Fundamentals of Nursing Chapter 36

  1. What are the factors that affect wound care?
    • Genetics and heredity
    • Age (older = thinner skin)
    • Chronic illnesses and their treatments (impaired skin integrity)
    • Medications
    • Poor nutrition
  2. What are the risk factors for pressure ulcers?
    • 1. Friction (force such as sheets rubbing) and shearing (friction and pressure - sliding down in bed, deep tissue is effected)
    • 2. Immobility
    • 3. Inadequate nutrition (need protein, carbs, and vitamins)
    • 4. Fecal and urinary incontinence (sitting in chemicals)
    • 5. Decreased mental status
    • 6. Diminished sensation 
    • 7. Excessive body heat (Increases metabolic rate = increased need for O2)
    • 8. Advanced age (Dryness, decreased strength/elasticity, loss of body mass, thinning epidermis)
    • 9. Presence of certain chronic conditions (cardio vascular disease, diabetes, and delayed blood flow, etc.)
    • 10. Other factors such as:
    •  - Poor lifting and transferring techniques
    •  - Incorrect positioning
    •  - Hard support surfaces
    •  - Incorrect application of pressure-relieving devices
  3. What are the risk assessment tools that can be used to assess for pressure sores?
    • 1. Braden Scale for Predicting Pressure Sore Risk Assesses the following areas: Sensory perception, Moisture, Activity, Mobility, Nutrition, Friction and Shearing. (See pg. 924)
    • Total scoring means: 
    •  - a)19-23 Not at risk 
    •  - b)15-18 at risk 
    •  - c)13-14 moderate risk 
    •  - d)10-12 high risk 
    •  - e) 6-9 very high risk
    • 2. Norton's Pressure Area Risk Assessment Form Scale (see pg. 922)
  4. How many stages are there in the formation of a pressure ulcer and what are they?
    • Stage I: Nonblanchable erythema
    • Stage II: Partial-thickness loss
    • Stage III: Full-thickness loss
    • Stage IV: Full-thickness loss with tissue necrosis or damage to muscle, bone, or supporting structures
  5. What stage is this ulcer in and what is it called?
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    • Stage I
    • Nonblanchable erythema
    • (If you press down on your thumbs, they turn white. But, when you let go, they return to normal . . . THIS picture, is NOT normal)
  6. What stage is this ulcer in and what is it called?
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    • Stage II
    • Partial-thickness loss
    • (Break in the skin, with tiny blisters)
  7. What stage is this ulcer in and what is it called?
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    • Stage III
    • Full-thickness loss
    • (Deep crater, moving into the muscle = TISSUE DAMAGE)
  8. What stage is this ulcer in and what is it called?
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    • Stage IV
    • Full-thickness loss with tissue necrosis or damage to muscle, bone or supporting structures
  9. Describe what is happening in this stage of the pressure ulcer development.
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    Nonblanchable erythema signaling potential ulceration
  10. Describe what is happening in this stage of the pressure ulcer development.
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    Partial-thickness skin loss involving epidermis and possibly dermis
  11. Describe what is happening in this stage of the pressure ulcer development.
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    Full-thickness skin loss involving damage or necrosis of subcutaneous tissue.
  12. Describe what is happening in this stage of the pressure ulcer development.
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    Full-thickness skin loss with tissue necrosis or damage to muscle, bone, or supporting structures
  13. Describe primary intention healing
    • Tissue surfaces approximated (closed)
    • Minimal or not tissue loss
    • Formulation of minimal granulation tissue and scarring
  14. What type of intention healing is this?
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    • Primary Intention Healing with steri strips
    • (Healthcare provider has created this opening = surgical)
  15. Describe secondary intention healing
    • Extensive tissue loss
    • Edges cannot be approximated
    • Repair time is longer
    • Scarring is greater
    • Susceptibility to infection is greater
  16. What type of intention healing is this?
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    • Secondary Intention Healing
    • NOTE: Top picture has a drain in it (upper left side of the wound)
  17. Describe tertiary intention healing or delayed primary intention
    • Initially left open 3-5 days
    • Edema, infection to resolve, or exudate to drain
    • Then closed with sutures, staples, or adhesive skin closures
  18. What type of intention healing is this?
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    • Tertiary Intention Healing OR
    • Delayed Primary Intention
  19. What are the three types of intention healing?
    • 1. Primary
    • 2. Secondary
    • 3. Tertiary or Delayed Primary
  20. What are the three phases of wound healing?
    • 1. Inflammatory
    • 2. Proliferative
    • 3. Maturation
  21. Describe the Inflammatory Phase of wound healing
    • Immediately after injury (lasts 3-6 days)
    • Hemostasis
    • Phagocytosis
    • NOTE: The body is trying to figure out how to get back into balance
  22. Describe the Proliferative Phase of wound healing
    • From post injury day 3 or 4 until day 21
    • Collagen synthesis
    • Granulation tissue formation
    • NOTE: Proliferative means "to grow"
    • This is a very important part of wound healing
  23. Describe the Maturation Phase of wound healing
    • From day 21 until 1 or 2 years post injury
    • Collagen organization
    • Remodeling or contraction
    • Scar stronger
    • NOTE: Scar is stronger, but NEVER as strong as it was prior to the injury
  24. Define exudate
    • Material, such as fluid and cells, that have escaped from blood vessels during the inflammatory process
    • Deposited in the tissue or on the tissue surface
  25. What are the three major types of exudate?
    • 1. Serous
    • 2. Purulent
    • 3. Sanguineous (hemorrhagic)
  26. Describe serous exudate
    • Mostly serum
    • Derived from blood and serous membranes of the body
    • Looks watery, few cells
    • EXAMPLE: Fluid in a blister from a burn
  27. Describe purulent exudate
    • Thicker than serous exudate
    • Presence of pus
    • Color varies with causative organism
    • NOTE: Smells VERY bad!
  28. Describe sanguineous exudate
    • Large number of RBC's
    • Indicates severe damage to capillaries
    • Frequently seen in open wounds
    • NOTE: "FRANK" red blood
  29. What are the two type of mixed exudates?
    • 1. Serosanguineous
    • 2. Purosanguineous
  30. Describe serosanguineous exudate
    Clear and blood-tinged drainage
  31. Describe purosanguineous exudate
    Pus and blood
  32. What are some of the complications of wound healing?
    • Don't HIDE from the complications of wound healing.
    • Hemorrhage
    • Infection
    • Dehiscence
    • Evisceration
  33. What are some of the factors that affect wound healing?
    • Nutritional status: 1) Malnurished can take longer to heal 2) Obesity can take longer to heal, due to adepose tissue (increased risk of infection)
    • Age: Thinning skin
    • Medications: Antiinflamatory (steroids or aspirin) and antineoplasmy agents
    • Lifestyle: 1) Exercise = better circulation and better healing 2) Smokers = Reduce hmg. in blood which affects the amount of O2 flowing to the wounds and restricts arterials which reduces the flow of blood
  34. What is involved with the NURSING ASSESSMENT in regard to wound healing?
    • Nursing History
    • Inspection
    • Palpation
    • NOTE: Includes both treated and untreated wounds
  35. What is involved with the NURSING ASSESSMENT when taking the nursing history?
    • Review of systems
    • Skin diseases
    • Previous bruising
    • General skin condition
    • Skin lesions
    • Usual healing of sores
  36. What type of assessment data will you collect when inspecting and palpating a wound?
    • Skin color distribution
    • Skin turgor
    • Presence of edema
    • Characteristics of any skin lesions
    • Particular attention paid to areas that are most likely to break down (bony prominences)
  37. What type of assessment data will you collect on an untreated wound?
    • Location 
    • Extent of tissue damage
    • Wound length, width, and dpth
    • Bleeding
    • Foreign bodies
    • Associated injuries
    • Last tentanus toxoid injection
  38. What type of assessment data will you collect on an treated wound?
    • Appearance
    • Size
    • Deainage
    • Presence of swelling
    • Pain
    • Status of drains or tubes
  39. What is involved in the NURSING ASSESSMENT of a pressure ulcer (p. 928)?
    • Location of the ulcer related to a bony prominence
    • Size of ulcer in centimeters including length (head to toe), width (side to side), and depth
    • Presence of undermining or sinus tracts
    • Stage of the ulcer
    • Color of the wound bed
    • Location of necrosis or eschar 
    • Condition of the wound margins
    • Integrity of surrounding skin
    • Clinical signs of infection
  40. Define an eschar
    A dry, dark scab or falling away of dead skin (dark black beef jerky - unstageable)
  41. Define necrosis
    The death of most or all of the cells in an organ or tissue due to disease, injury, or failure of the blood supply
  42. What is the nurse doing in this picture?
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    • Measuring a wound
    •  - Length (head to toe)
    •  - Width (side to side)
    •  - Depth (sinus tract = hole or canal)
    • NOTE: Need to know if there are any tunnels, as these need to be filled with moist gauze, to assist with the healing process)
  43. Define the type of complications of wound healing these pictures depict.
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    • Dehiscence:  The release of materials by the splitting open of an organ or tissue.
    • Evisceration: To take out the entrails of (disembowel)
    • NOTE: Treat with a sterile soaked gauze and have the client bend their knees (to releave the pulling pressure on the wound)
  44. What is the nurse collecting in these pictures?
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    • Wound drainage specimen for culture
    • Swab, put into tube, and send to the lab
    • NOTE: This helps the physician determine the proper antibiotics to be used for the client
  45. What type of laboratory data would be collected from a wound specimen?
    • Leukocyte count
    • Hemoglobin level
    • Blood coagulation studies
    • Serum protein analysis (Albumin levels)
    • Results of wound culture and sensitivities
  46. What are some NURSING DIAGNOSES for skin integrity?
    • Risk for Impaired Skin Integrity
    • Impaired Skin Integrity
    • Impaired Tissue Integrity
    • Risk for Infection
    • Acute Pain
  47. What are some GOALS a nurse can set for a diagnoses of RISK for Impaired Skin Integrity?
    • Maintain skin integrity
    • Avoid potential associated risk factors
  48. What are some GOALS a nurse can set for a diagnoses of Impaired Skin Integrity?
    • Progressive wound healing
    • Regain intact skin
  49. What are some GOALS a nurse can set for teaching the client and family, when dealing with impaired skin integrity?
    • Assess and treat existing wound
    • Prevention of pressure ulcers
    • Maintaining intact skin
    • Adequate nutrition (eat well)
    • Appropriate postions for pressure relief
    • Establish a turning or repositioning schedule
    • Providing supportive devices
    • Instruct to report persistent reddened areas
    • Identify potential sources of skin trauma
    • NOTE: Patient's in wheel chairs ALL DAY are at great risk for pressure ulcers!)
  50. What are some NURSING INTERVENTIONS a nurse can take for Impaired Skin Integrity?
    • Support wound healing
    • Moist wound healing
    • Nurtrition and fluids
    • Preventing infection
    • Positioning
    • Preventing pressure ulcers
    • Providing nutrition
    • Maintaining skin hygiene
    • Avoiding skin trauma
    • Providing supportive devices
    • Treating pressure ulcers
  51. What steps can a nurse take to prevent pressure ulcers?
    • Conduct a pressure assessment for all clients
    • Reassess clients risk for all clients daily
  52. What steps can a nurse take to ensure proper nutrition for a client with impaired skin integrity?
    • Fluids
    • Protein, vitamins, and zinc
    • Registered dietician
    • Weight/lab data monitoring
  53. What can be done to maintain skin hygiene?
    • Minimize the force and friction
    • Mild cleansing agents
    • Avoid hot water
    • Moisturizing lotions/skin protection
    • Skin should be clean and dry
    • Free of irritation and maceration
  54. Define maceration
    Softening due to soaking or steeping
  55. What are some steps that can be taken to avoid skin trauma?
    • Smooth, firm, and wrinkle free foundation (smoothe out sheets!)
    • Semi-Fowler's position
    • Frequent shifts in position
    • Exercise and ambulation (get them up!!)
    • Lifing devices
    • Reposition q2hrs (usually the orders, MUST document turns!!! IF YOU DO NOT DOCUMENT IT, YOU DID NOT DO IT!)
    • Turning schedule
  56. What are the body pressure areas a nurse would need to be concerned about, if a patient is in the supine position?
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  57. What are the body pressure areas a nurse would need to be concerned about, if a patient is in the prone position?
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  58. What are the body pressure areas a nurse would need to be concerned about, if a patient is in the Fowler's position?
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  59. What are the body pressure areas a nurse would need to be concerned about, if a patient is in the lateral position?
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  60. What are some of the supportive devices that can be used, to prevent pressure ulcers?
    • Mattresses
    • Beds
    • Wedges, pillows
    • Miscellaneous devices
    • NOTE: These can be expensive, know your agency's policy!
  61. What is this device called?
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    Heel protector
  62. What type of bed is this?
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    Alternating pressure mattress
  63. What type of bed is this?
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    Low-air-loss bed
  64. What type of bed is this?
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    Low-air-loss and air-gluidized combo bed
  65. How do you treat a pressure ulcer?
    • Minimize direct pressure
    • Reposition the client at least q2hrs
    • Schedule and record position changes
    • Provide devices to minimize pressure areas
    • Clean and dress the ulcer using surgical asepsis
    • Obtain C & S, if infected
    • Teach the client to move frequently
    • Provide ROM exercise
    • Never use alcohol or hydrogen peroxide 
    • NOTE: We want the wound bed to be moist!
  66. The proper technique for performing a wound culture includes what?
    Cleansing the wound prior to obtaining the specimen
  67. A client has a pressure ulcer with a shallow, partial skin thickness, eroded area but no necrotic areas. The nurse would treat the area with which dressing?
    A hydrocolloid dressing, it protects the shallow ulcer and maintains a proper healing environment
  68. If a person cannot change positions in bed, on their own, how often do they need to be turned?
  69. How do you treat the following wounds, according to the  following colors:
    • Red: Protect it, it is granulating
    • Yellow: Cleanse it, it is infected
    • Black: Debride it, it needs to come off
  70. What are the two types of complications that you are trying to prevent from happening, by applying a wound dressing?
    • Entry of microorganisms
    • Transmission of pathogens
  71. List the various types of wound dressings?
    • 1. Transparent film
    • 2. Impregnated nonadherent
    • 3. Hydrocolloids
    • 4. Clear absorbent acrylic
    • 5. Hydrogel
    • 6. Polyurethane foam
    • 7. Algintes
    • 8. Collagen
    • NOTE: See the table on pg. 940 for chart with more info
  72. What is the goal of a dressing?
    To keep the wound bed moist
  73. If a dressing is too wet, what should you do?
    Dry it out
  74. If a dressing is too dry, what should you do?
    Moisten it
  75. What is this a picture of?
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    A vacuum-assisted  closure system
  76. What are these pictures of?
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    • Foam strips laid into the wound
    • Occlusive draping applied and suction tubing in place, the finished dressing will be suctioned closed, with negative pressure
  77. What is the purpose of cleansing a wound?
    • Removal of debris
    • EXAMPLE: ER = cement chunks, gun shots, etc.
  78. Cleaning agents and methods for wound cleaning depend on what?
    • Agency protocol
    • Primary care provider's preference
  79. What are the practice guidelines for wound cleaning?
    • 1. Follow standard precautions for personal protection. Wear gloves, gown, goggles, and mask as indicated.
    • 2. Use solutions such as isotonic saline or wound cleansers to clean or irrigate wounds. if antimicrobial solutions are used, make sure they are well diluted.
    • 3. Microwave heating of liquids to be used on the wound is not recommended. When possible, warm the solution to body temperature before use. (This prevents lowering hte wound temperature, which slows the healign process. microwave heating could cauase the solution to become too hot.)
    • 4. If a wound is grossly contaminated by foreign material, bacteria, clough, or necrotic tissue, clean the wound at every dressing change. (Foreign bodies and devitalized tissue act as a focus for infetion and can delay healing)
    • 5. If a wound is clean, has little exudate, and reveals healthy granulation tissue, avoid repeated cleaning. (Unnecessary cleaning can delay wound healing by traumatizing newly produced, delicate tissues, reducing the surface temperature of the wound, and removing exudate which itself may have bactericidal properties)
    • 6. Use gauze squares. Avoid using cotton balls and other products that shed fibers onto the wound surface. (The fibers become embedded in granulation tissue and can act as foci for infection. They may also stimulate "foreign body" reactions, prolonging the inflammatory phase of healing and delaying the healing process)
    • 7. Clean superficial noninfected wounds by irrigating them with normal saline. (The hydraulic pressure of an irrigating stream of fluid dislodges contaminating debris and reduces bacterial colonization)
    • 8. Avoid drying a wound after cleaning it (This helps retain wound moisture)
    • 9. Hold cleaning sponges with forceps or with a sterile gloved hand.
    • 10. Clean from the wound in an outward direction to avoid transferring organisms from the surrounding skin into the wound.
    • 11. Consider not cleaning the wound at all if it appears to be clean.
  80. How should this wound be cleaned?
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    • 1. Down the middle
    • 2. Down one side close to wound
    • 3. Down the other side close to the wound
    • 4. Down the outer side of the wound
    • 5. Down the other outer side of the wound
  81. What's the purpose of irrigating a wound?
    • To clean the area
    • To apply heat and hasten the healing process
    • To apply an antimicrobial solution
  82. After completing POWER and preparing the equipment how do you irrigate a wound?
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    • Apply clean gloves
    • Instill a steady stram of irrigating solution into the wound. Make sure all areas of hte wound are irrigated
    • Use either a syringe with a catheter to reach tracks or crevices, insert the catheter into the wound until reistance is met. Do not force the catheter. (Forcing the catheter can cause tissue damage)
    • Continue irrigating until the solution becomes clear (no exudate is present)
    • Dry the area around the wound (Moisture left onthe skin promotes the growth of microorganisms and can cause skin irritation and breakdown)
    • Remove and discard clean gloves. Perform hand hygiene
    • Assess and dress the wound (see step 7 of skill 36-2)
  83. Define what a bandage is
    A strip of cloth used to wrap some part of the body
  84. List a few different types of bandages
    • Gauze
    • Elasticized
  85. How can gauze bandages be used for wound care?
    • Retain dressings on wounds
    • Bandage fingers, hands, toes, and feet
  86. How can elexticized bandages be used for wound care?
    • Provide pressure to an area
    • Improve venous circulation in leg
  87. How do you start a bandage?
    • With two circular turns
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  88. What wrapping technique is being shown in this picture.
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    Spiral wrap
  89. What wrapping technique is shown in this series of picture?
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    Spiral Reverse Turns
  90. What type of bandage or wrapping technique is shown in these pictures?
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    Recurrent bandage
  91. What type of wrapping technique is shown in this picture?
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    Figure-eight bandage
  92. These pictures show the application of what type of bandage?
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    A triangle arm sling
  93. What type of sling is depicted in this picture?
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    A commercial arm sling
  94. What type of bandage does this picture show?
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    • Abdominal binder
    • Can be used after a surgery to keep the incision in tact
  95. What is the purpose of heat and cold applications?
    • Local effect
    • Systemic effect
  96. What are the local effects of applying heat?
    • Vasodilation
    • Increases capillary permeability
    • Increases cellular metabolism
    • Increases inflammation
    • Sedative effect
  97. What are some of the indications that would call for using heat?
    • Joint stiffness from arthritis
    • Contractures
    • Low back pain
  98. What are the local effects of applying cold?
    • Relaxes muscles and decreases muscle contractility
    • Vasocontriction
    • Decreases capillary permeability
    • Decreases cellular metabolism
    • Slows bacterial growth
    • Decreases inflammation
    • Decreaes pain by slowing nerve conduction rate and blocking nerve impulses
    • Local anesthetic effect, creating an increaased pain threshold
    • NOTE: Opposite of HEAT
  99. What are some of the indications that would call for using cold?
    • Sprains
    • Strains
    • Fractures
    • Postinjury swelling and bleeding
  100. What are the physiological effects of heat?
    • Vasodilation
    • Increases capillary permeability
    • Increases cellular metabolism
    • Increases inflammation
    • Sedative effect
  101. What are the physiological effects of cold?
    • Vasoconstriction
    • Decreases capillary permeability
    • Decreases cellular metaolism
    • Slows bacterial growth, decreases inflammation
    • Local anesthetic effect
  102. What are some methods for applying dry heat?
    • Hot water bottle
    • Aquathermia pad
    • Disposable heat pack
    • Electric pad
    • NOTE: DO NOT place over medicine patches, the heat can exacerbate the delivery of the medicine
  103. What are some methods for applying moist heat?
    • Compress 
    • Hot pack
    • Soak
    • Sitz bath
  104. What are some methods for applying dry cold?
    • Cold pack
    • Ice bag
    • Ice glove
    • Ice collar
  105. What are some methods for applying moist cold?
    • Compress
    • Cooling sponge bath
  106. What are the contraindications to the use of cold treatments?
    • Open wounds: Cold can increase tissue damage by decreasing blood flow to an open wound
    • Impaired circulation: Cold can further impair nourishment of the tissues and cause tissue damage. In clients with Raynaud's disease, cold increases arterial spasm
    • Allergy or hypersensitivity to cold: Some clients have an allergy to cold that may be manifested by an inflammatory response, for example, erythema, hives, swelling, joint pain, and occasional muscle spasm. Some react with a sudden increase in blood pressure, which can be hazardous if the person is hypersensitive
  107. What are the contraindications to the use of hot treatments?
    • The first 24 hours after traumatic injury: Heat increase bleeding and swelling
    • Active hemorrhage: Heat causes vasodilation and increases bleeding
    • Noninflammatory edema: Heat increases capillary permeability and edema
    • Localized malignant tumor: Because heat accelerates cell metabolism and cell growth and increases circulation, it may accelerate metastases (secondary tumors)
    • Skin disorder that causes redness or blisters: heat can burn or cause further damage to the skin 
  108. What are the conditions that would indicate the need for special precautions during heat and cold therapy?
    • Neurosensory impairment: Persons with sensory impairments are unable to perceive that heat is damaging the tissues and are at risk for burns, or they are unable to perceive discomfort from cold and are unable to prevent tissue damage
    • Impaired mental status: Persons who are confused or have an altered level of consciousness need monitoring and supervision during applications to ensure safe therapy
    • Impaired circulation: Persons with peripheral vascular disease, diabetes, or congestive heart failure lack the normal ability to dissipate heat via the blood circulation, which puts them at risk for tissue damage with heat applications. Cold applications are contraindicated for these people.
    • Open wounds: Tissues around an open wound are move sensitive to heat and cold
  109. What are the Pyodermas?
    • Impetigo
    • Folliculitis
    • Furuncles
    • Carbuncles
  110. Define what impetigo is
    Superficial infection of kin caused by staphylococci, streptococci, and multiple bacteria
  111. Define what Folliculitis is
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    • Infection of bacterial or fungal orgin, arising within the hair follicle
    • NOTE: The infection can spread to the surrounding dermis and become a Furuncle
  112. Define what a Furuncle is
    • Acute inflammation spreading to surrounding dermis
    • NOTE: The inflammation can spread and become a Carbuncle
  113. Define what a Carbuncle is
    Abscess of skin and subcutaneous tissue
  114. What is contact dermatitis?
    Inflammatory reaction of skin to physical, chemical, or biological agents
  115. What are the noninfectious inflammatory dermatoses?
    • Psoriasis
    • Exfoliative Dermatitis
  116. What is psoriasis?
    A common skin condition that causes skin redness and irritation. Most people with psoriasis have thick, red skin with flaky, silver-white patches called scales.
  117. What is exfoliative dermatitis?
    Widespread scaling of the skin, often with itching (pruritus), skin redness (erythroderma), and hair loss.
  118. Explain what cellulitis is
    • It enters through a break in the skin barrier
    • Allows bacteria to enter and release toxins in teh subcutaneous tissue
    • Localized swelling, redness, and pain
    • Also systemic reaction of fever, chills, and sweating
    • Treatments include oral and IV antibiotic therapy (depending on the severity)
    • Nursing management: elevate affected areas, apply warm moist packs, and education in prevention of a reoccurrance
  119. What is Herpes Zoster?
    • An infection caused by carcella-zoster virus (chicken pox) that follows the nerve tract
    • Also called Shingles
  120. What are the two types of Herpes Simplex?
    • Type 1: Typically occurs on the mouth
    • Type 2: Typically occurs on teh genitals
  121. What are two of the main strains of herpes?
    • Herpes Zoster
    • Herpes Simplex
  122. What can happen to a child that is born naturally (vaginally) to a woman who has herpes simplex, type 2?
    Herpes simplex two can cause the child to be born with a mental deficit and blindness.
  123. What are four of the fungal (mycotic) infections?
    • Tinea Pedis: Athlete's foot
    • Tinea Corporis: Ringworm of the body
    • Tinea Capitis: Ringworm of the scalp
    • Tinea Cruris: Ringworm of the groin
  124. What is pediculosis?
    Infestation of lice
  125. Define Pediculosis Capitis
    Head lice
  126. Define Pediculosis Corporis
    Body lice
  127. Define Pediculosis Pubis
    Pubic lice
  128. What is Scabies?
    An infestation by the itch mite: Sarcoptes scabiei
  129. What are some statistics on venous insufficiency?
    • Venous abnormalities exist in over 27% of the US population
    • 2% result in ulceration (500,000 new cases annually)
    • 70-80% of all lower extremity ulcers involve venous insufficiency as a component
    • Venous ulcers have recurrnce rates up to 70%
  130. Medicare will no longer reimburse health facilities for clients who need to be treated for pressure ulcers. What is the average amount being paid for these treatments?
    • Annual healthcare costs = $750M to $1B
    • Average cost per ulcer = $2,000 - $10,000
    • Quality of life issues
    • Lost workdays
  131. Define venous function works, when you are standing
    • In the upright position, blood returning to the heart from the lower extremities must battle GRAVITY
    • One way simi-lunar valves prevent back flow of blood
    • Calf muscle contraction compresses the deep veins and propels blood upwards, towards the heart
  132. What are the various parts of the venous system?
    • Superficial veins
    • Deep veins
    • Perforating veins
    • One-way valves
    • Calf muscle pump
  133. List the deep veins of the venous system
    • Femoral
    • Popliteal
    • Tibial
  134. List the superficial veins of the venous system
    • Greater saphenous
    • Lesser saphenous
  135. Define venous hypertension
    • Backflow or pooling of blood in the deep veins generates hypertension
    • High pressure is communicated to the superficial veins
    • Varicosities result when the superficial veins stretch (vericose veins)
  136. Ulcers on the lower extremity can come from which vessels?
    • Veins 
    • Arteries
  137. What are the potential causes of leg ulcers?
    • Venous insufficiency
    • Arterial insufficiency
    • Diabetic neuropathy
    • Pressure
    • Sickle cell anemia
    • Rheumatoid arthritis
    • Systemic lupus
    • Squamous or basal cell carcinoma
    • Malignant melanoma
    • Pyoderma gangrenosum
  138. What are the crontic venous insufficiency complications of venous ulcers?
    • Over medial or interior ankle
    • Superficial, pink in color
    • Skin has a brown discoloration, cyanotic when on it
    • Normal skin temperature
    • Usually edematous
    • Mild, aching pain
    • Normal pulses
    • NOTE: Difficult time getting blood out of the foot, to the heart
  139. What are the crontic venous insufficiency complications of arterial ulcers?
    • Over the toes, feet, shin
    • Ulcer is deep and pale
    • Skin is pale when elevated, red when walking
    • Skin is cool to tough
    • No to little edema
    • Pain is severe and constant
    • may get infected (gangrene)
    • Pulses are decreased or absent
    • NOTE: Difficult time getting blood down to the foot, but not UP the leg
    • Pale and cool
  140. Diabetes is what type of a disease?
    • Microvascular
    • Blood is like syrup
  141. What does a melanoma look like?
    • Irrecgular shape
    • Raised
    • Dark color
  142. Name the different types of wounds
    • Incision
    • Contusion
    • Abrasion
    • Puncture
    • Laceration
    • Penetrating wound
  143. Describe the characteristics and tell what causes, an incision?
    • Description: Open wound; deep or shallow
    • Caused by: Sharp instrument (e.g., knife or scalpel)
  144. Describe the characteristics and tell what causes, a contusion?
    • Description: Closed wound, skin appears ecchymotic (bruised) because of damaged blood vessels
    • Caused by: Blow from a blunt instrument
  145. Describe the characteristics and tell what causes, an abrasion?
    • Description: Open wound involving the skin
    • Caused by: Surface scrape, either unintentional (e.g., scraped knee from a fall) or intentional (e.g., dermal abrasion to remove pockmarks)
  146. Describe the characteristics and tell what causes, a puncture?
    • Description: Open wound
    • Caused by: Penetration of the skin and often the underlying tissues by a sharp instument, either intentional or unintentional
  147. Describe the characteristics and tell what causes, a laceration?
    • Description: open wound; edges are often jagged
    • Caused by: Tissues torn apart, often from accidents (e.g., with machinery)
  148. Describe the characteristics and tell what causes, a penetrating wound?
    • Description: Open wound
    • Caused by: Penetration of hte skin and the underlying tissues, usually unintentional (e.g., from a bullet or metal fragments)
Card Set
Fundamentals of Nursing Chapter 36
Skin Integrity and Wound Care, Chapter 36, Week 11