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Skin & wound care
MCC fall10 block 1 kozier ch 36
| Question | Answer |
|---|---|
| List the 5 factors that affect skin integrity... | 1. genetics/heredity, 2. age, 3. chronic illness/treatment, 4. medications, 5. poor nutrition |
| The types of clients who are at risk for pressure ulcers are... | those who are at an advanced age, immobile, have diminished sensations, excessive body heat, poor nutrition, incontinence, & decreased mental status |
| Pressure ulcers come in how many stages? | 4 Stages |
| Describe a Stage 1 pressure ulcer: | A nonblachable erythema signaling potential ulceration. |
| Describe a Stage 2 pressure ulcer: | Partial-thickness skin loss involving epidermis and possibly dermis. |
| Describe a Stage 3 pressure ulcer: | Full-thickness skin loss involving damage or necrosis of subcutaneous tissue |
| Describe a Stage 4 pressure ulcer: | Full-thickness skin loss with tissue necrosis or damage to muscle, bone or supporting structures |
| External causes of pressure ulcers | Friction/shearing, poor lifting/transfering, incorrect positioning, hard support surfaces, & incorrect application of pressure-relieving devices. |
| Name four ways to prevent pressure ulcers. | 1. Provide proper nutrition, 2. maintain skin hygiene, 3. avoid skin trauma, 4. provide supportive devices |
| Descibe Primary wound healing characteristics | The tissue surface is closed, there is minimal or no tissue loss, and there is formulation of granulation and scarring. |
| Describe Secondary wound healing characteristics. | There is extensive tissue loss, the edges can not be closed, the repair time is longer, the scarring is greater, and there is a higher susceptibility to infection |
| Describe Tertiary wound healing characteristics. | The wound is initially left open, edema, infection, or exudate resolves and then the wound is closed. |
| Identify the three major types of exudate. | Serous, Purulent, Sanguineous (hemorrhagic) |
| What are the characteristics of Serous exudate? | Serous exudate is mostly serum, watery and clear of cells (like fluid in a blister) |
| What are the characteristics of Purulent exudate? | Purulent exudate is thicker, has pus, odor and color (can be blue, green, or yellow) |
| What are the characteristics of Sanguineous exudate? | Sanguineous exudate is hemorrhagic (bloody), has a lrge # of RBC's and indicative of severe capillary damage. |
| What are the complications associated with would healing? | Hemorrhage, infections, dehiscence (partial or rupturing of a wound), and evisceration (protrusion of internal viscera through and incision). |
| List four factors that affect wound healing. | 1. age, 2. nutrition, 3. lifestyle, 4. medications. |
| Identify assessment data for untreated wounds. | Check location, extent of tissue damage, wound LxWxD, bleeding, foreign bodies, any associated injuries, and last tenus shot. |
| Identify assessment data for treated wounds. | check appearance, size (LxWxD), drainage, presence of swelling, pain level, and status of drains/tubes. |
| Name the three phases of wound healing. | 1. Inflammatory, 2. Proliferative, 3. Maturation |
| Describe the Inflammatory Phase of wound healing. | Immediately after injury, lasts 3-6 days, two major process occur during this phase: hemostasis (cessation of bleeding), phagocytosis (pac-man cells move into engulf cellular debris) |
| Describe the Proliferative Phase of wound healing. | Occurs post injury on day 3/4 to 21. Collagen synthesis begins (whiteish chunky protein in wound) and granulation (beefy red) tissue forms. |
| Describe the Maturation Phase of wound healing | Occurs around day 21 until 1/2 years post injury. Collagen is structured/organized (not blotchy) and the wound is remodeled and contracted. Scarring is formed. |
| RYB color guide to wound care means: | R (red) = Protect: Y (yellow) = Cleanse; B (black) = Debride. |
| Desribe ways to promote wound healing and prevent complications. | Increase fluid intake, monitor zinc, protein, and vitamins, get dietary consult (supplements) monitor weight/lab values, prevent microorganisms, and transmission of pathogens. |
| List some types of wound dressings; | Transparent film (protection), impregnated non-adherent (cover wounds w/o exudate), hydrocolloids (absorbs), clear absorbant acryllic (bacterial/shearing protection), hydrogel (liquiefy naecrotic) , polyurethane foam (absorb), alginate (ordor absorbing) |
| List the types of bandages | Gauze, elasticized, and binders (girdles) |
| Gauze bandage is used for... | Retain dressings on wounds, and bandage hands and feet |
| Elasticisized bandage is used for... | To provide pressure to an area, and improve venous circulation in legs |
| Binders are used for... | The support of large areas of the body. Ex: Girdle and triangular arm sling. |
| What are the indications for using a HEAT? | Muscle spasm, inflammation, pain, contracture, joint stiffness |
| What are the effects of using HEAT? | Vasodilation, increase capillary permeability, increase cellular metabolism, increase inflammation, produces sedative effect |
| What are the indications for using COLD? | Muscle spasms, inflammation, pain, traumatic injury. |
| What are the effects of using COLD? | Vasoconstriction, decrease in capillary permeability, decrease in cellular metabolism, slows bacterial growth, and decreases inflamation. Has a local anesthetic effect |
| Cold application ranges: Celcius | very cold 15* for ice bags. Cold 15-18* for cold packs. Cool 18-27* for cold compress. |
| Heat application ranges: Celcius | Tepid 27-37* for alcohol sponge bath, Warm 37-40* for warm bath/aquathermia pads, Hot 40-46* for hot soak/compress/irrigation, Very hot 46* above for hot water bags for adults |
| Viral skin infections | Herpes Zoster and Herpes Simplex |
| Herpes zoster is | an infection caused by varicella zoster virus "shingles" |
| Herpes simplex | Type 1 is typically occurs in the mouth. Type 2 typically occurs on the genitals. |
| Tinea type infections are what type? bacterial or fungal? | Fungal (Myotic) Infections |
| Tinea Pedis is | athletes foot |
| Tinea Corporis is | Ringworm of the body |
| Tinea Capitis is | Ringworm of the scalp |
| Tinea Cruris | Ringworm of the groin |
| Pediculosis is | Infestation with lice |
| When you are infected with the itch mite Sarcoptes scabiei you have... | Scabies |
| Chronic Venous Insufficiency (CVI) is when.. | you have inadequate venous return (venous blood travels up to the heart from the LE) over a prolonged epriod of time. |
| An increases in venous pressure equals | impaired arterial circulation |
| A decrease in O2 and nutrients means | cellular death |
| What is happening when a patient exhibits hard, shiny skin? | skin atrophies and the subq fat deposits become necrotic |
| When RBC's begin to breakdown skin starts to look ... | brown and ulcers start to develop |
| PVD stands for | Peripheral Vascular Disease |
| Signs of PVD | Brown/purple discoloration around ankles. Persons prone for DVT (Deep Vein Thrombosis) |
| Signs of Venous Ulcers with CVI | Located over medial or interior ankle, superficial (pink color), skin has a brown discoloration that turns cyanotic when on it, normal skin temp, usually edematous, mild/aching pain, normal pulses |
| Signs of Arterial Ulcers with CVI | Located over toes, feet, shin, ulcer is deep and pale, skin remains pale colored when elevated & turns red when walking, skin is cool to touch, none/little edema, severe/constant pain, may get infected (gangrene), pulses are decreased/absent |
| Patient Education for CVI | Elevate legs, Walk/avoid long periods of sitting/standing, No leg cross, no restrictive clothes, TED hose when prescribed, keep skin clean/soft/dry, prevent injury & inspect daily |
| Medical care for Stasis Ulcers includes... | NS wet/moist gauze dressings, possible diluted topical antibiotic, Unna boot (Semirigid) padded bony parts, changed 1/2weeks, hyperbaric chamber, surgery for large non healing areas |
| Common types of venous insufficiency include... | Deep Vein Thrombosis, Vericose Veins, Stasis Dermatitis and Ulcer |
| List the six types of wounds | 1. Incision, 2. Contusion, 3. Abrasion, 4. Puncture, 5. Laceration, 6. Penetrating wound |
| An incision is | an open wound; deep or shallow, caused by a sharp instument, knife/scalpel |
| A contusion is | a closed wound, skin appears bruised (ecchymotic) due to damaged blood vessels, caused by a blow from blunt instrument |
| An abrasion is | an open wound involving the skin caused by a surface scrape (scrapped knee) unintentional (dermal abrasion to remove pockmarks on face (intentional) |
| A puncture is | and open wound, penetration of the skin and underlying tissue caused by a sharp instrument |
| A laceration is | open wound with jagged edges due to tissue being torn apart usually from accidents (machinery) |
| A penetrating wound is | an open wound that usually penetrates the skin and underlying tissue and is usually unintentional (a shooting) |
| What is ischemia? | a deficiency in the blood supply to the tissue. |
| What is maceration? | issue softened by prolonged wetting or soaking. Incontinence can cause this. |
| What is excoriation? | the loss of the superficial layers of the skin AKA: DENUDED |
| what is hemostasis? | the cessation of bleeding. Hemostasis is when bleeding is halted to an injured blood vessel (vasoconstiction) so that cellular repair can begin. |
| What is a Keloid? | A type of raised scar formed from too much fibrin/collagen being deposited into the wound. It usually goes beyond the original wound borders. |
| What is a hemotoma? | A bruise. Collection of blood underneath the skin. |
| The partial or total rupturing of a sutured wound is called... | dehiscence. |
| The protrusion of the internal viscera through an incision is called.. | evisceration. When the inside of a wound is popping out. |
| What is debridement? | When you remove dead tissue/necrotic nonviable tissue from a wound. |
| NANDA Diagnosis: "Risk for Impaired Skin integrity" relates to | At risk for skin being adversely infected |
| NANDA Diagsosis: "Impaired Skin Integrity" relates to | Altered epidermis and/or dermis. Applies to pressure ulcers and to wounds extending through the epidermis but not through the dermis. |
| NANDA Diagnosis: "Impaired Tissue Integrity" relates to | Damage to mucous membranes, corneal, integumentary, or subcutaneous tissue. Applies to pressure ulcers and wounds extending to subq tissue, muscle, or bone |
| Teaching skin integrity. To maintain intact skin educate about | relatioship between adequate nutrition and healthy skin (protein, vitamins b/c, iron, hydration. Appropriate positions to relieve pressure, turn schedule, use of skin protection or applications, reporting of red areas, identify potential sources of trauma |
| Teaching skin integrity. To promote wound healing educate about | Nutrition (protein, vit b/c, iron, hydration. Instruct in wound assessment/documenttion, asepsis hand hygiene, s/s of wound infection to report, prevention, demonstrate wound care techniques, pain control |
Created by:
lucky duck
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