Skin Integrity & Wound Care

A __________is a localized injury to the skin and other ynderlying tissue, usually over a bony prominence, as a result of pressure or pressure in combination w/shear and/or friction

Age related changes, such as:
__________
__________
__________
cause the older adults skin to be easily torn in response to mechanical trauma, especially shearing forces

________ & _______, which are common in the older adult, are factors that interfere w/wound healing

Name some factors that put a client at risk for pressure ulcer development...(4)

Prolonged, intense pressure affects cellular metabolism by decreasing or obliterating blood flow, resulting in tissue _______ & ultimately tissue death

The three pressure related factors that contribute to pressure ulcer development are:

A nurse can quote pressure ulcer stage if it has been established by a wound care specialist but nurses can not diagnose stages of pressure ulcers

*Once you have staged a ulcer, this stage endures een as the ulcer heals ex: healing stage III pressure ulcer

This is the minimal amount of pressure required to collapse a capillary

If the hyperemia area blanches and the erythema returns when you remove your finger, the hyperemia is transient and is an attempt to overcome the ischemic episode, thus called _____________

Dark skinned ppl do not blanch. How do you assess for possible skin breakdown?

The extrensic factors of ____,____ and _____affect the ability of the skin to tolerate pressure.

A factor related to tissue tolerance pertains to the ability of the underlying skin structures to assist in redistributing pressure. Systemic factors such as: (3) affect the tissue's tolerance to externally applied pressure

When ____ is present, the skin and subcutaneous layers adhere to the surface of the bed and the layers of muscle and the bones slide in the direction of body movement

Mechanical force excerted when skin is dragged across a coarse surface such as bed linens

Pressure ulcer assessment includes (5)

List the decubitus stage:
Intact skin w/nonblanchable redness of a localized area

List the decubitis stage:
Partial-thickness skin loss involving epidermis, dermis or both. The ulcer is superficial and presents clinicall as an abrasion, blister or shallow crater.

List the decubitis stage:
Full-thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed. May include undermining or tunneling

List the decubitis stage:
Full-thickness tissue loss w/exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound. Often includes undermining & tunneling

The NPUAP has developed a definition for an ulcer in which the base of the wound cannot be visualized. An _______ ulcer is a full-thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, black) in the wound bed

________is red moist tissue composed of new blood vessls, the presence of which indicates progression toward healing

soft yellow or white tisue is characteristic of ________(stringy substance attached to the wound bed)

Wound _______ describes the amount, color, consistency and odor of wound drainage and is part of the wound assessment

Wound classification system describes:5

Process of wound healing with little tissue loss. The skin edges are approximated or closed and the risk for infection is low

Process of wound healing involving loss of tissue such as a burn, pressure ulcer or sever laceration. The wound is left open until it becomes filled w/scar tissue.

This wound is left open for several days, then the wound edges are approximated. The closure of wound is delayed until risk of infection is resolved

Wound that proceeds through an orderly and timely reparative process that results in sustained restoration of anatomical & functional integrity

Wound that fails to proceed through an orderly & timely process to produce anatomical & functional integrity

There are three components involved in the healing process of a partial-thickness wound:

A wound left open to air can resurface in 6-7 days whereas a wound that is kept moist can resurface in 4 days. The difference in the healing rate is related to the fact that epidermal cells _________________

The three phases involved in the healing process of a full-thickness wound are:

Leukocytes reach wound w/in a few hours. The primary WBC is the neutrophil, which begins to injest bacteria. The 2nd important leukocyte is the monocyte which transforms into macrophages "garbage cells" and clean a wound of bacteria, dead cells and debris by way of phagocytosis

Impairment of healing during the proliferative phase usually results from systemic factors such as age, anemia, hypoproteinemia and zinc deficiency

Complications of wound healing:
Internal bleeding from a hemorrage is detected by:

_____is a localized collection of blood underneath the tissues that appears as a swelling, change in color, sensation or warmth or mass that often takes on a bluish discoloration

True or false:
If a wound culture is taken and has negative results, if purulent material drains from the wound, it is considered infected
True False

A surgical wound infection usually does not develop until the ___ or ____ postoperative day.

_________is the partial or total seperation of wound layers.
Clients often report that it feels as something has "given way".

With total separation of wound layers, ___________ is a protrusion of visceral organs through a wound opening

A _______ is an abnormal passage between two organs or between an organ and the outside of the body. Most result from poor wound healing or a complication of disease such as Crohn's

Types of wound drainage:
Clear, watery plasma

Types of wound drainage:
Thick, yellow, green, tan, or brown

Types of wound drainage:
Pale, red, waters: mixture of clear and red fluid

Types of wound drainage:
Bright red: indicates active bleeding

Name 2 common scales for predicting pressure ulcer risk:

Your patient returns from surgery and after a few hours you notice the surgical dressing is soaked w/blood. What would be your course of action?

Pressure ulcers usually develop w/in the _________of hospitalization

Physiological processes of wound healing depend on the availability of ____, vitamins __ & ___ and the trace minerals ____ & ______.
A well nourished surgical pt still requires at least _____kcal/day for nutritional maintenance

______proteins are biochemical indicators of malnutrition

An _______ is superficial w/little bleeding and is considered a partial-thickness wound. The wound appears "weepy" because of plasma leakage from damaged capillaries.

A _______sometimes bleeds more profusely, depending on the wound's depth and location

_________wounds bleed in relation to the depth and size of the wound.

Frequent skin assessment should be performed at least ______/day.
High-risk clients will need more frequent shik assessments, such as _______

Elevating the head of the bed to 30 degrees or less will decrease the chance of pressure ulcer development from shearing forces

You clean pressure unlcers with _______ or ____________

Wound irrigation (high-pressure irrigation and pulsatile high pressure lavage) and whirlpool treatments are all methods of _______debridement

_________debridement uses synthetic dressings over a wound to allow the eschar to be self-digested by the action of enzymes that are present in wound fluids

You can accomplish _____debridement with the use of a topical enzyme preparation, Dakin's solution or sterile maggots

_______debridement is the removal of devitalized tissue by using a scalpel, scissors, or other sharp instrument

A friction injury occurs in clients who are:

Observing all surgical wounds closely withing the _________to______hrs, when risk of hemorrhage is the greatest