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Skin/Wound P&P
Potter and Perry 7th Edition Chapter 48
Question | Answer |
---|---|
Skin General Info. | Largest organ, 15% of total body weight, and synthesizes Vit. D. |
Skin how many layers and names? | 2; Epidermis and dermis. |
Layer separating the Epi/dermis? | Dermal-epidermal junction. |
Stratum corneum, location and importance? | Outermost layer of skin, location where skin cells flatten and die. Protection layer from dehydration and germs. |
Dermis, mostly consists of what? | Connective tissue and very few skin cells. |
Dermis, important functions? | Tensile strength, mechanical support, and protection of underlying tissues. |
In what layer of skin are blood vessels and nerves located? | Dermis. |
Collagen, location and origin? | Located in the dermis and originates from fibroblasts. |
Pressure ulcer define. | Localized injury to the skin and other underlying tissue as a result of pressure or pressure in combination with shear or friction. |
RF for pressure ulcers? | Decreased mobility, sensory perception, fecal/urinary incontinence, poor nutrition. |
Pressure ulcer general info. | Location of tissue injury/death due to decreased circulation. |
Three factors of pressure ulcers? | Intensity, duration, and tissue tolerance. |
Pressure Intensity, increase damage levels? | If reddened areas blanches, transient "blanching hyperemia" If area does not blanch, deep tissue damage possible. |
Signs of cellular damage in dark skinned people | Page 1281 - Box 48-2 |
Pressure duration, which is worse... low pressure over long periods of time, or high pressure over a short period? | Both are equally damaging. |
3 factors related to tissue tolerance? | Shear, friction, and moisture. |
Other factors related to tissue tolerance? | Integrity of underlying structures, nutrition, age, low BP. |
Shear define. | Force exerted parallel to skin resulting from both gravity pushing down on the body and resistance. |
What layer of skin does shearing affect? | Deep tissue layers. |
Friction define? | Force of two surfaces moving across one another such as carpet burn. |
What layers of skin does friction affect? | Epidermis. |
Moisture, how does it increase risk of ulcers? | Moisture softens skin undermining its protective properties. |
In a four-stage classification system, what level would a Stage III ulcer be as it heals? | Healing stage III pressure ulcer. |
Describe Stage I of a PU. | Intact skin, nonblanching. |
Describe Stage II of a PU. | Partial-thickness skin loss, Superficial ulcer such as abrasion, blister, or shallow crater. |
Describe Stage III of a PU. | Full-thickness tissue loss, subcutaneous fat possible visible, no bone, tendon, muscle exposed, may include undermining or tunneling. |
Describe Stage IV of PU. | Full-thickness tissue loss, exposed bone, tendon, muscle, often includes undermining and tunneling. |
Describe an "unstageable" ulcer. | Full-thickness tissue loss, base is covered by slough and/or eschar in the wound bed. |
What is best lighting to assess dark skin tones and why? | Natural or halogen, fluorescent light causes blue tones in some darker pigmented skin. |
After staging, what is next step in intervention? | Determining viable tissue in wound base. |
Assessment of viable/nonviable tissue includes what 2 measurements? | Amount (percentage) and appearance (color) of each type of tissue. |
What is a sign of healing of a wound? | Granulation tissue. |
What is granulation tissue? | Red, moist tissue composed of new blood vessels. |
What does slough look like? | Stringy substance attached to wound bed. |
What is eschar? | Black or brown necrotic tissue. |
Wound define. | Disruption of the integrity and function of tissues in the body. |
"All wounds are not created equally" true or false? | True. |
What 5 factors should be included in a wound classification? | Skin integrity, cause of the wound, severity, cleanliness of the wound, and descriptive qualities. |
What are the 2 types of wounds? | Tissue loss and non-tissue loss. |
What are the 2 types of healing and examples? | Primary intention such as surgical wounds that are sutured. Secondary intentions such as burns or ulcers that are left open to heal. |
What causes a difference in wound repair? | The epidermis regenerates, but damage done to deeper level tissues would only heal via scarring because they do NOT regenerate. |
Healing process of partial-thickness wounds involves which 3 components? | Inflammatory, epithelial proliferation and migration, and reestablishment of the epidermis. |
Should a wound be kept moist or dry in order for it to heal faster and why? | Moist, epithelial cells can only move across moist surfaces so it would take longer if the wound is dry. |
What are the 3 components of full-thickness wound repair? | Inflammation, proliferation, and remodeling. |
What is the process in which blood vessels constrict and platelets coagulate to stop blood flow? | Hemostasis. |
What clots together to form later framework for cellular repair? | Fibrin. |
What is the primary acting leukocyte? | Neutrophil. |
What is the role of a monocyte? | Transforms into a macrophage and cleans wound of dead cells and debris. |
What is the main component in scar tissue? | Collagen. |
What are the 3 stages of the proliferation stage of full-thickness wounds repair. | Vascular bed is reestablished, area filled with new tissue, and surface is repaired. |
What occurs during the remodeling stage of wound healing? | Collagen continuously reorganizes to gain strength before assuming its final appearance. |
When should hemorrhaging stop? | After hemostasis occurs, which is within several minutes unless a large vessel is included or poor clotting function. |
How do you know if there is internal hemorrhaging? | Swelling, change in drainage, color, sensation, warm, mass, or hypovolemic shock. |
What is the 2nd most common nosocomial infections? | Wound infections. |
What defines infected? | If purulent discharge is noted, regardless if a culture is taken. |
How many organisms/gram would indicate infection? | 100,000 or 10^5 |
What are signs of infection other than discharge? | Fever, tenderness, pain, and an elevated WBC count. |
What is dehiscence and who is at risk? | Partial or total separation of wound layers; Poor wound healers and obese. |
What is evisceration and what should be done? | Total separation of wound layers in which protrusion of visceral organs may occur; sterile towels soaked in saline should be applied over organs. Surgery is required. |
What is a fistula and what are some RFs? | Abnormal passage between 2 organs or between an organ and the outside of the body; Crohn's disease, trauma, infection, radiation exposure, or cancer. |
Norton scale consist of how many risk factors and what are they? | 5; physical condition, mental condition, activity, mobility, and incontinence. |
Which is a better score on the Norton scale? | Higher the better max score of 20. |
Braden scale is composed of how many subscales and what are they? | 6; sensory perception, moisture, activity, mobility, nutrition, and friction/shear. |
Which is better on a Braden scale: a score of 6 or 23? | 23 is the better score and the best possible. |
What is the cutoff score for Braden scale for the risk of ulcers in adults? | 18. |
Which scale is most commonly used to assess risk for pressure ulcers? | Braden |
How many calories does a well nourished adult need to maintain well-being? | 1500 kcal/day. |
What are some specific nutrients needed in wound healing? | Protein, Vit. A and C, Zinc, and Copper. |
What are serum proteins? | Biochemical indicators of malnutrition. |
What is the best measure of malnutrition and why? | Prealbumin because it reflect what has been ingested, absorbed, digested, and metabolized. |
What fuels the cellular functions essential to healing? | Oxygen perfusion. |
When you suspect abnormal reactive hyperemia what should you do and why? | Mark it with a marker so you can reassess it later to see if there are changes. |
What should be performed upon admission into a care facility? | Systematic pressure ulcer risk assessment tool such as Braden or Norton scales. |
What acidic bodily fluids are the lowest risk for PU? | Silava and serosanguineous drainage. |
What acidic bodily fluids are in the moderate range of risk for PU and higher risk for infection? | Urine, bile, stool, ascitic fluid, and purulent would exudates. |
What acidic bodily fluids carry the highest risk for tissue breakdown? | Gastric and pancreatic drainage. |
When are 2 times that wounds are generally assessed? | At initial time of injury before treatment and after treatment. |
A superficial wound with little bleeding and partial-thickness tissue loss is what? | An abrasion. |
How deep does a laceration go before it causes serious bleeding? | Approx. 5 cm or 2 inches long and 2.5 cm or 1 inch deep. |
What are the primary dangers of puncture wounds? | Internal bleeding and infection. |
What is the first thing to assess when looking at a wound? | Foreign bodies or contaminant materials. |
What is the second step in assessing a wound after checking for foreign materials? | Size and depth. |
A wound involving a dirty penetrating object, what should be considered next? | When last tetanus shot was; if not in previous 5 years, one is necessary. |
If a patient has a covered wound and you are assessing it, but the Dr. has not ordered it changed... what should you do? | Assess only things you can see without removing the dressings. |
While changing dressings, what are some things you should do? | Give analgesic 30 mins prior and be careful of drains. |
Crust along an incision site would indicate what? | Normal healing. |
If a brownish or yellow color is noted around a healing wound, what would this indicate? | A fading bruise (hematoma) |
How would you measure the amount of drainage in a dressing? | Measure the dressing while clean and dry and compare the dressing after it has been soiled... weigh them. |
What holds a penrose drain in place to prevent it from sliding further into the wound? | A pin or clip. |
What is the "gold standard" of wound cultures? | Tissue biopsy. |
Why is it important to know a client's expectations as far as wound care is concerned? | Realistic goals/expectations help clients in adhering to the specific treatments and preventions. |
List of ND associated with wound/impaired skin integrity. | Risk for infection, Imbalanced nutrition: less than requirements, Acute or chronic pain, Impaired physical mobility, Risk/Impaired skin integrity, Ineffective tissue perfusion, Impaired tissue integrity. |
How can a concept map help with individualizing a client's care? | Assists when multiple health concerns are considered and which NI are the best approaches for the given circumstances. |
What is a common time frame for wound improvement? | 2-week period. |
What are some possible goals for short term wound care? | Higher % of granulation tissue, no further tissue breakdown, increase caloric intake, preventing infection, gaining comfort, promoting wound hemostasis. |
If a client has a chronic wound, which is more important the wound or other influential factors such as hygiene and diet? | Hygiene and diet are more important if the wound is stable. |
What is more important in an acute wound, the wound or influential factors such as hygiene and diet? | The wound is most important if it is acute and unstable. Other factors need to be considered only after the wound has been stabilized. |
What are the most effective interventions for problems involving skin integrity? | Prevention and prompt identification. |
3 major NIs for prevention of PU are? | Skin care, mechanical loading and support devices, and patient education. |
When bathing high risk PU clients, which all should you use: hot or warm water, soap, nonionic surfactants, lotion? | Avoid hot water and soap... use warm water, nonionic solutions, and lotion. |
What is a "moisture barrier" used for and when? | It protects the skin against excess moisture usually from bowel/urinary incontinence. |
Where should the bed be set at to avoid shearing and decreasing PU? | 30 deg or less. |
Clients should be moved every how many hours? | 2 or less depending on how active they are. |
What are some ways to avoid PU during sitting? | No longer than 2 hrs generally, shift every 15 minutes, sit on foam, gel, or air cushions. |
Would a rigid or donut cushion be good or bad for a high risk PU client and why? | Bad because they can restrict blood flow. |
Would massage be good or bad for tissue ichemia and why? | Bad because it can cause further capillary damage which can increase the damage to the tissue. |
Acute wound require more monitoring than a stable chronic wound, how often must an acute wound be checked? | At least every 8 hrs. |
What evaluation tool would you use to evaluation whether wound care is effective? | Pressure Ulcer Status Tool (PSST) which addresses 15 wound characteristics. |
What is the main goal of effect wound management? | Maintenance of a physiological local wound environment. |
What would you use to cleanse a wound? | Saline water or a noncytotoxic wound cleanser such as Dakin's solution (sodium hypochlorite solution), acetic acid, povidone-iodine, and hydrogen peroxide. |
Why is selecting the correct wound cleanser important? | You do not want to use anything that will damage or kill fibroblasts or the healing tissue, but will remove harmful bacteria and debris/ nonviable tissue. |
What is a good way to deliver irrigation and at what pressure will it be? | 19-gauge needle or an angiocatheter with a 35-mL syringe at a pressure of 8 psi (per square inch) |
Why should necrotic tissue be removed from a wound bed? | To remove a source of bacteria, clearly see the wound bed, and to provide a clean base to build healthy new tissue. |
Where should necrotic tissue not be removed in certain situations? | On heels of feet. |
Why should necrotic tissue not be removed from the heels of feet? | Stable, dry, black eschar on heels should not be debrided if it is non-tender, nonfluctuant, nonerythematous, and non supportive. |
What should be observed during wound care to determine possible infection? | Exudate amounts, color, odor, and wound size. |
What are the 4 types of debridement? | Mechanical, autolytic, chemical, and sharp/surgical. |
What would the "wet gauze" debridement technique be considered? | Mechanical. |
Why would "wet gauze" debridement not be used? | It is nonselective and may pulled healthy tissue as well as nonviable tissue from wound. |
When should "wet gauze" never be used? | In a wound with granulation tissue present. |
What are other mechanical techniques to use? | Irrigation and whirlpool treatments. |
What is autolytic debridement? | Use of bandages that will allow eschar to be digested via wound fluids already present. |
Should moisture be added or removed from autolytic techniques and why? | Added when the wound bed is dry and removed when exudate is excessive. |
What are some examples of autolytic dressings? | Use of transparent film dressings and hydrocolloid dressings. |
Why is excess exudate an issue to would healing? | Excess moisture presents a prime environment for the growth of bacteria in an excess to what the body can normally fight against. |
What are some examples of chemical debridement? | Dakin's solution, enzyme preparations, and sterile maggots. |
What are some examples of surgical debridement? | Use of scalpels, sissors, or other sharp instruments. |
What is a key to supporting a wound as it heals? | Continuous reassessment of the wound and change as it progresses through healing stages. |
When does the Joint Commission recommend a nutritional assessment be performed? | Within 24 hrs of admission. |
What is the recommended protein intake for an adult? | 0.8 g/kg/day. |
How much protein is recommended for an adult healing from a wound? | 1.8 g/kg/day. |
What should hemoglobin levels be? | 12 g/100 mL if possible. |
When should pressure dressings be used for a wound? | The first 24 to 48 hrs. |
When should bleeding NOT be stopped and why? | A puncture wound, so the blood can wash out any contaminates. |
If a client has been stabbed, should the knife be removed, why, and what should be done? | No, because the knife provides a source of pressure to control bleeding... pressure should be apply to the surrounding area. |
Should you place a dressing over a wound that is still bleeding and why? | Yes, it protects the wound from bacteria until the client can be evaluated at a hospital. |
When are dressing usually removed from a wound that is healing from primary intention? | As soon as drainage stops. |
What is a PRIMARY function of wound dressings? | Drainage absorption. |
If a dressing dries to a wound how should it be removed? | Apply saline solution to loosen the dressing to prevent damage to fragile new tissues. |
What type of dressing should be used to keep a wound moist as well as wick moisture away? | Gauze sponges. |
What should be used on a wound with little to no exudate? | Nonadherent gauze dressing such as Telfa. |
What dressing should be used to trap a wound's fluids over the wound to hold in moisture as a secondary dressing? | Self-adhesive transparent film. |
What type of dressing can absorb drainage, seal in moisture, and protect the wound at the same time? | Hydrocolloid dressings. |
What type of dressing is good for burns, necrotic wounds, and radiation damaged skin because it is soothing to the client? | Hydrogel dressings. |
What is a complication that "dead space" can cause? | Wound debris can accumulate in the dead space and cause detrimental occurrences. |
VAC techniques should be read... | Pages 1319 and on... |
VAC Instill is different from VAC/NPWT why? | It intermittently "instills" fluids into the wound, which is especially helpful for wounds that don't respond to normal VAC techniques. |
Other than wounds, when would NPWT be used? | Split-thickness skin grafts. |
How should tape be properly applied? | Ensure that it is adhered to several inches of skin on each side of dressing, press the tape away from the wound. |
How should sutures be removed? | Cut the end farthest from the knot generally and pull the suture out without pulling the outer portion through the underlying skin. |
What are drainage evacuators and why do they help in healing? | Low pressure vacuum that remove and collect drainage. Promotes healing environment by removing excess fluid that can cause bacteria growth. |
Where should a piece of cloth be tied if using it as a sling? | To the side of the neck to avoid pressure on the cervical spine. |
When is heat contraindicated? | When localized inflammation is present, bleeding, or cardiovascular problems. |
When is cold contraindicated? | If the area is already has edema, neuropathy, also if the client is shivering prior to using cold packs. |
Before use of heat/cold therapies, what should be done? | Assess the patient for conditions that should prohibit the use of heat/cold and assess the condition of the equipment b/c the nurse is legally responsible for the results of these. |
What affects does heat cause that could be helpful? | If less than 1 hr, causes vasodilation. Removal and reapplication is needed to continue dilation. |
What affects does cold cause that could be helpful? | Diminishes swelling and pain, vasodilation. |
When should warm, moist, compresses be used and why? | Open wounds; improves circulation, relieves edema, promotes consolidation of pus and drainage. |
Tips for properly applied heat compresses. | Warm compresses can have heating pad on it on LOW setting, Dry can have higher settings... Can use plastic or dry cloth to retain heat. |
What is a Sitz bath and what purpose does it serve? | Soak the pelvis area without soaking the lower extremities. It can be used for relief, cleansing, or medication application. |
What are aquathermia pads used for? | Used like heating pads, with hot water flowing through plastic pad. |
What are ranges for heating pad/water temperatures? | 40.5-43C or 105-110F |
What should cold pad/water temperatures be? | Approx 15C or 59F |
How long can an ice pack be applied for? | Up to 30 mins, can be reapplied after 1 hr. |