Wound Care 3

Front 1

Primary intention

Back 1

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

Front 2

Secondary intention

Back 2

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

Front 3

Partial thickness wounds are what?

Back 3

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. EX: the repair of a clean surgical wound or an abrasion.

Front 4

Full-thickness wounds are what?

Back 4

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

Front 5

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

Back 5

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

Front 6

Inflammatory stage of partial thickness wound repair

Back 6

is triggered by tissue trauma, causing redness and swelling to the area with a moderate amount of serous exudate. This response is generally limited to the first 24 hours after wounding.

Front 7

Epithelial proliferation and migration of partial thickness wound repair

Back 7

starts at both the wound edges and the epidermal cells lining the epidermal appendages, allowing for quick resurfacing. 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 8

Three phases involved in the healing process of a full-thickness wound

Back 8

inflammatory, proliferative, and remodeling

Front 9

Inflammation stage of full-thickness wound

Back 9

is the body's reaction to wounding and begins within minutes of injury and lasts approximately 3 days.

Front 10

Proliferative stage of full-thickness wound

Back 10

begins and lasts 3 to 24 days. The main activities during this phase are the filling of the wound with granulation tissue, contraciton of the wound, and the resurfacing of the wound by epithelialization.

Front 11

Remodeling stage of full-thickness wound

Back 11

Maturation, the final stage of healing may take place for more than a year, depending on the depth and extent of the wound.

Front 12

A healed wound usually does not have the ___ ___ of the tissue it replaces

Back 12

tensile strength

Front 13

hematoma

Back 13

is a localized collection of blood underneath the tissues.

Front 14

How does a hematoma appear?

Back 14

swelling, change in color, sensation, or warmth or mass that often takes on a bluish discoloration.

Front 15

Role of Selected Nutrients in Wound Healing

Back 15

Calories, Protein, Vitamin C (ascorbic acid), Vitamin A, Vitamin E, Zinc, Fluid

Front 16

Calories role in healing

Back 16

fuel for cell energy "protein protection"

Front 17

Protein role in healing

Back 17

Neogenesis, collagen formation, wound remodeling

Front 18

Vitamin C (ascorbic acid) role in healing

Back 18

Collagen synthesis, capillary wall integrity, fibroblast function

Front 19

Vitamin A role in healing

Back 19

Epithelialization, wound closure

Front 20

Vitamin E role in healing

Back 20

No known role in wound healing

Front 21

Zinc role in healing

Back 21

Collagen formation and protein synthesis

Front 22

Fluid role in healing

Back 22

essential fluid environment for all cell function

Front 23

Recommendation for calories in wound healing

Back 23

30-35 kcal/kg/day, or enough to maintain positive nitrogen balance

Front 24

Recommendation for Protein in wound healing

Back 24

1.25-1.50 g/kg/day, or enoughto maintain positive nitrogen balance

Front 25

Recommendation for Vitamin C (ascorbic acid) for wound healing

Back 25

RDA=60 mg. Supplement if deficient 500mg big. Need long time to develop clinical scurvy from vitamin C deficiency. Low toxicity

Front 26

Recommendation for Vitamin A for wound healing

Back 26

RDA=4000 international units. Supplement if deficient. 20,000 units X 10 days

Front 27

Vitamin A role in wound healing

Back 27

Epithelialization, wound closure. Can reverse steroid effects on skin and delayed healing

Front 28

Recommendation for Vitamin E for wound healing

Back 28

None

Front 29

Recommendation for Zinc for wound healing

Back 29

RDA=12-15 mg. Correct deficiencies. No improvement in wound healing with supplementation unless zinc deficient. Use with caution-large doses can be toxic. May inhibit copper metabolism and impair immune function.

Front 30

Recommendation for fluid for wound healing

Back 30

30-35 ml/kg/day. Increase by another 10-15 ml/kg if client is on an air-fluidized bed

Front 31

When doing an skin assessment, who is responsible and who should not be delegated to perform?

Back 31

nurse; assistive personnel

Front 32

Critical thinking model for skin integrity and wound care assessment: assessment

Back 32

(1)identify the client's risk for developing impaired skin integrity, (2)identify S/S associated with impaired skin integrity or poor wound healing, (3)Examine client's skin for actual impairment in skin integrity

Front 33

Critical thinking model for skin integrity and wound care assessment: Experience

Back 33

(1)Caring for clients with impaired skin integrity or wounds, (2)Observation of normal wound healing

Front 34

Critical thinking model for skin integrity and wound care assessment: Attitudes

Back 34

(1)Use discipline to obtain complete and correct assessment data regarding client's skin and/or wound integrity, (2)Demonstrate responsibility for collecting appropriate specimens for diagnostic and lab tests related to wound management

Front 35

Critical thinking model for skin integrity and wound care assessment: Knowledge

Back 35

(1)Pathogenesis fo pressure ulcers, (2)Factors contributing to pressure ulcer formation or poor wound healing, (3)Factors contributing to wound healing, (4)Impact of underlying disease process on skin integrity, (5)Impact of medication on skin integrity and wound healing

Front 36

Critical thinking model for skin integrity and wound care assessment: Standards

Back 36

(1)Apply intellectual standards of accuracy, relevance, completeness, and precision when obtaining health history regarding skin integrity and wound management, (2)Knowledge of AHCPR standards for prevention of pressure ulcers, (3)Knowledge of standards of wound care management from Wound and Ostomy Care Nurses (WOCN)

Front 37

Because pressure ulcers have multiple etiological factors, assessment for pressure ulcer risk includes several important factors. What are they?

Back 37

Using an appropriate predictive measure and assessing the client's mobility, nutrition, presence of body fluids, and comfort level

Front 38

Some nursing diagnosis associated with impaired skin integrity and wounds

Back 38

Risk for infection; imbalanced nutrition: less than body requirement; Acute or chronic pain; Impaired physical mobility; Impaired skin integrity; Risk for impaired skin integrity; Ineffective tissue perfusion; Impaired tissue integrity

Front 39

Goals frequently identified when working with a client with a wound improvement within a 2 week period.

Back 39

(1)Higher percentage of granualtion tissue in the wound base, (2)No further skin breakdown in any body location, (3)An increase in the caloric intake by 10%

Front 40

Other goals of care for clients with wounds include the following:

Back 40

Promoting wound hemostatis; Preventing infection; Promoting wound healing; Maintaining skin integrity; Gaining comfort; and Health promotion

Front 41

Three major areas of nursing interventions for prevention of pressure ulcers are:

Back 41

(1)skin care, which includes hygiene and skin care; (2)mechanical loading and support devices, which include proper positioning and the use of therapeutic surfaces; and (3)education

Front 42

___ and ___ are two initial defenses for preventing skin breakdown

Back 42

Assessment and skin hygiene

Front 43

A Quick Guide to Pressure Ulcer Prevention: Decreased sensory perception: Nursing Intervention

Back 43

Assess pressure points for signs of nonblanching reactive hypermia. Provide pressure reduction or relief surface.

Front 44

A Quick Guide to Pressure Ulcer Prevention: Moisture: Nursing Intervention

Back 44

Assess need for incontinence management. Following each incontinence episode, cleanse area with no-rinse perineal cleanser and protect skin with a moisture barrier ointment.

Front 45

A Quick Guide to Pressure Ulcer Prevention: Friction and shear: Nursing Intervention

Back 45

Reposition client using a drawsheet and lifing off of surface. Provide a trapeze to facilitate movement.

Front 46

A Quick Guide to Pressure Ulcer Prevention: Decreased activity/mobility: Nursing Intervention

Back 46

Establish and post individualized turning schedule. Position client at a 30-degree lateral turn and limit head elevation to 30 degrees.

Front 47

A Quick Guide to Pressure Ulcer Prevention: Poor Nutrition: Nursing Intervention

Back 47

Provide adequate nutritional and fluid intake; assist with intake as necessary. Consult dietitian for nutritional evaluation.

Front 48

Elvating the head of the bed to what will decrease the chance of pressure ulcer development from shearing force?

Back 48

30 degrees or less

Front 49

What position is recommended in teh AHCPR guidelines for positioning to protect bony prominence?

Back 49

30-degree lateral

Front 50

A client at risk for skin breakdown in a sitting position should be taught to what?

Back 50

shift weight every 15 minutes.

Front 51

What should a client sit on to redistribute weight away from the ischial areas?

Back 51

foam, gel or an air cushion

Front 52

Pressure relieving device

Back 52

relieves the interface pressure (the pressure between the body and the support surface) below 32 mm Hg (capillary closing pressure).

Front 53

Pressure reducing devices

Back 53

reduce the interface pressure, but not necessarily below the capillary closing pressure

Front 54

The Support Surface Consensus Panel identified three purposes fo support surfaces:

Back 54

comfort, postural control, and pressure management

Front 55

The Support Surface Consensus Panel identified nine parameters to use when evaluating support surfaces and their relationship to each of the three purposes:

Back 55

life expectancy, skin moisture control, skin temperature control, redistribution of pressure, product service requirements, fall safety, infection control, flammability, and client-product friction

Front 56

Methods of debridement are what?

Back 56

mechanical, autolytic, chemical, and sharp/surgical