Skin Integrity and Wound Care Flashcards

  1. Stage 1 Pressure Ulcer
    Intact skin with an area of persistent, non-blanchable redness, typically over a bony prominence, that may feel warm or cool to the touch. The tissue is swollen and congested, with possible discomfort at the site. With darker skin tones, the ulcer may appear blue or purple.
  2. Stage 2 Pressure Ulcer
    Partial-thickness skin loss involving the epidermis and the dermis. The ulcer is visible and superficial and may appear as an abrasion, blister, or shallow crater. Edema persists, and the ulcer may become infected, possibly with pain and scant drainage.
  3. Stage 3 Pressure Ulcer
    Full-thickness tissue loss with damage to or necrosis of subcutaneous tissue. The ulcer may extend down to, but not through, underlying fascia. The ulcer appears as a deep crater with or without undermining of adjacent tissue and without exposed muscle or bone. Drainage and infection are common.
  4. Stage 4 Pressure Ulcer
    Full-thickness tissue loss with destruction, tissue necrosis, or damage to muscle, bone, or supporting structures. There may be sinus tracts, deep pockets of infection, tunneling, undermining, eschar(black scab-like material), or slough(tan, yellow, or green scab-like material)
  5. RYB Color Code of Wounds
    • Red- Healthy Regeneration of tissue
    • Yellow- Presence of purulent drainage and slough
    • Black- Presence of eschar that hinders healing and must be removed
  6. Goals of Wound Care for RYB color Code
    • Red- Protect/Cover
    • Yellow- Cleanse
    • Black- Debride
  7. Preferred cleansing agents for wounds
    Isotonic Solutions
  8. Transparent Film Dressing
    • Provides protection against contamination and friction
    • Maintain a clean moist surface that facilitates cellular migration
    • Provide insulation by preventing fluid evaporation
    • Facilitate wound assessment
  9. When to use Transparent Film Dressing
    • IV dressing
    • Central line Dressing
    • Superficial Wounds
    • Stage 1 Pressure Ulcers
  10. Impregnated Nonadherent Dressing
    Cover, soothe, and protect partial- and full-thickness wounds without exudate
  11. When to use Impregnates Nonadherant Dressing
    • Postoperative Dressing
    • Over staples/sutures
    • Superficial burns
  12. Hydrocolloid Dressing
    • Absorb exudate
    • Produce a moist environment that facilitates healing but does not cause maceration of surrounding skin
    • Protect the wound from bacterial contamination, foreign debris, and urine or feces
    • Prevent shearing
  13. When to use Hydrocolloid Dressing
    • Stage 2-4 Pressure Ulcers
    • Autolytic debridement of eschar
    • Partial-Thickness Wounds
  14. Clear absorbant Acrylic Dressing
    • Maintains a transparent membrane for easy wound bed assessment
    • Provides bacterial and shearing protection
    • Maintains moist wound healing
    • Can be used with alginates to provide packing to deeper wound beds
  15. When to use Clear absorbant Acrylic Dressing
    • Pressure Ulcers
    • Skin tears
    • Venous stasis ulcers
    • Surgical Wounds
    • Wounds undergoing chemical debridement agents
  16. Hydrogel Dressing
    • Liquefy necrotic tissue or slough
    • Rehydrate the wound bed
    • Fill in dead space
  17. When to use Hydrogel Dressing
    • Pressure Ulcers
    • Skin Tears
    • Partial-thickness wounds
  18. Polyurethane Foam Dressing
    • Absorbs up to heavy amounts of exudate
    • Provides and maintains moist wound healing
  19. When to use Polyurethane Foam Dressing
    • Light to highly exudating wounds
    • Pressure Ulcers
    • Skin Tears
    • Venous stasis Ulcers
    • Surgical Wounds
    • Wounds Undergoing chemical debridement agents
  20. Alginates(Exudate absorbers) Dressing
    • Provide a moist wound surface by interacting with exudate to form a gelatinous mass
    • Absorb Exudate
    • Eliminate dead space or pack wounds
    • Support debridement
  21. When to use Alginates Dressing
    • Pressure Ulcers
    • Skin tears
    • Venous stasis ulcers
    • Surgical wounds
    • Wounds undergoing chemical debridement agents
  22. Dehiscence
    Partial or total rupture of a sutured wound, usually with separation of underlying skin layers
  23. Evisceration
    Dehiscence that involves the protrusion of visceral organs through a wound opening
  24. Sharp Debridement
    Scalpel or scissors are used to separate and remove dead tissue
  25. Mechanical Debridement
    Accomplished through scrubbing force or moist to moist dressing
  26. Chemical Debridement
    Uses collagenase enzyme agents such as papain-urea
  27. Autolytic Debridement
    Dressings that contain wound moisture, ie:hydrocolloid and clear absorbant acrylic dressings, to trap the wound drainage against the eschar. The body's own enzymes break down necrotic tissue. It takes longest but causes less damage.
  28. When to use heat application
    • Relax muscle spasms and increase muscle contractility
    • Soften exudates
    • Relieve pain and provide comfort
    • Increases joint ROM and reduces stiffness
  29. When to use cold application
    • Relax muscles and decrease muscle contractility
    • Reduce inflammation and decrease pain by slowing nerve conduction rate and blocking nerve impulses and causing numbness
    • Decrease bleeding
Card Set
Skin Integrity and Wound Care Flashcards
Nurs 3344 Test 3