Skin Integrity And Wound Care

Front 1

What is the largest organ in the body?

Back 1

skin (15% total body weight)

Front 2

epidermis

Back 2

top layer of skin

Front 3

dermis

Back 3

inner layer of skin

Front 4

pressure ulcer

Back 4

a localized injury to the skin and underlying tissue, usually over a bony prominence

Front 5

what is the major contributor to pressure ulcers?

Back 5

PRESSURE!!!

Front 6

blanching

Back 6

normal red tones of skin are absent.

Front 7

what happens If pressure applied over a capillary exceeds the normal capillary pressure and the vessel is occluded for a prolonged period of time?

Back 7

tissue ishemia

Front 8

low pressures can cause

Back 8

tissue damage

Front 9

extended pressure can cause

Back 9

cell death

Front 10

Impaired sensory perception

Back 10

cannot feel their body sensations.

Front 11

impaired mobility

Back 11

cannot change or shift their bony prominences

Front 12

friction

Back 12

force of two surfaces moving across one another, such as the mechanical force exerted when the body is dragged across another surface.

Front 13

alterations in LOC

Back 13

unable to protect themselves

Front 14

sheer

Back 14

force exerted parallel to skin resulting from both gravity pushing down on the body and resistance (friction) between the client and a surface.

Front 15

moisture

Back 15

reduces skins resistance to other physical factors

Front 16

stage 1

Back 16

skin intact, non-blanchable redness

Front 17

stage 2

Back 17

partial thickness skin loss

Front 18

stage 3

Back 18

full thickness skin loss with visible fat

Front 19

stage 4

Back 19

full thickness skin loss with visible bone, muscle, or tendon

Front 20

Who defined pressure ulcers?

Back 20

NPUP
National Pressure Ulcer Advisory Panel

Front 21

what is granulation?

Back 21

red moist tissue composed of new red blood cells= healing

Front 22

what is slough?

Back 22

yellow or white stringy tissue--> remove before healing can occur

Front 23

what is eschar?

Back 23

brown or black necrotic tissue --> also must be removed before healing

Front 24

what do we record when assessing wounds?

Back 24

-size of wound
-exudate (drainage)
-surrounding skin's appearance

Front 25

wounds

Back 25

disruption in skin integrity and function of tissues in the body.

Front 26

what are two methods of classification for skin wounds?

Back 26

describe status or skin integrity and describe qualities of the wound such as color

Front 27

when does primary intention occur?

Back 27

the edges are approximated or closed and risk of infection is low

Front 28

when does secondary intention occur?

Back 28

when the wound is left open until it becomes filled by scar tissue (Burn, pressure ulcer or severe laceration)

Front 29

when does tertiary intention occur?

Back 29

occurs when wounds are left open for several days and then closed or approximated (Infection)

Front 30

how does partial thickness heal?

Back 30

via the inflammatory response, epithelial proliferation, and migration with reestablishment of epidermal layers

Front 31

how does full thickness heal?

Back 31

via inflammatory response, proliferation, and remodeling

Front 32

what are complications of a wound?

Back 32

hemorrhage, infections, dehiscence, evisceration, and fistulas.

Front 33

s/s hemorrhage

Back 33

swelling
hypovolemic shock if internal.
exudate change

Front 34

s/s infection

Back 34

fever, tenderness, pain at wound site and elevated WBC

Front 35

s/s dehiscence

Back 35

note increased in sersanguinous drainage, BE ALERT FOR RISK OF DEHISCENCE.

Front 36

what do you do when someone with dehiscenence is coughing or getting up?

Back 36

USE A BLANKET OR PILLOW OVER SURGICAL SITE!!!

Front 37

s/s evisceration

Back 37

Place sterile towel soaked in saline over extruding tissues to reduce risk for infection.

Front 38

which complication is an emergency and requires surgical care?

Back 38

evisceration!!!

Front 39

s/s fistula

Back 39

result of poor wound healing and usually a complication of disease.

Front 40

prevention of pressure ulcers include...

Back 40

special beds and mattresses, good hygiene, good nutrition, adequate hydration, and impeccable nursing care.

Front 41

what 5 risk factors are on the norton scale?

Back 41

Physical and mental condition, continence, activity, and mobility,
pam and cam

Front 42

what does the score range from on the norton scale?

Back 42

5-20

Front 43

what 6 risk factors are on the braden scale?

Back 43

Sensory perception, moisture, activity, mobility, nutrition, and friction and shear

Front 44

what does the score range from on the braden scale?

Back 44

6-23

Front 45

which one is more commonly used in a nursing home?

Back 45

braden

Front 46

what is tissue perfusion?

Back 46

tissue oxygenation fuels cellular function

Front 47

who is at risk for tissue perfusion?

Back 47

diabetes mellitus

Front 48

what can wound infection cause to the healing proccess?

Back 48

inflammatory phase, delays collagen synthesis, and prevents epithelialization and tissue destruction

Front 49

what can age cause to the healing process?

Back 49

inflammatory phase, delays collagen synthesis, and prevents epithelialization and tissue destruction

Front 50

what are nutritional requirements for wound healing?

Back 50

clients need 1500 kcal/day

Front 51

what are some assessment guidelines for skin intergrity?

Back 51

Skin
ulcers
Mobility
Nutrition
Pain
wounds
Wound culture
wow pm sun :)

Front 52

what are some interventions for pressure sores?

Back 52

turn 1-2 hours, clean and protect bony prominences, dont raise HOB over 30 degrees.

Front 53

what is the key to implementation?

Back 53

health promotion and prevention

Front 54

what do support surfaces do?

Back 54

Decrease the amount of pressure exerted over bony prominences.

Front 55

how often should you turn patient?

Back 55

1-2 hours minimum

Front 56

what else does skin contribute to the body?

Back 56

makes vitamin d

Front 57

what do we do to aid the pressure ulcer?

Back 57

reduce pressure

Front 58

what are you ischemial tuberosities?

Back 58

butt bones

Front 59

who does blanching not occur in?

Back 59

dark skinned clients

Front 60

are all wounds created equal?

Back 60

NO!

Front 61

on the braden and norton scales, what score = a higher risk for pressure ulcer?

Back 61

low scores

Front 62

debridment is

Back 62

cleaning our the wound

Front 63

what are some types of debridment?

Back 63

mechanical, autolytical, chemical, or surgical/ sharp

Front 64

mechanical

Back 64

example is wet to dry saline gauze dressing or whirlpool treatments

Front 65

autolytical

Back 65

use of dressings over a wound to allow eschar to be self-digested by action of enzymes (Hydrocolloid, transparent dressings)

Front 66

chemical

Back 66

use of topical enzyme preparations or sterile maggots. It breaks down the necrotic tissue

Front 67

surgical/ sharp

Back 67

removal of devitalized tissue by using scapel or scissors

Front 68

who do we need to educate on acute care?

Back 68

client and client's family

Front 69

hemostasis

Back 69

control bleeding by holding direct pressure

Front 70

what do we need nutritionally for wounds?

Back 70

protein

Front 71

who will decrease if protein is low?

Back 71

serum albumin and hemoglobin

Front 72

who is the preferred cleaning agent by WOCN?

Back 72

normal saline
(wound,ostomy, and continence nurses society)

Front 73

what are the purpose of dressings?

Back 73

Protect
healing
Supports site
moist environment.

Front 74

what is a dry or moist dressing?

Back 74

gauze

Front 75

what does hyrdrocolloid do?

Back 75

Protects the wound from surface contamination

Front 76

what does hydrogel do?

Back 76

Maintains a moist surface to support healing

Front 77

what does wound V.A.C do?

Back 77

Uses negative pressure to support healing

Front 78

what are some ways of securing dressings?

Back 78

tapes, ties, and binders
(DONT PUT BINDERS TOO TIGHT!)

Front 79

what do we offer before dressing changes?

Back 79

pain meds

Front 80

how do we clean wounds?

Back 80

area least contaminated to outside skin

Front 81

what does irrigation do?

Back 81

Removes exudates, use sterile technique with 35-ml syringe and 19-gauge needle

Front 82

what do we assess with bandage/binders application?

Back 82

inspect skin for abrasions, edema, discoloration, open wounds, circulatory impairment (coolness, pallor, cyanosis, pulses, swelling, numbness or tingling).

Front 83

why heat?

Back 83

arthritis, joint disease, muscle strain, menstrual cramping, hemorrhoid, perianal inflammation or abscess.

Front 84

why cold?

Back 84

sprain, strain, fracture
muscle spasms, laceration, minor burn, arthritis, post-injection or joint trauma.

Front 85

what are the fat soluble vitamins?

Back 85

adek

Front 86

do we massage bony prominences?

Back 86

no

Front 87

dont postion on bony prominences or..?

Back 87

a donut pillow

Front 88

what can decrease wound healing?

Back 88

smoking ( decrese hemoglobin --> o2 to tissues)
chemo and radiation therapy
some drugs (decrease immune response)

Front 89

what is vitamin c in?

Back 89

citrus fruits (collagen)

Front 90

what foods have protein?

Back 90

meat, fish, ..?

Front 91

what has vitamin a?

Back 91

liver

Front 92

what is vitamin a good for?

Back 92

skin and reverse steroid effects on skin

Front 93

what is in folic acid?

Back 93

b vitamins