Wound Care 2

Front 1

Pressure ulcers must be assessed how?

Back 1

at regular intervals using systematic parameters to evaluate wound healing, plan appropriate interventions, and evaluate progress

Front 2

What should be included in assessing a pressure ulcer?

Back 2

should include depth of tissue involvement (staging), type and approximate percentage of tissue in wound bed, wound dimensions, exduate description, and condition of surrounding skin

Front 3

Accurate staging of an ulcer requires what? And what is the drawback?

Back 3

knowledge of the skin layers, and a major drawback of a staging system is that an ulcer covered with necrotic tissue is covering the depth of the ulcer.

Front 4

Pressure ulcer staging is used to what?

Back 4

describe the pressure ulcer depth at the point of assessment

Front 5

Stage 1 Pressure ulcer

Back 5

is an observable pressure-related alteration of intact skin whose indications, as compared with an adjacent or opposite area on the body, may include changes in one or more of the following: skin temperature, tissue consistency, and/or sensation.

Front 6

Stage 1 Pressure ucler continued

Back 6

The ulcer appears as a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones the ulcer may appear with persistent red, blue, or purple hues. There are no open skin areas.

Front 7

Stage 2 Pressure ulcer

Back 7

Partial-thickness skin loss involving epidermis and/or dermis. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater

Front 8

Stage 3 Pressure ulcer

Back 8

Full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue.

Front 9

Stage 4 Pressure ulcer

Back 9

Full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures. Undermining and sinus tracts also may be associated with this stage

Front 10

Red, moist tissue is indication of what?

Back 10

granulation tissue

Front 11

slough

Back 11

stringy substance attached to wound bed

Front 12

eschar

Back 12

necrotic tissue

Front 13

Wound dimensions should include what?

Back 13

consistent measurements of depth, length, and width

Front 14

Exduate describes what?

Back 14

the amount, color, consistency, and odor of wound drainage.

Front 15

Excessive exduate can indicate what?

Back 15

infection

Front 16

Wound

Back 16

is a disruption of normal anatomical structure and function that results from pathological processes beginning internally or externally to the involved organ

Front 17

It is imperative for the nurse to know what about a wound?

Back 17

all wounds are not created equal

Front 18

Five questions that may be included in the nursing assessment of a wound's history

Back 18

wound etiology, occurence, chronology, aggravating and alleviating factors, and associated symptoms

Front 19

Wound classification systems describe what about a wound?

Back 19

the status of skin integrity, cause of the wound, severity or extent of tissue injury or damage, cleanliness of the wound, or desriptive qualitites of the wound such as color

Front 20

Wound Classification: Open

Back 20

wound involving a break in skin or mucous membranes; Causes: Trauma by sharp object or blow (surgical incision, venipunture, gun shot wound)

Front 21

Wound Classification: Status of Skin Integrity: Open; Implications for Healing

Back 21

Break in skin exposes body to invasion by microorganisms. Loss of blood and body fluids through wound occurs. Functions of body parts is reduced

Front 22

Wound Classification:Status of Skin Integrity: Closed; Causes

Back 22

Wound involving no break in skin; Causes: Part of body being struck by blunt object; twisting, straining, or deceleration force against body (bone fracture, tear of visceral organ)

Front 23

Wound Classification: Status of Skin Integrity: Closed; Implications for Healing

Back 23

Wound may predispose person to internal hemorrhage. Function of affected body part is reduced.

Front 24

Wound Classification: Status of Skin Integrity: Acute; Causes

Back 24

Wound that proceeds through an orderly and timely reparative process that results in sustained restoration of anatomical and functional integrity. Causes: Trauma from a sharp object

Front 25

Wound Classification: Status of Skin Integrity: Acute; Implications for Healing

Back 25

Wounds are usually easily cleaned and repaired. Wound edges are clean and intact.

Front 26

Wound Classification: Status of Skin Integrity: Chronic; Causes

Back 26

Wound that fails to proceed through an orderly and timely process to produce anatomical and functional integrity. Causes: Ulcers exposed to friction, shear, moisture, or pressure

Front 27

Wound Classification: Status of Skin Integrity: Chronic; Implications for Healing

Back 27

Continued exposure to pressure, friction, shear, and moisture impedes wound healing. Wound tissue may be necrotic, and drainage may be present

Front 28

Wound Classification: Cause: Intentional and Causes

Back 28

Wound resulting from therapy; Causes: Surgical incision; introduction of needle into body part

Front 29

Wound Classification: Cause: Intentional and Implications for Healing

Back 29

Incision is usually performed under aseptic technique to minimize chance of infection. Wound edges are usually smooth and clean

Front 30

Wound Classification: Cause: Unintentional and Causes

Back 30

Wound that occurs unexpectedly. Causes: Traumatic injury (knife wound, burn)

Front 31

Wound Classification: Cause: Unintentional and Implications for Healing

Back 31

Wound occurs under unsterile conditions. Wound edges are often jagged.

Front 32

Wound Classification: Severity of Injury: Superficial and Causes

Back 32

Wound that involves only epidermal layer of skin. Causes: Result of friction applied to skin surface (abrasion, first-degree burn, shearing)

Front 33

Wound Classification: Severity of Injury: Superficial and Implications for Healing

Back 33

Break creates risk of infection. Wound does not involves underlying injury to tissues or organs. Blood supply to area is intact.

Front 34

Wound Classification: Severity of Injury: Penetrating and Causes

Back 34

Wound involving break in epidermal skin layer, as well as dermis and deeper tissues or organs: Causes: Foreign object or instrument entering deep into body tissues; usually unintentional (gunshot wound, stab wound)

Front 35

Wound Classification: Severity of Injury: Penetrating and Implications for Healing

Back 35

There is high risk of infection because foreign objects is contaiminated. Wound may cause internal and external hemorrhage; damage to organs causes temporary or permanent loss of function

Front 36

Wound Classification: Severity of Injury: Perforating and Cause

Back 36

Penetrating wound in which foreign objects enters and exists an internal organ. Causes: Foreign object or instrument entering deep into body tissues; usually unintentional (gunshot wound, stab wound)

Front 37

Wound Classification: Severity of Injury: Perforating and Implications for Healing

Back 37

There is high risk of infection. Nature of injury depends on organ perforated (lung, compromised oxygenation; major vessel, hemorrhage; intestine, contamination of abdominal cavity by feces).

Front 38

Wound Classification: Cleanliness: Clean and Causes

Back 38

Wound containing no pathogenic organisms. Causes: Closed surgical wound not entering GI, respiratory, genital, or uninfected urinary tract or oropharyngeal cavity.

Front 39

Wound Classification: Cleanliness: Clean and Implications for Healing

Back 39

There is low risk of infection

Front 40

Wound Classification: Cleanliness: Clean-Contaminated and Causes

Back 40

Wound made under aseptic conditions but involving body cavity that normally harbors microorganisms. Causes: Surgical wound entering GI, respiratory, genital, or urinary tract or oropharyngeal cavity under controlled conditions.

Front 41

Wound Classification: Cleanliness: Clean-Contaminated and Implications for Healing

Back 41

There is greater risk of infection than with clean wound

Front 42

Wound Classification: Cleanliness: Contaminated and Causes

Back 42

Wound existing under conditions in which presence of microorganisms is likely. Causes: Open, traumatic, accidental wounds; surgical wound in which break in asepsis occurred

Front 43

Wound Classification: Cleanliness: Contaminated and Implications for Healing

Back 43

Tissues are often not healthy and show inflammation. There is high risk of infection.

Front 44

Wound Classification: Cleanliness: Infected and Causes

Back 44

Bacterial organisms present in wound site, usually above 1,000,000 organisms per gram of tissue. Causes: Any wound that does not properly heal and grows organisms, old traumatic wound, surgical incision into area infected (e.g., ruptured bowel)

Front 45

Wound Classification: Cleanliness: Infected and Implications for Healing

Back 45

Wound presents signs of infection (inflammation, purulent drainage, skin separation).

Front 46

Wound Classification: Cleanliness: Colonized and Causes

Back 46

Wound containing microorganisms (usually multiple). Causes: Chronic wound (vascular stasis ulcer; pressure ulcer)

Front 47

Wound Classification: Cleanliness: Colonized and Implications for Healing

Back 47

Wound healing is slow, and high risk of infection exists.

Front 48

Wound Classification: Descriptive Qualities: Laceration and Causes

Back 48

Tearing of tissues with irregular wound edges. Causes: Severe traumatic injury (knife wound, industrial accident involving machinery, tissues cut by broken glass)

Front 49

Wound Classification: Descriptive Qualities: Laceration and Implications for Healing

Back 49

Wound is usually created by contaminated objects. Depth of wound determines other implications.

Front 50

Wound Classification: Descriptive Qualities: Abrasion and Causes

Back 50

Superficial wound involving scraping or rubbing of skin's surface. Causes: Wound often resulting from fall (skinned knee or elbow); wound also resulting from dermatological procedure for removing scar tissue.

Front 51

Wound Classification: Descriptive Qualities: Abrasion and Implications for Healing

Back 51

Wound is painful from exposure of superficial nerves; deeper tissues are not involved. There is risk of infection from exposure to contaminated surface.

Front 52

Wound Classification: Descriptive Qualities: Contusion and Causes

Back 52

Closed wound caused by a blow to body by blunt object; contusion or bruise characterized by swelling, discoloration, and pain. Causes: Bleeding in underlying tissues caused by blunt force against body part.

Front 53

Wound Classification: Descriptive Qualities: Contusion and Implications for Healing

Back 53

Wound is more severe if internal organ is contused. Wound may cause temporary loss of function of body part. Localized bleeding into tissues may form hematoma (collection of blood).

Front 54

Three components involved in the healing process of a partial-thickness wound

Back 54

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

Front 55

Inflammatory response in partial-thickness wound

Back 55

Is triggered by tissue trauma, causing redness and swelling to the area with a moderate amount of serous exduate. Response is generally limited to the first 24 hours after wounding. The epithelial cells begin to proliferate, providing new cells to replace the lost cells

Front 56

Epithelial proliferation and migration in partial-thickness wound

Back 56

starts at both the wound edges and the epidermal cells lining the epidermal appendages, allowing for quick resurfacing. A wound left open to air can resurface within 6 to 7 days, whereas a wound that is kept moist can resurface in 4 days.

Front 57

Primary Intention

Back 57

The skin edges are approximated, or closed, and the risk of infection is low. Healing occurs quickly; the inflammation typically subsides in less than 24 hours, and the wound is resurfaced between day 4 and 7.

Front 58

Secondary Intention

Back 58

A wound involving loss of tissue, such as a burn, pressure ulcer, or severe laceration, heals by secondary intention. The wound is left open until it becomes filled by scar tissue. It takes longer for a wound to heal by secondary intention, and thus the chance of infection is greater

Front 59

Partial-thickness wounds

Back 59

are shallow wounds involving loss of the epidermis (top layer) and possibly partial loss of the dermis. These wounds heal by regeneration because epidermis can regenerate. Example: the repair of a clean surgical wound or an abrasion.

Front 60

Full-thickness wounds

Back 60

extending into the dermis (involving both layers of tissue) heal by scar formation because deeper structures do not regenerate. Example: pressure ulcers

Front 61

Dehiscence

Back 61

is the partial or total separation of wound layers

Front 62

Evisceration

Back 62

protrusion of visceral organs through a wound opening

Front 63

Fistula

Back 63

is an abnormal passage between two organs or between and organ and the outside of the body.

Front 64

Most fistulas form from what?

Back 64

poor wound healing or as a complication of a disease, such as Crohn's disease.

Front 65

What can prevent tissue layers from closing and allowing a fistula tract to form?

Back 65

Trauma, infection, radiation exposure, and diseases such as cancer

Front 66

Fistulas increase what?

Back 66

the risk of infection and fluid and electrolytes imbalances from fluid loss

Front 67

What does the nurse do when evisceration happens?

Back 67

places sterile towels soaked in sterile saline over the extruding tissues to reduce chances of bacterial invasion and drying of the tissues. The client should be allowed NPO, observed for S/S of shock, and prepared for surgery

Front 68

Norton Scale: Physical Condition

Back 68

Good: 4
Fair: 3
Poor: 2
Very Bad: 1

Front 69

Norton Scale: Mental Condition

Back 69

Alert: 4
Apathetic: 3
Confused: 2
Stuporous: 1

Front 70

Norton Scale: Activity

Back 70

Walks: 4
Walks with help: 3
Sits in chair: 2
Remains in bed: 1

Front 71

Norton Scale: Mobility

Back 71

Full: 4
Slightly limited: 3
Very limited: 2
Immobile: 1

Front 72

Norton Scale: Continence

Back 72

Good: 4
Occasional incontinence: 3
Frequent incontinence: 2
Urine and fecal incontinence: 1

Front 73

A score of ___ or less indicates risk of pressure ulcer, a score of less than ___ indicates high risk.

Back 73

14; 12

Front 74

Norton Scale consist of what five factors

Back 74

Physical Condition, Mental Condition, Activity, Mobility, and Continence

Front 75

Braden Scale is composed of 6 subscales:

Back 75

Sensory perception; Moisture; Activity; Mobility; Nutrition; Friction and shear

Front 76

Score range for Braden Scale

Back 76

6 to 23; a lower score indicates a higher risk for pressure ulcer development

Front 77

What is the cutoff score for onset of pressure ulcer risk?

Back 77

In the general adult population, it is 18. For black adn Latino clients with darkly pigmented skin, a cutoff score of 18 has been suggested.

Front 78

Factors That Impair Wound Healing

Back 78

Age; Malnutrition; Obesity; Impaired Oxygenation; Smoking; Drugs; Diabetes; Radiation; Wound stress

Front 79

Factors That Impair Wound Healing: Age

Back 79

Aging alters all phases of wound healing. Vascular changes impair circulation to wound site. Reduced liver function alters synthesis of clotting factors. Inflammatory response is slowed. Formation of antibodies and lymphocytes is reduced. Collagen tissue is less pliable. Scare tissue is less elastic.

Front 80

Factors That Impair Wound Healing: Age: Nursing Implications

Back 80

Instruct client on safety precautions to avoid injuries. Be prepared to provide wound care for longer period. Teach support persons in home wound care techniques

Front 81

Factors That Impair Wound Healing: Malnutrition

Back 81

All phases of wound healing is impaired. Stress from burns or severe trauma increases nutritional requirement

Front 82

Factors That Impair Wound Healing: Malnutrition: Nursing Implications

Back 82

Provide balanced diet rich in protein, carbohydrates, lipids, vitamins A and C, and minerals (zinc, copper). Assess ability to chew foods; if problem noted, provide with liquid supplements. Provide adequate amounts of calories and fluid.

Front 83

Factors That Impair Wound Healing: Obesity

Back 83

Fatty tissue lacks adequate blood supply to resist bacterial infection and deliver nutrients and cellular elements for healing

Front 84

Factors That Impair Wound Healing: Obesity: Nursing Implications

Back 84

Observe obese client for signs of wound infection and evisceration.

Front 85

Factors That Impair Wound Healing: Impaired Oxygenation

Back 85

Low aterial oxygen tension alters synthesis of collagen and formation of epithelial cells. If local circulating blood flow is poor, tissues fail to receive needed oxygen. Decreased hemoglobin in blood (anemia) reduces arterial oxygen levels in capillaries and interferes with tissue repair

Front 86

Factors That Impair Wound Healing: Impaired Oxygenation: Nursing Implications

Back 86

Provide diet adequate in iron, Vitamin B12, and folic accid. Monitor hematocrit and hemoglobin levels of clients with wound

Front 87

Factors That Impair Wound Healing: Smoking

Back 87

Smoking reduces amount of functional hemoglobin in blood, thus decreasing tissue oxygenation. Smoking may increase platelet aggregation and cause hypercoagulability. Smoking interferes with normal cellular mechanisms that promote release of oxygen to tissue.

Front 88

Factors That Impair Wound Healing: Smoking: Nursing Impications

Back 88

Discourage client from smoking by explaining its effects on wound healing

Front 89

Factors That Impair Wound Healing: Drugs

Back 89

Steroids reduce inflammatory response and slow collagen synthesis. Antiinflammatory drugs suppress protein synthesis, wound contraction, epithelialization, and inflammation. Prolonged antibiotic use may increase risk of superinfection. Chemotherapeutic drugs can depress bone marrow function, lower number of leukocytes, and impair inflammatory response.

Front 90

Factors That Impair Wound Healing: Drugs: Nursing Implications

Back 90

Carefully observe clients reveiving these drugs because signs of inflammation may not be obvious. Vitamin A can counteract effects of steriods. Caution client to use only prescribed medications.

Front 91

Factors That Impair Wound Healing: Diabetes

Back 91

Chronic disease causes small blood vessel disease that impairs tissue perfusion. Diabetes causes hemoglobin to have greater affinity for oxygen, so it fails to release oxygen to tissues. Hyperglycemia alters ability of leukocytes to perform phagocytosis and also supports overgrowth of fungal and yeast infection.

Front 92

Factors That Impair Wound Healing: Diabetes: Nursing Implications

Back 92

Instruct diabetic clients to take preventive measures to avoid cuts or breaks in skin. Provide preventive foot care. Control blood sugar to reduce the physiological changes associated with diabetes.

Front 93

Factors That Impair Wound Healing: Radiation

Back 93

Fibrosis and vascular scarring eventually develop in irradicated skin layers. Tissue become fragile and poorly oxygenated.

Front 94

Factors That Impair Wound Healing: Radiation: Nursing Implications

Back 94

Closely observe clients who have surgery after radiation for wound complications

Front 95

Factors That Impair Wound Healing: Wound Stress

Back 95

Vomiting, abdominal distention, and respiratory effort may stress suture line and disrupt wound layer. Sudden, unexpected tension on incision inhibits formation of endothelial cell and collagen networks.

Front 96

Factors That Impair Wound Healing: Wound Stress: Nursing Implications

Back 96

Control nausea with ordered antemetics. Keep nasogastric tubes patent and draining to avoid accumulation of secretions. Instruct and help client to splint abdominal wound during coughing

Front 97

Successful critical thinking requires what?

Back 97

a synthesis of knowledge, experience, information gathered from clients, critical thinking attitudes, and intellectual and professional standards.

Front 98

Clinical judgement requires what?

Back 98

the nurse to anticipate the information necessary, analyze the data, and make decisions regarding client care.

Front 99

When caring for a client who have impaired skin integrity and chronic wounds, the nurse must do what?

Back 99

integrate knowledge from nursing and other disciplines, previous experiences, and information gathered from clients to understand the risk to skin integrity and wound healing

Front 100

Knowledge of what enables the nurse to have a scientic basis of care?

Back 100

normal musculoskeletal physiology, the pathogenesis of pressure ulcers, normal wound healing, and the pathophysiology of underlying diseases

Front 101

Pressure ulcer sites (22)

Back 101

(1)occipital bone, (2)scapula (3)spinous process (4)elbow (5)iliac crest (6)sacrum (7)ischium (8)achilles tendon (9)heel (10)sole (11)ear (12)shoulder (13)anterior iliac spine (14)trochanter (15)thigh (16)medial knee (17)lateral knee (18)lower leg (19)medial malleolus (20)lateral malleolus (21)lateral edge of foot (22)posterior knee

Front 102

Assessment of Abnormal Healing in Primary Intention Wounds

Back 102

Incision line poorly approximated; Drainage present more than 3 days after closure; Inflammation decreased in first 3-5 days after injury; No epithelialization of wound edges by day 4; No healing ridge by day 9

Front 103

Assessment of Abnormal Healing in Secondary Intention Wounds

Back 103

Pale or fragile granulation tissue, granulation tissue bed may be excessively dry or moist; Exudate present; Necrotic or slough tissue present in wound base; Epithelialization not continuous; Fruity, earthy, or putrid odor present; Presence of fistula(s), tunneling, undermining