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148 Cards in this Set
- Front
- Back
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List 5 factors affecting skin integrity.
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age
impaired mobility nutrition & hydration diminished sensation impaired circulation medications moisture on the skin contamination or infection fever lifestyle (tanning, freq. bathing, exercise, diet, smoking, piercings, tattoos) |
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Name 3 reasons hemmorhage can occur after surgery.
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large vessels are injured
clotting disorder taking anticoagulant slipped suture |
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Give 2 examples of drainage devices.
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Jackson-Pratt (JP)
Hemovac |
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When irrigating wounds, what PPE do you wear? Sterile or clean?
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gown, mask, goggles
clean for most |
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Ideal irrigation pressures range from ____ to ____.
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4 to 15
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Wound cleansing removes what 4 things?
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exudate
slough foreign materials microoganisms |
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Describe would care by color using the RYB color-code system.
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Red: granulation tissue (protect) keep moist & clean
Yellow: slough w/ drainage (cleanse) irrigation, wet to damp, or absorptive dressings Black: eschar (debridement)except at heel |
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What tool is used to evaluate pressure ulcers? What does a lower score indicate?
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PUSH tool
lower score = healing |
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What is the effect of adding moisture to a hot or cold treatment?
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it amplifies the intensity of the treatment
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How long should heat or cold be applied to an area?
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no more than 15 minutes
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What precautions should you take before using heat or cold therapy?
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- avoid direct contact with the heating/cooling device
- apply hot or cold intermittently - check the skin frequently for 1) redness, 2) blistering, 3) cyanosis, 4) blanching |
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Means "without life"
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sterile
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When would you suspect infection during wound healing?
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- if the wound fails to heal in the anticipated recovery time
- presence of purulent drainage |
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What are the 3 signs of internal bleeding?
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swelling in the affected body part
pain change in vital signs (dec. blood pressure, inc. pulse) hematoma |
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Organism capable of causing a disease.
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pathogen
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successful invasion of the body by a pathogen.
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infection
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List 4 common pathogens.
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bacteria
viruses fungi (yeasts & molds) protozoa (amoebae) worms (helminths) prions |
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What is the name of an infectious agent?
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microorganism
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A source of infection (place where pathogens survive & multiply)
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reservoir
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Microbes need these to thrive in the human body.
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hospitable temperature
nutrients electrolytes proper pH |
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Name 3 nonliving reservoirs.
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food
contaminated water stagnant ponds garbage soiled diapers discarded wound dressings raw sewage surfaces in healthcare facilities |
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Name 4 portals of exit.
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blood
mucus saliva breast milk urine feces vomitus semen cuts bites abrasions |
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What are the 3 modes of direct contact for transmission of a microorganism?
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touching
kissing sexual intercourse |
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Contact with a fomite (contaminated object).
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Indirect contact
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Organism that carries a pathogen to a susceptible host, either by biting or by carrying the pathogen on its body (e.g., mosquito carrying malaria).
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vector
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What is the difference between a normal and an abnormal portal of entry?
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Normal - body openings
Abnormal - cuts, scapes, wounds, surgical sites, insertion sites of tubes/needles |
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Give an example of a latent infection.
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HIV
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What type infection causes harm in a limited region of the body?
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local infection
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What type infection occurs when pathogens invade the blood or lymph and spread throughout the body?
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systemic infection
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The clinical presence of bacteria in the blood.
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bacteremia
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A symptomatic, systemic infection spread via the blood.
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septicemia
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What type of urinary diversion allows for urinary continence?
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Kock pouch (urine has to be manually drained)
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A wound that is uninfected with minimal inflammation.
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clean wound
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Surgical incisions that enter the GI, respiratory, or GU tracts. Increased risk for infection.
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clean-contaminated wound
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Open, traumatic or surgical wound where a major break in asepsis occurred. High risk for infection.
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contaminated wound
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A wound with a bacteria count of greater than 100,000.
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infected wound
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A wound to the epidermal layer only.
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superficial wound
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A wound that extends through the epidermis into the dermis.
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partial-thickness wound
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A wound that extends into the subcutaneous tissue and beyond.
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full-thickness wound
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A wound that involves internal organs (e.g., a gunshot wound).
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penetrating wound
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Straw-colored exudate from a clean wound.
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serous exudate
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Bloody drainage from a wound, indicating damage to capillaries.
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sanguinous exudate
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A mixture of bloody & clear drainage from a wound.
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serosanginous exudate
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Thick, yellow, malodorous drainage from a wound containing pus caused by an infection.
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purulent exudate
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Pus that is pink/red-tinged draining from a wound.
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purosanguineous exudate
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A type of healing of the epidermis that does not leave a scar.
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regenerative / epithelial healing
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Healing where the wound edges come together leaving little scarring from a clean wound.
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primary intention
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A wound that is left open to heal from the inner layer to the surface; wound edges are not approximated. There is usually extensive tissue loss.
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secondary intention
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Delayed primary closure of a wound that requires the endges of the wound be sutured after granulation partially fills in the wound. Strict aseptic technique is required.
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tertiary intention
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The wound healing phase where hemostasis occurs and inflammation is evident. Edema, erythema, pain, inc. temperature, and WBCs aggregate at site.
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Inflammatory phase
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The wound healing phase where cells develop to fill wound and resurface the skin. Fibroblasts form collagen and granulation tissue appears.
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proliferative phase
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The wound healing phase where collagen is remodeled into scar tissue and epithelialization continues.
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maturation phase
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Give three external factors that contribute to the development of a pressure ulcer.
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friction
shearing moisture |
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Give three internal factors that contribute to the development of a pressure ulcer.
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immobility
impaired sensation malnourishment aging low arteriolar pressure fever |
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The staging system of classification of pressure ulcers describes the _____ of the tissue destroyed. When is the ulcer staged?
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depth
at the point of initial assessment (keeps its stage even as the ulcer heals) |
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The process by which the WBCs (phagocytes) engulf and destroy pathogens directly.
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phagocytosis
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What are the 4 symptoms of inflamation?
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localized heat
erythema (redness) edema pain |
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What should be included in a wound assessment?
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1) location
2) size 3) appearance (type, color, condition of wound bed) 4) skin surrounding wound 5) drainage 6) pain (patient responses) |
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A pressure ulcer with full-thickness skin loss and tissue necrosis (eschar), may include damage to muscle, bone, or support structures.
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Stage IV pressure ulcer
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A pressure ulcer with partial-thickness skin loss of epidermis, dermis, or both (abrasion, blister, or shallow crater).
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Stage II pressuer ulcer
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A pressure ulcer that is a nonblanchable erythema of intact skin; may be itchy or painful.
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Stage I pressure ulcer
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A pressure ulcer with full-thickness skin loss and damage to sucutaneous tissue, maybe down to fascia; deep cratar with undermining.
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Stage III pressure ulcer
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What are the 4 most common lab data reviewed for clients with wounds or those at risk?
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WBC count: 4,500-10,000/mm3
Serum protein levels protein: 6-8 g/dl albumin: 3.8-4.6 g/dl pre-albumin: 12-42 mg/dl Coagulation: aPTT critical values - > 70 sec, < 53 sec Wound cultures (-/+) |
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List 5 medication that can affect skin integrity.
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blood pressure meds
anti-inflammatory meds anti-coagulants chemotherapeutic agents antibiotics herbal products |
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Denuding of superficial skin layers.
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excoriation
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Give the 4 types of chronic wounds.
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1) pressure (ischemia)
2) arterial (dec. circulation) 3) venous (inc. pooling) 4) diabetic ulcers |
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What type of dressing is used for a wound with a large amount of exudate?
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gauze or absorption dressing
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Why would a gauze dressing be used on a wound?
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absorbency
packing cleaning to protect the wound |
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What type of dressing is used for a wound with minimal to no exudate?
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transparent film
(promotion of moist environment) |
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What type of dressing is used to provide a moist environment with minimal exudate?
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hydrocolloid
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What type of dressing would be used to soften slough or liquefy eschar when there is minimal exudate?
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hydrogel
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Describe the 4 ways to secure a dressing.
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adhesive tape (can add pressure)
foam tape (ideal for joints) nonallergenic & paper Montgomery straps (freq. changes) |
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Describe when binders would be used on a patient.
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to keep a wound closed when there is a danger of dehiscence or to immobilize a body part to aid in healing.
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What stage of infection describes the following:
tissue repair & return to health |
convalescence
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What stage of infection describes the following:
immune defenses & therapies decrease the number of microbes |
decline
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What stage of infection describes the following:
appearance of signs & symptoms of the disease |
illness
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What stage of infection describes the following:
first appearance of vague symptoms |
prodromal
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What stage of infection describes the following:
between invasion and first appearance of symptoms |
incubation
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Describe the body's 3 lines of defenses against infection.
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1) primary - structural barriers (skin, respiratory tree, eyes, mouth, GI & GU tracts)
2) secondary: phagocytosis, complement cascade, inflammation, fever 3) tertiary: specific immunity, humoral immunity, cell-mediated immunity |
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The flow of fluids from a wound or cavity.
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exudate
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Describe the complement cascade.
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A set of blood proteins (complement) trigger the release of chemicals that attack the cell membranes of pathogens, causing them to rupture. Also signals WBCs to release histamine, resulting in inflammation.
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Molecules that trigger a specific immune response.
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antigens
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Immunity that acts directly against antigens. B cells produce antibodies (immunoglobulins) to kill by phagocytosis, neutralization, agglutination, and activation of complement and inflammation.
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humoral immunity
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Immunity that acts to destroy body cells that have become infected; T-cells are responsible.
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cell-mediated immunity
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Class of immunoglobulin:
antibody is encountered fo the first time |
IgM
(Mono) |
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Class of immunoglobulin:
most common, gives passive immunity |
IgG
(Generation) |
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Class of immunoglobulin:
responsible for immune response |
IgE
(Emergency) |
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Class of immunoglobulin:
found in mucus membranes around body openings |
IgA
(Anus) |
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Class of immunoglobulin:
form on surface of Bcells; traps |
IgD
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What 5 lifestyle factors help break the chain of infection?
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nutrition
hygeine (intact skin) rest & exercise stress reduction immunizations |
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What are the 6 links in the chain of infection?
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infectious agent
reservoir portal of exit mode of transmission portal of entry susceptible host |
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Absence of contamination by disease-causing organisms.
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asepsis
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Many clinicans do NOT treat a fever lower than ___ F.
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102 degrees
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Elimination of all microorganisms except prions
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sterilization
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What are the 5 key factors in handwashing?
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time >/= 15 seconds
water soap friction drying |
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When are standard precautions used?
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With all clients, and when there is a risk of coming in contact with blood, body fluids (except sweat), excretions & secretions, mucous membranes, and breaks in the skin.
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What type of precautions are used when a patient is under contact isolation?
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clean gown & gloves
pt in a private room or with like organism double bag all linen/trash |
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What is protective (reverse) isolation?
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Used to protect an unusually vulnerable patient from organisms brought in by healthcare workers and visitors
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When is sterile technique used outside of surgery?
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- when administering an injection
- when starting an IV - when performing a sterile dressing change |
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Give 4 rules to follow when working with sterile fields.
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1) only the horizontal plane is sterile
2) 1" margin around field is not sterile 3) no persons without sterile garb withing 1 ft. of sterile field 4) attire is only sterile in front of body from shoulders to waist 5) never turn your back on a sterile field 6) never assume an item is sterile |
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Softening of the skin, most commonly by fever or incontinence.
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maceration
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Wounds are considered infected when bacteria counts are above ______?
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100,000 organisms per gram of tissue
OR the presence of beta hemolytic strep in any number |
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A scar is only _____% as strong as the original tissue.
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80
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When using a Braden scale, a score of 14 indicates what?
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Higher risk (18 or less)
23 indicates no risk |
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Identify the tissue type by it's wound color: beefy red
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granulation
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Identify the tissue type by it's wound color: pale, dry pink
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delayed healing
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Identify the tissue type by it's wound color: black
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necrotic
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Identify the tissue type by it's wound color: pale yellow / gray (may be moist and stringy)
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slough
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Name 4 types of wound closures.
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steri strips
sutures surgical staples surgical glue vacuum-assisted wound closure compression stockings |
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What are the 2 key variables related to development of pressure ulcers?
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Time
Pressure |
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Identify the major interventions for preventing pressure ulcers.
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- providing skin care
- providing nutrition - frequent positioning (Q2H) - therapeutic mattresses and cushions - patient & family teaching Prevention is key! |
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What are the 3 methods of obtaining a wound culture?
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1) swabbing
2) needle aspiration 3) tissue biopsy |
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Separation of a wound, usually in abdominal wounds. Patient hears a pop or feels a tear.
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dehiscence
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Total separation of a wound with protrusion of viscera.
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evisceration
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In the case of evisceration, what should the nurse do?
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- cover the wound w/ sterile towels or dressings soaked in sterile saline
- notify the MD - ready the patient for surgery |
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Connection of two body cavities as the result of infection / abcess formation.
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fistula
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What type of wound debridement is the following:
scalpel or scissors |
sharp
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What type of wound debridement is the following:
lavage, wet to dry dressings or hydrotherapy/whirlpool |
mechanical
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What type of wound debridement is the following:
topical enzymatic agent is applied |
enzymatic
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What type of wound debridement is the following:
use of an occlusive moisture retaining dressing & the body's own mechanism to destroy necrotic tissue |
autolysis
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What are 4 purposes for a wound dressing?
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protect from contamination & heat loss
aid in hemostasis absorb drainage debride the wound splint the wound site prevent drying of the wound bed keep the surrounding tissue dry & intact provide comfort to the patient |
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What is the goal of all wound care?
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to heal the wound in the most RAPID & COMFORTABLE manner
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Abnormal passage between two body cavities.
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fistula
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Tie tapes used for dressings that require frequent changing.
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Montgomery straps
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A Jackson-Pratt is an example of what?
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a surgical drain
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softening of the skin
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maceration
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What would you expect to occur under an Op-Site brand dressing?
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autolysis
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Which of the following factors puts the patient at greatest risk for impaired skin integrity?
a)peripheral vascular disease b)tanning once a week c)an 1800kcal diet d)a temperature of 101.5 degrees F |
a)peripheral vascular disease
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Mr. Smith had a small basal cell carcinoma lesion removed from his back. The plastic surgeon removed an area of skin 3 in. in diameter and 1/2 in. deep around and under the lesion and left the wound open to heal. The wound will heal by:
a)primary intention b)secondary intention c)third intention d)tertiary intention |
b)secondary intention
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Which of the following is a complication of wound healing?
a)three centimeters of sanguinous fluid on a surgical dressing b)hypotension and increased pain at the surgical site c)presence of beef red tissue in the center of a closing wound d)low-grade temperature |
b)hypotension and increased pain at the surgical site
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Jan is a RN and today she is working with Mary, the new aide. The nursing supervisor knows that Jan understands proper delegation in relationship to wound care when she asks Mary to:
a)debride a wound b)evaluate how treatment is working for a decubitus ulcer c)turn a comatose pt every 2 hrs. d)irrigate an open wound using vigorous flushing |
c)turn a comatose pt every 2 hrs
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The nurse is ambulating Mr. Sanchez, who had a bowel resection yesterday. Suddenly, Mr. Sanchez states, "It feels like I've popped open." The nurse observes that the abdominal incision has opened three inces and a small section of the bowel is protruding. In addition to calling the physician immediately, the nurse would do which of the following:
a)place the pt supine in bed, knees flexed, and cover the wound with sterile gauze soaked with sterile saline. b)lay the pt prone to put pressure on the area, and instruct the pt not to cough. c)place the pt supine in bed, legs flat, and cover the wound with dry sterile dressings d)place the patient in Trendeleberg's position, knees flexed, and cover the wound with an occlusive dressing |
a)place the pt supine in bed, knees flexed, and cover the wound with sterile gauze soaked with sterile saline
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The Braden scale is a way to measure the depth of a decutibus (pressure) ulcer.
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False
it measures risk |
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Deeper level tissue damage, known as undermining, may be present in a stage IV pressure ulcer.
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True
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Serosanguinous drainage on a surgical dressing is an abnormal finding and should be reported to the physician immediately.
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False
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When applying an "ace" wrap (roller bandage) to a limb, it is important to begin at the most distal point and wrap toward the body.
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True
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Identify 3 major functions of the skin.
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Protection of the internal organs
Unique identification of an individual Thermoregulation Metabolism of nutrients and metabolic waste products Sensation |
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What is the function of the stratum corneum, the outermost layer of the skin?
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The stratum corneum serves as a barrier, which has three functions:
Restrict water loss Prevent entry of fluids into the body Protect the body against the entry of pathogens and chemicals |
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What are 2 functions of the subcutaneous layer of skin?
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The subcutaneous layer, which is primarily connective and adipose tissues, has three functions:
Insulation Protection Reserve of calories in the event of severe malnutrition |
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What are 2 effects that aging has on skin?
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As adults age, aging has the following effects on the skin:
The activity of the sebaceous and sweat glands diminishes resulting in drier skin. The subcutaneous tissue layer thins, giving the individual a sharp angular appearance. Excess caloric intake and weight gain can offset this change of appearance. The strong bond between the epidermal and dermal layers decreases as the dermal layer looses elasticity. These changes make the skin prone to breakdown and slow the healing of a wound. |
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What effect does immobility have on skin?
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Patients with impaired mobility often cannot reposition themselves, leading to pressure over bony prominences, which can lead to skin breakdown.
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Identify 5 factors that affect skin integrity.
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Age
Mobility status Nutrition Hydration Sensory status Circulation Medications Exposure to moisture Exposure to harmful microorganisms Fever Lifestyle |
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What nutritional components are essential to maintain skin?
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Adequate intakes of five nutritional components are essential to maintain skin:
Protein Calories Fluid Vitamin C Minerals |
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Explain the difference between an acute and a chronic wound.
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Acute wounds are expected to be of short duration. Acute wounds may be intentional (surgical incisions) or unintentional (trauma).
Wounds are classified as chronic when they exceed the anticipated length of recovery. Chronic wounds include pressure, arterial, venous, and diabetic ulcers. These wounds are frequently colonized with bacteria, and healing is very slow because of the underlying disease process. A chronic wound may linger for months or years. |
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Identify the type of wound healing (primary, secondary, or tertiary intention):
A wound that heals from inner layer to the surface |
secondary intention
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Identify the type of wound healing (primary, secondary, or tertiary intention):
A wound with approximated edges |
primary & tertiary intention
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Identify the type of wound healing (primary, secondary, or tertiary intention):
A wound that heals by approximating two surfaces of granulation tissue |
tertiary intention
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Identify the type of wound healing (primary, secondary, or tertiary intention):
A wound that heals by approximating two surfaces of granulation tissue |
primary intention
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