis prevents entrance of microorganisms
- sebum removes bacteria from hair follicles - acidic pH further slows bacterial growth - Sensation: contains sensory receptors for touch, pain, heat, cold, and pressure - temperature regulation: controlled by evaporation, conduction, convection, and radiation - excretion and secretion |
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What are the different statuses of skin integrity in wound classification?
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- Open: involves a break in skin or mucosa
- Closed: involves no break in the skin |
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What are the different causes of wounds?
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- intentional: results from therapy
- unintentional: occurs accidentally |
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What are the different depths of tissue disruption in wounds?
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- Superficial: involves only epidermis
- Partial thickness: involves epidermis and dermis - Full thickness: involves the epidermis, dermis, subcutaneous tissue, and possibly muscle and bone - Penetrating: involves the epidermis, dermis, and possibly deeper tissues (muscle and bone). Ex.) stab wound - Perforating: exists when a foreign object enters and/or exits an internal organ |
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What are the different states of cleanliness of wounds?
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- Clean: contains no pathogens, minimal inflammation, respiratory, alimentary, genital, or urinary tracts are not entered. Primarily closed wounds
- Clean contaminated: surgical wounds made under aseptic conditions, but involves a body cavity that normally harbors microorganisms (respiratory, alimentary, genital, urinary); shows no evidence of infection - Contaminated: open, unintentional wound, surgery with major break in aseptic technique or with major contamination from the GI tract, shows evidence of inflammation - Infected: contains pathogens, dead tissue, and evidence of infection, such as purulent drainage |
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What are the descriptive qualities of wounds?
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- Laceration: tissue torn with jagged uneven edges
- Incision: made with a sharp cutting edge - Abrasion: results from scraping or rubbing off skin or mucosa - Contusion (bruise): damage to tissue with intact, caused by a blow from a hard object - Ulceration: a localized open lesion characterized by sloughing of necrotic tissue or mucosa - Burn: results from excessive exposure to thermal, electrical, or chemical agents |
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How does a wound heal by first intention (primary intention, primary union)?
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- edges and skin layers are approximated; minimal tissue loss
- minimal granulation tissue; thin scar |
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How does a wound heal by secondary intention?
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- very painful
- heals by filling in with granulation tissue; involves extensive tissue loss in which edges cannot or should not be approximated - slower healing, more scar tissue - pressure ulcer or burn |
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How does a wound heal by third intention (secondary closure, delayed primary closure, tertiary healing)?
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- Delay between wound occurrence and suturing, or wound is sutured open and then re-sutured
- small scar |
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What happens during hemostasis after initial injury to the skin?
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- vasoconstrictive agent is released by platelets, causing retraction or drawing back of the larger blood vessels injured
- coagulation factors are released and platelet aggregation occurs at the site of the injury - polymerized fibrin forms a thrombus (clot) and bleeding normally stops |
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What is Phase 1 of the phases of wound healing?
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- Inflammatory phase
- occurs within several hours after hemostasis - redness, swelling, heat, pain, and exudate - lasts 2-3 days, wound strength is low - phagocytosis: macrophages engulf microorganisms and cellular debris - scab forms |
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What is Phase 2 of the phases of wound healing?
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- Proliferative phase
- takes longer to heal - collagen is deposited; angiogenesis occurs - wound strength increases - granulation tissue forms, beginning at the base of the wound - epithelialization: epidermal cells have migrated over wound edges - lasts from 3-21 days, most likely time for wound disruption occurs in 5th-8th days - sutures usually removed in phase 2 |
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What is Phase 3 of the phases of wound healing?
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- Remodeling (contraction, maturation)
- lasts from 21st day up to weeks, months, or years - takes place within the scar tissue - blood flow to the wound decreases, scar lightens - collagen fibers are broken down and reorganized (contraction) - wound strength increases to not more than 70% of original tensile strength of intact skin - scar continues to fade in color and shrink in size for many months or years |
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What are the general principles of wound healing?
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-keep skin dry and intact
- response to injury is more effective if proper nutrition has been maintained - body responds systemically to trauma in any of its parts - blood transports substances to and from injured tissue - intact skin and mucus membranes are the first line of defense against microorganisms - normal healing is promoted when the wound is free of foreign bodies, including bacteria |
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What are the effects of nutrition on wound healing?
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- undernourished clients have difficulty mounting their cell-mediated defense system associated with t-lymphocyte activity
- some leukocyte functions are diminished in the presence of protein deficiency - wound healing requires energy, certain quantities are needed to meet increased metabolic activity - vitamin A needed for collagen synthesis - vitamin B complex serves in enzyme reactions needed for healing |
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What are complications of wound healing?
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- hemorrhage: excessive loss of blood, risk greatest during 1st 48 hrs
- Infection: microbial contamination of a wound - Wound disruption: may only involve superficial layers of skin or all layers |
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What is dehiscence?
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- separation of the edges of a wound
- partial or TOTAL RUPTURE of sutured wound - most likely to occur 4-5 days post-op |
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What is evisceration?
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- wound SEPARATION with the protrusion of an organ/internal viscera thru the wound opening
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What is a fistula?
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- an abnormal passage from an internal organ to the surface or between two internal organs
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What is ischemia?
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- a deficient blood supply to the tissue; a decreased supply of oxygenated blood to a body part
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What are keloids?
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- a raised, thickened scar that results from the deposition of abnormal amts of collagen into the tissue surrounding a wound
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What are contractures?
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- pathological shrinkage of a scar causing immobility
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What is assessed using the CLOSEDD method?
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- Color
- Location - Odor - Size - Erythema - Depth - Drainage and/or closure devices |
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What are the physiologic effects of heat application?
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- increased capillary permeability (and increased edema)
- cellular metabolism - inflammation - SEDATIVE EFFECT - brings oxygen, nutrients, antibiotics, and leukocytes with vasodilation - promotes soft tissue healing and increased suppuration (pus) - used for JOINT STIFFNESS from arthritis, contractures, and low back pain |
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What are the physiologic effects of cold application?
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- reduces supply of oxygen supply and metabolites (decreased metabolism)
- decreased capillary permeability - decreased inflammation - LOCAL ANESTHETIC EFFECT - slows bacterial growth - decreases removal of wastes - used for sports injuries, sprains, strains, and fractures to decrease post-injury bleeding and edema |
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What are the systemic effects of heat application?
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- applied to large body area causes vasodilation and a drop in BP
- significant drop in BP can cause fainting - use with caution in clients with heart or pulmonary disease and circulatory disturbances |
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What are the systemic effects of cold application?
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- extensive cold application causes vasoconstriction and an increase in BP
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What are factors to consider regarding thermal tolerance?
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- neurosensory impairment
- impaired mental status - impaired circulation: lack normal ability to dissipate heat via circulation - immediately after injury or surgery: heat increases bleeding and edema - open wounds: cold decreases blood flow to the area inhibiting healing |
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What are variables affecting physiologic tolerance to heat and cold?
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- certain body parts more sensitive (wrist and forearm, the neck, and perineal area)
- size of exposed body part (large areas - lower tolerance) - individual tolerance - length of exposure: tolerance increases with exposure - adaptive - intactness of skin: injured skin is more sensitive to temperature variations |
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What is the rebound phenomenon?
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- occurs when maximum therapeutic effect of the hot or cold application is achieved and the opposite effect begins
- Ex.) heat brings vasodilation within 20-30 minutes. Application beyond 30-45 minutes causes blood vessel constriction |
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What are the guidelines for local applications of heat and cold?
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- determine client's ability to tolerate therapy
- identify conditions that may contraindicate treatment - explain application to client - assess skin area before beginning application - instruct client to report any discomfort/pain - return to client 15 minutes after starting application to observe for adverse effects to area - reassess area that received application and record client's response |
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When should heat application not be used?
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- 1st 24 hrs after traumatic injury
- active hemorrhage - non-inflammatory edema - localized malignant tumor - skin disorder that causes redness or blisters |
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When should cold application not be used?
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- open wounds
- impaired circulation - allergy or hypersensitivity to cold |
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What are the causes of pressure ulcers?
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- Pressure: capillaries collapse and blood cannot flow
- Shear: sliding down in bed, blood vessels are stretched and constricted - Friction: superficial mechanical force rubbing against skin, ex.) pulling client up in bed - Moisture: prolonged, excessive moisture can result in maceration (softening and breaking down of skin) |
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What are contributing factors to pressure ulcers?
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- immobility -> increased pressure
- moisture -> causes maceration - heat/fever -> increases metabolic needs and reduces nutrition to ulcer - poor hygiene - disease conditions - edema -> increased fluid increases pressure on vessels - obesity -> fatty tissue has decreased blood supply - debilitation -> weakened skin integrity - malnutrition -> causes dry, scaly, peeling skin, increases risk for breakdown - damaged tissue - altered mental status |
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What is the Braden Scale?
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- reliable predictive tool for pressure ulcers
- Maximum score = 23 - 15-16 = low risk (under 75 yo) - 15-18 = low risk (over 75 yo) - 13-14 = moderate risk - Under 12 = high risk |
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What are the characteristics of a Stage 1 Pressure Ulcer?
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- Erythema that does not go away and does not blanch
- discoloration of dark skin - warmth - edema - induration |
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What are the characteristics of a Stage 2 Pressure Ulcer?
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- partial thickness skin loss involving the epidermis or dermis, or both
- shallow crater - abrasion - blister |
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What are the characteristics of a Stage 3 Pressure Ulcer?
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- full-thickness skin loss involving damage or necrosis of the subcutaneous tissue which may extend to the fascia
- deep crater - may have undermining |
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What are the characteristics of a Stage 4 Pressure ulcer?
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- full-thickness skin loss with extensive destruction and tissue necrosis
- damage to muscle, bone, and tendon - undermining may be present |
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What are some ways of preventing pressure ulcers?
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- turn/reposition q2h
- air mattresses - use 30 degree turns, keep bed elevated no more than 30 degrees - totally relieve pressure on heels - use cornstarch or protective coverings to reduce friction injury - keep skin clean, dry, and intact - mild soap, avoid hot water - limit use of diapers - maintain good nutrition |
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What are nursing interventions for Stage 1 pressure ulcers?
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- use ointments: A&D or aloe vesta
- may use transparent film (Tegaderm) on non-fragile skin - may use hydrocolloids (Duo-Derm) |
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What are nursing interventions for Stage 2 pressure ulcers?
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- partial-thickness loss (epidermis/dermis)
- cleanse every shift with saline/wound cleanser, do not scrub - apply hydrocolloid or transparent film to non-infected wounds - causes autolytic debridement - provide moist environment - protect from contamination |
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What are nursing interventions for Stage 3 pressure ulcers?
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- full-thickness, loss of skin layers and subcutaneous tissue
- debride as prescribed - treat infection - apply dressings - encourage granulation (continue wound care as prescribed and maintain proper nutrition) |
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What is debridement?
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- removal of necrotic tissue so that healthy tissue can regenerate
- surgical/sharp: use of scalpel, scissors, or other sharp instrument mechanical: wet-to-dry dressings, hydrotherapy, wound irrigation - enzymatic: topical debriding enzymes to tissue on wound surface (Santyl) - autolytic debridement: dressings applied to allow necrotic tissue to self-digest by the action of enzymes present in wound fluids (transparent film, hydrocolloids) not used for infected wounds |
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What are alginates?
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- non-adherent wounds that absorb up to 20x their weight in exudates
- require secondary dressing - elminate dead space, pack wounds, and support debridement - used on partial and full-thickness wounds, tunneling wounds, infected and non-infected - used on Stage 3 pressure ulcers - Ex.) Sorbsan, Curasorb |
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What are hydrogels?
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- glycerin or water-based non-adhesive sheets, granules, or gels that are oxygen permeable
- may require secondary dressing - liquify necrotic tissue, rehydrate the wound bed, and fill in dead space - partial and full-thickness wounds and wounds with necrosis or slough - Stage 3 pressure ulcers - Ex.) Aquasorb, Easto-gel |
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What are nursing interventions for Stage 4 pressure ulcers (full-thickness, extensive destruction of subcutaneous tissue, damage to muscle, bone)?
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- Stage III measures
- consider special beds - sharp debridement may be required - assess for undermining (extension beneath the crater) - assess for complications of osteomyelitis and sepsis - manage tissue load - prevent maceration - treat infection - encourage granulation - protect surrounding skin - improve nutrition - encourage client participation and responsibility - teach client and family about preventive measures |
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How do you collect a specimen for wound culture when indicated?
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- clean wound first with normal saline before taking culture
- do not culture old drainage or old blood as resident colonies of bacteria grow in exudate - culture swab should be sterile and must be placed in sterile container - culture must be kept in a moist medium |
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How do you document a wound?
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- record length, width, depth measurements, exudate, and odor. Describe tissue type in wound bed. Estimate percentage of viable and non-viable tissue
- describe surrounding tissue - describe nursing interventions: solutions and dressings - pressure-lowering devices: cushions, pads, mattresses, and beds - Include all of this on nursing plan of care |
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