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89 Cards in this Set
- Front
- Back
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Aquathermia pad
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A water flow pad used for treating muscle sprains and areas of mild inflammation or edema
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Blanching
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the absence of normal red tones, to become pale
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Debridement
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the removal of necrotic tissue so healthy tissue can regenerate
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Dehiscence
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the partial or total separation of wound layers
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Deep tissue injury (DTI)-
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before stage one in a pressure ulcer, redness and bruising below skin.
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Ecchymosis
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(Contusion) bruising, bluish discoloration of the skin
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Eschar
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a scab or dry crust that results from the death of skin
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Evisceration
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protrusion of visceral organs through a wound opening
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Excoriation
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an injury to the surface of the body caused by trauma (scratch, abrasion, burn)
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Fistula
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an abnormal passage between two organs or between an organ and the outside of the body
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Granulation tissue
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connective tissue that forms during the healing process; it has a more abundant blood supply than collagen
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Hypermeia
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an excess of blood in part of the body, caused by increased blood flow
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Induration
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hardening of tissue caused by an area of localized swelling under the skin
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Ischemia
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a decreased supply of oxygenated blood to a body part or organ
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Pressure ulcer
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- “ Localized area of tissue necrosis (death) that tends to develop when soft tissue is compressed between a bony prominence and an external surface for a prolonged period. “ (NPUAP) National Pressure Ulcer Advisory Panel.
- A specific type of skin trauma, almost exclusively those with limited mobility. - Occur as a result of mechanical trauma and tissue anoxia. |
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Purpura
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hemorrhage under tissue, particularly beneath skin or mucous membranes, producing ecchymosis or petechiae
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Tissue ischemia
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tissues not getting enough blood supply related to atrophy.
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Unstageable wound-
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necrotic tissue, can not assess depth until scared tissue is removed, making it unstageable.
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~ Epidermis- Desquamation happens here
- 1mm thick, lacks blood supply - 2 layers: |
- STRATUM CORNEUM- outermost layer
•Flattened, dead, keratinized cells •Prevents dehydration and entrance of certain chemical agents •Allows for evaporation of water & the absorption of some topical medications - STRATUM BASAL- bottom layer • Cells divide, proliferate & migrate towards the surface |
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~ Basal Layer of Epidermis
• Deepest layer. • Cells continuously grow. • New cells push old cells toward the outer layers of epidermis. • Cells shrink, die, & become filled with hard protein called keratin. • Keratinized cells allow skin to act as barrier to infection. (hair & nails) |
• Contains special cells called melanocytes which produce black pigment melanin:
- Gives skin color - Protects against ultraviolet rays of sun - Protects against skin cancer - Reduces formation of wrinkles |
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~ Dermis- “True skin” – the inner layer of the skin.
• Is living tissue with very good blood supply. (it’s own blood supple, dermis does not) • Provides the tensile strength, mechanical support & protection to underlying bone, muscle, & organs. • Composed of connective tissue and collagen fibers (few skin cells) • Made of strong fibrous protein |
• Houses hair follicles, sweat glands, sebaceous glands, collagen, blood vessels, lymph vessels, sensory receptors, nerve fibers, and muscle fibers
• Provides strength, mechanical support • Protects underlying muscles, bones and organs • Fibroblasts are the only distinctive cell found in the dermis • Restores structural integrity and physical properties (collagen, vessels). |
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~ Subcutaneous Layer
• Third and deepest layer • Formed of fat • Fatty tissue called lipocytes or fat cells • Protects the deeper tissues of body • Acts as insulation for heat and cold |
• Subcutaneous Fat (adipose tissue)
– covers muscle and bone – numerous blood vessels |
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~ JOB OPPURTUNITIES FOR SKIN
• Protection • Homeostasis (water balance) • Temperature Regulation • Sensory Organ • Vitamin Synthesis (Vitamin D) • Psychosocial |
~Primary Function
• Protection • Homeostasis- Forms 2-way barrier – Keeps out: • Pathogens (disease-causing organisms) & • Harmful chemicals– Prevents critical body fluids from escaping body • Protects internal organs • Temperature regulation • Sensory organ • Vitamin synthesis (absorption) |
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~ Sensory Receptors
• Detect: – Temperature – Pain – Touch – Pressure |
• Are located in skin
• Nerve endings in middle layer of skin convey messages to brain and spinal cord. |
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~Hair
– Fibers composed of protein keratin – Melanin gives hair its color. – Sebaceous glands release sebum into hair follicles. ~Nails - Flat plates of keratin - Serves as tools - Grow longer from root |
~ Sweat Glands
- 2 million throughout the body - In the dermis - Function in cooling the body as sweat evaporates - Called apocrine glands in pubic and underarm area - Fluids Produced by sweat glands: – Assist body in maintaining internal temperature – Create cooling affect when sweat evaporates ~ Sebaceous Glands • Found in dermis • Secrete the oil sebum • Open into hair follicles • Lubricate the hair and skin • Secretion increases during adolescence • Decreases in old age - Fluids Produced by Sebaceous glands: – Oil glands – Produce sebum – Lubricates the skin surface |
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~ Minor Irritations
• Dryness- need to rehydrate skin • Pruritus (itching)- may be the skin OR systemic condition • Sunburn- 1st degree burn • Uritcaria (hives)- white/red edematous papules or plaques, from an allergic rxn • Nebi- moles |
~ Skin Lesions
• Primary lesions: initial reaction to an underlying problem that alters structural component of skin • Secondary lesions: changes in the appearance of the primary lesion ~ Infections • Bacterial infections – folliculitis, furuncles (boils), cellulitis • Viral infections – Herpes simplex Type I and 2- Cold sores and genital herpes – Herpes Zoster- shingles • Fungal infections – Tinea infections- can come from cats |
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~Trauma
• Injury to the skin • Surgical Incision, neat with minimal tissue loss • Pressure ulcer, infected, draining with significant tissue damage • Requires wound healing |
~Wounds
• Any physical injury involving a break in the skin, usually caused by an act or accident rather than by a disease. • Variety of definitions exists. • Two types: Primary intention & Secondary tintention, * The wound healing process is the same for all wounds. Variations depend upon location and severity of the wound, and the extent of the injury. * |
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~ Primary Intention: Wounds with no loss of tissue
• Wounds with minimal tissue loss • Wound edges brought together (approximated) and held in place until healing is complete • Healing occurs quickly • Drainage usually stops by day 3 and epithelialized by day 4 • Risk of infection is low • e.g. Clean laceration, surgical incision |
~ Secondary Intention: Wounds with loss of tissue
• Deep tissue injuries and wounds with tissue loss that requires gradual filling of dead space with connective tissue • Wounds edges do not approximate • Prolongs repair process • e.g. pressure ulcers, venous stasis ulcers, burns, severe lacerations • May be a much longer process • Inflammation can be chronic • Wound may fill with granulation tissue rather than collagen • Scarring is larger • Risk for infection is high |
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~ Healing by Third Intention
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• Delayed primary closure of a wound that is a deliberate attempt by the surgeon to allow for the effective draining and cleansing of a contaminated wound.
• Wound isn’t closed until all evidence of edema and wound debris has been removed • e.g. Surgical incision that enter nonsterile body cavity or traumatic wounds |
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Data to obtain when performing a wound assessment:
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• Bleeding
• Foreign bodies & contaminant materials • Size- measure &/ or trace wound area, & depth • Progress toward healing • Appearance- open or closed edges, look for dehiscence or evisceration • Drains & drainage- condition of apparatus/ type (color), amount, odor, increasing or decreasing • Wound closures- staples, sutures • Palpation of Wound- to detect localized areas of tenderness or drainage • Pain • Wound edges- assess for undermining and conditions of margins • Surrounding skin- assess for color, moisture, uppleness • Wound bed- assess for necrotic and granulation tissues, fibrin slough, epithelium, exudates and odor |
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Wounds are classified by:
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A: Status of Skin Integrity
• Open- break in skin or mucous membranes • Closed- no break in skin • Acute (surgical wound) - orderly reparative, with restoration • Chronic (pressure ulcer) - fails to follow orderly, reparative process B: Cause • Intentional- resulting from therapy, e.g. surgical incision, introduction of needle, usually aseptic technique • Unintentional- unexpectedly, e.g knife wound, burn, usually unsterile conditions |
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Wounds are classified by:
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C: Severity of Injury
• Superficial- only epidermal layer, from friction, e.g. abrasion, 1st degree burn, shearing • Penetrating- penetrates dermis and deeper • Perforating- foreign object enters and exits internal organ D: Cleanliness • Clean: no pathogens • Clean-contaminated: aseptic wound, but cavity harbors microorganisms • Contaminated: microorganisms likely • Infected: bacterial organisms present • Colonized: usually multiple microorganisms |
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Wounds are classified by:
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E: Descriptive Qualities
• Laceration- tearing of tissues with irregular wound edges (Jagged) • Abrasion- superficial wound involving scraping of skin’s surface • Contusion- (ecchymosis) closed wound caused by a blow by blunt object - swelling, discoloration and pain |
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Identify and describe the character of the 4 types of wound drainage:
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1) Serous- clear, watery plasma
2) Purulent- thick, yellow, green, tan, brown 3) Serosanguineous- pale, red, watery 4) Sanguineous- bright red, active bleeding |
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Purpose and types of drains used in a surgical incision:
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- Penrose- Drains onto surrounding bandages
- Jackson Pratt (JP) - Has bulb container that collects drainage, maintains vacuum. Empty and measure accurately, reapply vacuum (While maintaining pressure, replace the plug. Slowly release your grip to re-establish suction.) - Hemovac- Flat and round. Empty drainage fluid into a measuring cup and record the amount of fluid. While maintaining pressure, replace the plug. Slowly release your grip to reestablish suction. - Wound Vac- creates negative pressure to pull wound edges together and drain. |
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3 phases of wound healing (the 3R’s):
1) Inflammatory Phase (Reaction) |
• Within minutes of injury or cell death and lasts 3-5 days
• Immediate response: vasoconstriction and clot formation • Ten minutes: Vasodilation with plasma and proteins into surrounding tissue • WBC’s (esp’lly macrophages) • Local edema, pain erythema and warmth |
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3 phases of wound healing (the 3R’s):
2) Proliferative Phase (Regeneration) |
• 4th day after injury, lasts 2-4 weeks
• Fibrin strand scaffolding • Fibroblast migration and collagen secretion • Inflexible scar tissue • New blood vessels develop • Granulation tissue forms and wound contraction • Epithelial cells grow over granulation bed • Scabbing |
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3 phases of wound healing (the 3R’s):
3) Maturation (Remodeling) |
• 3 weeks to a year
• Collagen reorganized and provides more strength • Scar tissue becomes thinner and paler in color • Mature scar is firm and inelastic when palpated • Collagen collects • Scar matures |
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Complications of wound healing:
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• Hemorrhage- BP drops HR increases
• Infection- bacterial (boil, cellulites), viral (herpes), or fungal (tinea) • Dehiscence- when the wound fails to heal properly and the skin/tissue separate (those most at risk are obese, poor nutrition, infection) • Evisceration- protrusion of organs through a wound opening. Life threatening emergency • Fistulas- an abnormal passage b/w two organs or an organ and the outside of the body • Delayed Wound Closure- 3rd intension, not completely closed up to let some drainage out. |
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~ Local Wound Care
• Debridement: removal of necrotic tissue so healthy tissue can regenerate – eschar, sloughing and necrotic tissue – Ulcers with eschar cannot be staged until debridement has occurred – Mechanical (wet-to-dry), autolytic, chemical/enzymatic and surgical. |
~ Wound cleansing
• Normal saline • Commercial wound cleanser that will not damage or kill cells and healing tissue • Avoid cytotoxics such as Dakin’s solution, acetic acid, povidone iodine, hydrogen peroxide and certain wound cleansers • Wound is considered less contaminated than surrounding skin |
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~ Wound Dressing Considerations
• Protect ulcer or wound • Maintain moist healing environment • Prevent maceration of surrounding tissue • Absorption of wound drainage • Location of wound • Elimination of dead space • Time and cost |
~ Clean technique
• Clean technique is used on pressure ulcers • All pressure ulcers are considered contaminated • Use clean gloves • Least to most contaminated |
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~ Surgical Wounds
• If healing by primary intention, dressing is removed after drainage stops • Dressing is “reinforced prn” immediately after surgery |
~ Sutures
• Sutures: wire, nylon, silk, steel, etc – deep sutures: absorbable – superficial: final wound closure • Steel staples • Usually removed 7-10 days • Steri-strips: butterfly tape to keep edges closed |
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~ 3 elements responsible for pressure ulcer development:
1) Intensity of pressure and capillary closing pressure (pressure greater than 32mmHg) 2) Duration and sustenance of pressure (time/pressure relationship) 3) Tissue tolerance (skin is less sensitive than muscle) |
~ Risk Factors for Pressure Ulcer Formation: Contributing Factors
• Shearing • Friction • Moisture • Poor nutrition • Anemia • Infection • Impaired peripheral circulation • Obesity • Cachexia • Age • Fever |
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4 stages in the classification of pressure ulcers:
Stage I |
• Skin is intact
• Warmth or firmness may be present • Sensation of pain or itching • Area is persistently red and does not blanch with external pressure (in darker skin tones, ulcer may appear red, blue or purplish hue) • Blanched -use transparents film dressing (tegadern) - Thin hydrocolloid dressing (x-thin, duoderm) |
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4 stages in the classification of pressure ulcers:
Stage II |
• Skin is not intact
• Partial thickness skin loss of epidermis or dermis • Ulcer is superficial, abrasion, blister, shallow crater - use hydrocolloid dressing - composite dressing ( viasorb, alldress) - hydrogel dressing (vigilon, saf-gel) - foam dressing (lyofoam, polymen) |
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4 stages in the classification of pressure ulcers:
Stage III |
• Skin loss is full thickness
• Subcutaneous tissues may be damaged or necrotic • Damage extends down to but not through underlying fascia • Deep crater or eschar may be present • Undermining of adjacent tissue may or may not be present - use polyurethane foam - hydrocolloid dressing (duoderm, comfeel - hydrogel dressing - alginate dressing (kaltostat, algisite) |
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4 stages in the classification of pressure ulcers:
Stage IV |
• Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures
• Undermining is present • Sinus tracts may develop • (From US Dept. of Health and Human Services) ~ Full-Thickness Wounds: - Extends to subcutaneous layer or deeper - Depth - May include necrotic tissue or infection - Often extensive tissue damage - May have damage to muscle bone or supporting structures - hydrocolloid dressing -hydrogel dressing gauze roll dressing |
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Therapeutic beds and mattresses
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pressure relieving- reduces the pressure between the body and the support surface to below 32mmHg or the capillary closing pressure
– pressure reducing- reduces pressure, but not below the level of capillary closing pressure |
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~ Assessment of Pressure Ulcers
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• Location
• Size • Sinus tracts • Undermining • Tunneling • Exudate • Necrotic Tissue • Granulation tissue • Epitheliazation |
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~ Elements of pressure ulcers
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• Intensity of pressure and capillary closing pressure – greater than 32 mm Hg
• Duration of pressure – time and pressure relationship • Tissue tolerance – skin less sensitive than muscle |
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~ Nursing Diagnosis for pressure ulcers:
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• Actual or risk for impaired skin integrity related to pressure on bony prominences, restricted mobility, shearing force, friction, moisture
• Impaired Physical mobility related to effects of bed rest, decreased strength, musculoskeletal impairment • Risk for infection and wound extension related to open wound and impaired local blood supply • Pain related to pressure ulcer, wound infection, and wound treatment • Body image disturbance related to loss of skin and altered appearance • Ineffective Individual coping related to chronicity of ulcer, changes in lifestyle required to promote healing • Knowledge deficit related to lack of information about or unclear explanation of the treatment regimen. |
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Heat: - Vasodilation
- Inflamed body part - New surgical wound - Infected wound - Arthritis - DJD - Muscle strain - Low back pain - Joint disease/pain |
• Vasodilation- improves blood flow to the area, promotes nutrient delivery and waste removal
• Reduced blood viscosity- improves delivery of leukocytes and antibodies • Reduced muscle tension- reduces pain and spasms • Increased tissue metabolism- increased blood flow provides localized warmth • Increased capillary permeability- promotes movement of waste products and nutrients |
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Cold:- vasoconstriction
- Sprains - Strains - Fractures - Muscle spasms - Minor burns - Arthritis - Joint trauma - Superficial laceration - Puncture wound |
• Vasoconstriction- reduces blood flow to the affected body part, prevents swelling, reduces inflammation
• Local anesthesia- reduces localized pain • Reduced cell metabolism- reduces the oxygen need of the tissue • Increased blood viscosity- promotes coagulation at the injury site • Decreased muscle tension- relieves pain |
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Indications for using sterile technique:
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• Procedures that require intentional perforation of skin
• Skin integrity broken due to trauma, surgical incision, burns • Procedures that involve insertion of catheters or surgical instruments into sterile body cavities (catheter vs enemas) |
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~A 38 year-old quadriplegic patient has a Stage I pressure ulcer and is being turned frequently. Which dressing is most appropriate?
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A. None, as the patient is being turned to relieve pressure *
B. Moist-to-dry C. Hydrocolloid D. Absorptive |
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~When obtaining a wound culture the nurse should:
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A. Collect specimen from old drainage to determine correct bacterial counts
B. Rinse the wound bed with normal saline before obtaining the culture * C. Allow the culturette swab to dry after obtaining the specimen D. Swab the surrounding skin as well as the wound bed |
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~An elderly patient is admitted from a nursing home for treatment of pressure ulcers. During the initial physical assessment, the nurse notes that the client is dehydrated and the skin is dry and scaly. The nurse immediately applies emollients to the patient’s skin and changes the dressing on the pressure ulcers. Legally:
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A. The nurse should have instituted a plan to increase activity
B. The nurse provided supportive nursing care for the well being of the patient C. No treatment should have been instituted for the patient until the physician ordered it D. Debridement of the pressure ulcer should have been done by the nurse before the dressing was applied. * |
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~A patient with severe burns is placed on a circulating air bed primarily to:
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A. Increase mobility
B. Prevent contractures C. Limit orthostatic hypotension D. Prevent pressure on peripheral blood vessels * |
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abnormal reactive hyperemia
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- hyperemia over a pressure site lasting longer than 1 hour after the removal of pressure
- surrounding skin does not blanch |
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fibroblasts
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- cells that are responsible for collagen formation
- the only distinctive cell type within the dermis |
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hemostasis
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termination of bleeding by mechanical or chemical means or by the coagulation process of the body
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normal reactive hyperemia
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- hyperemia over a pressure site that lasts 1 hour or less after the removal of pressure
- surrounding skin blanchs |
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purulent
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exudate producing or containing pus
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sanguineous
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exudate fluid containing RBC
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serosanguineous
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exudate containing both serum and blood
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serous
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a clear, plasms like fluid that forms an exudate at the site of an inflammation
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The skills of physical assessment are inspection, palpation, percussion, and auscultation. The order in which these skills are performed during an abdominal examination differs slightly. The nurse should complete which two skills first?
A. Inspection and percussion B. Palpation and inspection C. Inspection and auscultation D. Palpation and auscultation |
c. The nurse begins with inspection and then follows with auscultation. It is important to perform auscultation before palpation and percussion because palpation and percussion may alter the frequency and character of bowel sounds.
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The nurse should assist the client to a sitting position for the best position to examine what area of the client?
A. Lungs B. Heart C. Abdomen D. Pulse sites |
a. Sitting upright provides full expansion of lungs and provides better visualization of symmetry of upper body parts.
b. The lateral recumbent position aids in detecting heart murmurs. c. The dorsal recumbent position is used for abdominal assessment because it provides relaxation of abdominal muscles. d. The supine position provides easy access to pulse sites. |
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Turgor is the skin’s elasticity, which can be diminished by edema or dehydration. Which is the best place for the nurse to assess skin turgor in the older adult?
A. Back of the hand B. Palm of the hand C. Side of the neck D. Over the sternal area |
d. To assess the skin turgor, a fold of skin on the back of the forearm or sternal area is grasped with the fingertips and released. Normally the skin lifts easily and snaps back immediately when turgor is good. The skin stays pinched when turgor is poor. The hands and neck are not the best places to test for turgor because the skin is normally loose and thin in those areas.
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While using percussion to assess the client’s lungs, the nurse notes that the lungs are normal upon percussion, which means:
A. Hyperresonance B. Resonance C. Tympany D. Dullness |
b. Resonance is the low hollow sound of normal lungs.
a. Hyperresonance can be heard over emphysematous lungs by a booming sound. c. Tympany is the high-pitched, drumlike sound heard over gastric air bubble. d. Dullness is the soft thudlike sound that would be heard over dense organ tissue. |
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During inspection of the skin a common abnormality may be pallor. Pallor is easily seen in the face, mucosa of the mouth, and nail beds. How would pallor appear in a brown-skinned client?
A. Bluish B. Yellowish C. Ashen gray D. Shiny |
b. Pallor would appear yellowish-brown in brown-skinned people.
a. Pallor would appear bluish in light-skinned people. c. Pallor would appear ashen gray in black-skinned people. d. Shiny skin indicates edema. |
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Using an otoscope, the nurse can inspect the tympanic membrane. The normal tympanic membrane appears:
A. Dark yellow and sticky B. Round and white C. Translucent, shiny, and pearly gray D. Pink and bulging |
c. The normal tympanic membrane is translucent, shiny, and pearly gray.
a. Dark yellow and sticky describes normal moist cerumen (earwax) in front of the tympanic membrane. b. A white color reveals pus behind the membrane. d. A pink or red bulging membrane is an indication of inflammation. |
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The nurse hears adventitious breath sounds that are high-pitched, continuous musical sounds like a squeak heard continuously during inspiration or expiration, usually louder on expiration. This adventitious breath sound is known as:
A. Pleural friction rub B. Crackles C. Rhonchi D. Wheezes |
d. a. Pleural friction rub has a dry, grating quality heard best during inspiration. b. Crackles can be a fine, high-pitched, short interrupted crackling sound; moist, low sound in the middle of inspiration; or coarse, loud bubbly sounds. c. Rhonchi are loud, low-pitched, rumbling coarse sounds heard during inspiration.
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The nurse should use which anatomical sites for the auscultation assessment of cardiac function?
A. Aortic, carotid, coronary, and jugular B. Apical, lateral, anterior, and posterior C. Aortic, pulmonic, tricuspid, and mitral D. Inner costal, outer costal, and sternal |
c. Aortic, pulmonic, tricuspid, mitral, and epigastric are the sites for auscultation assessment of cardiac function. Auscultation of the carotid arteries is not the same as the heart itself. The sternal region is not an appropriate site. There are no costal sites where heart sounds can be heard well. Anterior, posterior, and lateral are too vague.
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While the nurse was palpating the calf muscles of the client’s right leg, the client complained of tenderness. Further assessment by the nurse should include which of the following?
A. Observe area for swelling, warmth, redness, and for positive Homan’s sign. B. Observe for cyanosis, pallor, and change in pigmentation around the ankles. C. Observe for reduced hair growth and ulceration. D. Observe for vein distention while client is standing. |
a. Complaints of tenderness in the calf during palpation may indicate phlebitis. Other characteristics of phlebitis are swelling, warmth, and redness and sometimes a positive Homan's sign.
b and c. Cyanosis, pallor, and brown pigmentation around the ankles; ulceration and reduced hair growth are indications of venous or arterial insufficiency. d. Vein distention may be indicative of varicosities. |
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During general inspection of the musculoskeletal system of an older client, the nurse notes kyphosis. Kyphosis is:
A. Increased lumbar curvature B. Exaggeration of the posterior curvature of the thoracic spine C. Lateral spinal curvature D. Loss or little muscle tone |
b. Kyphosis (hunchback) is an exaggeration of the posterior curvature of the thoracic spine and is common in older adults.
a. Lordosis (swayback) is an increased lumbar curvature. c. Scoliosis is lateral spinal curvature. d. Hypotonic muscle has little tone and feels flabby, usually due to atrophy of muscle mass. |
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Prolonged, intense pressure affects cellular metabolism by decreasing or obliterating blood flow, resulting in tissue ischemia and ultimately tissue death. There are four stages of pressure ulcer formation. The nurse observes partial-thickness skin loss involving the epidermis and possibly the dermis. What stage will the nurse document?
A. Stage I B. Stage II C. Stage III D. Stage IV |
b. Partial-thickness skin loss involving the epidermis and possibly the dermis is stage II.
a. In stage I the ulcer appears as a defined area of persistent redness in lightly pigmented skin and appears darker red, blue, or purple in darker pigmented skin with no open skin areas. c. In stage III the ulcer appears as a full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, the underlying fascia. d. In stage IV the ulcer appears as a full-thickness loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures. |
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There are three phases of wound healing. The nurse observes granulation tissue in a client ’s pressure ulcer. What phase of wound healing is represented by granulation tissue?
A. Maturation phase B. Proliferative phase C. Inflammatory phase D. Hemostasis phase |
b. Tissue granulation occurs in the proliferative phase.
a. Maturation is the final stage of wound healing. c and d. Hemostasis occurs during the inflammatory phase. |
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The nurse observes all wounds closely. At what time is the risk of hemorrhage the greatest, particularly in surgical wounds?
A. During the first 24 to 48 hours after surgery B. Between 48 and 60 hours after surgery C. Between 60 and 72 hours after surgery D. 7 days after surgery, when the client is more active |
a. The risk is highest during the first 24 to 48 hours after surgery because of the possibility of poor clotting formation, slipped surgical suture, or trauma to a blood vessel by a foreign object. The more time that passes after surgery, the greater amount of healing, which lessens the risk of hemorrhage.
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Often occurring during wound management, autolylic, chemical, and surgical are all methods of what?
A. Cleansing B. Dressings C. Debridement D. Growth factors |
c. Methods of debridement include mechanical, autolytic, chemical, and surgical. All of these methods share the common objective of removing nonviable, necrotic tissue. Cleansing the wound is done to prevent and help manage infection. Although there are many types of dressings, their usual purpose is to protect the wound. Growth factors regulate most of the key actions of cells during healing and include epidermal, platelet derived, fibroblast, and transforming.
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There are several instruments for assessing clients who are at high risk for developing a pressure ulcer. The Braden Scale is the most commonly used. What risk factors are assessed using the Braden Scale?
A. Physical condition, mental condition, activity, mobility, and incontinence B. Infection, hemorrhage, dehiscence, evisceration, and fistulas C. Nutrition, tissue perfusion, infection, age, shear force and friction, and moisture D. Sensory perception, moisture, activity, mobility, nutrition, friction and shear |
d. The Braden Scale measures these risk factors: sensory perception, moisture, activity, mobility, nutrition, friction and shear.
a. The Norton Scale measures five risk factors, and they are physical condition, mental condition, activity, mobility, and incontinence. b. Infection, hemorrhage, dehiscence, evisceration, and fistulas are the complications of wound healing. c. The factors that influence pressure ulcer formation and wound healing are nutrition, tissue perfusion, infection, age, shear force and friction, and moisture. |
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A 40-year-old client is a new paraplegic. The client is about to be discharged from the rehabilitation center. Prevention of pressure ulcers has been an important part of the client’s education. Regarding that education, the nurse should have included which of the following guidelines?
A. Should sit in chair for 3 hours B. Should shift his weight in a chair every 15 minutes C. Should use a donut-shaped chair cushion D. Should use a rigid cushion for full support |
b. Shifting weight frequently prevents prolonged pressure that may lead to pressure ulcer formation.
a. The guideline for sitting up in a chair is 2 hours or less, but it is only a guideline. The nurse should individualize activity for each client. c and d. Sitting on rigid or donut-shaped cushions is contraindicated because they reduce blood supply to the area, resulting in increased area of ischemia. |
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During the skin assessment of an older adult client who had a stroke, the nurse noted a reddened area over the coccyx. The next actions of the nurse for this client should include:
A. Placing the client in Fowler’s position and returning in 2 hours B. Massaging the reddened area and repositioning the client C. Inserting a urinary catheter to prevent moisture from urinary incontinence D. Repositioning the client off the coccyx area and reassessing the area in an hour |
d. Repositioning the client and reassessing the area in an hour is the most appropriate action for the nurse. When pressure is relieved from an area, the blood flow returns and the redness will disappear, if no damage has occurred. This is the appropriate assessment.
a. Fowler's position would only increase pressure on the coccyx. b. Massaging of a reddened area is not recommended because it could cause further injury if the tissue is already compromised. c. Insertion of a urinary catheter will not relieve pressure on the coccyx. |
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The nurse is to collect a specimen for culture after assessing the client’s wound drainage. The best technique for obtaining the culture is:
A. Collecting the specimen from accumulated drainage B. Swabbing from the outside skin edge inward C. Cleansing the wound first D. Sending the soiled dressing to the laboratory |
c. By cleansing the wound first and swabbing the granulation tissue, the culture should show a more accurate picture of any causative organisms of wound infection.
a and d. Sending a soiled dressing and collecting a specimen from accumulated drainage are not appropriate, because old and new drainage are mingled, possibly growing organisms of their own and may not demonstrate a true reflection of the wound. b. Swabbing from the outer edge of the skin inward may introduce organisms into the wound and contaminate the culture |
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The nurse applies a hydrogel dressing to a client with radiation-damaged skin. Why was the hydrogel dressing the best choice for this client?
A. It is soothing and reduces pain in the wound. B. It can be used as a preventative dressing for high-risk friction areas. C. It permits the nurse to view the wound. D. It provides a wicking action. |
a. Hydrogel dressings are water- or glycerin-based amorphous gel, impregnated gauze, or sheet dressings. They are very useful in painful wounds because they are very soothing to the client and do not adhere to the wound bed, causing little trauma during dressing removal.
b. The hydrocolloid dressing may be used as a preventative dressing for clients with high-risk friction areas. c. The self-adhesive, transparent film dressing allows for viewing the wound. d. The oldest and most common dressing is the gauze sponge and is especially useful in wounds to wick away exudate. |
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The nurse places an aquathermia pad on a client with a muscle sprain. The nurse informs the client the pad should be removed in 30 minutes. Why will the nurse return in 30 minutes to remove the pad?
A. Reflex vasoconstriction occurs. B. Reflex vasodilation occurs. C. Systemic response occurs. D. Local response occurs. |
a. If heat is applied for 1 hour or more, blood flow is reduced by reflex vasoconstriction. Vasoconstriction is the opposite of the desired effect of heat application.
b. Reflex vasodilation occurs when an application of cold is left on too long. Reflex vasodilation is the opposite of the desired effect of cold application. c and d. Systemic and local responses are general and vague terms. |
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petechia
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-pinpoint sized red or purple spots on the skin caused by small hemorrhages in the skin layer
- can indicate serious blood-clotting disorders, drug reactions, or liver disease |
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role of nutrition in wound healing:
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- at least 1500calories a day
- protein - vitamin A & C trace minerals zinc & copper -FLUID |
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nutrition and wound healing
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- calories
- protein- collagen formation, wound remodeling - Vitamin C- collagen synthesis, capillary wall integrity, fibroblast function - Vitamin A- epithelialization, wound closure - Zinc- collagen formation & protein synthesis - Fluid- essential fluid environment for all cell function |
