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ADN002 MED SURG > Week 1 Wound > Flashcards

Week 1 Wound Flashcards

1
Q

Blood changing from a liquid to a gel

A

Hemostasis

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2
Q

Phases of Healing

A

Vascular

Contraction of the smooth muscle produces vasoconstriction

Formation of the Platelet Plug

Lesion of the endothelium exposes the collagen fibers platelet adhesion is triggered

Platelets release mediators which further enhance platelet aggregation platelet plug is formed

Coagulation

Fibrin Filaments polymarize red and white blood cells get trapped and blood clot is formed

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3
Q

Inflammation

A

Response to cellular injury marked by capillary dilatation, leukocytic infiltration, redness, heat, and pain and that serves as a mechanism of initiating the elimination of noxious agents and damaged tissue.

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4
Q

Stages of healing

A

Mast Cells Histamine

Initiation- Prostaglandins - Leukotrienes- Class switching Lipoxins- Termination

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5
Q

Proliferation

A

Rapid increase in reproduction of new cells

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6
Q

Granulation

A

Formation of new connective tissue and blood vessels on surface of a wound = result proliferation

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7
Q

Phases of Healing

A

Hemostasis
Blood Clot

Inflammatory
Fibroblasts
Macrophages

Proliferative
Fibroblasts proliferating
Subcutaneous Fat

Remodeling
Freshly healed epidermis and dermis

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8
Q

Pressure Injury

A

Localized Damage to the skin and underlying soft tissue

Usually over a bony prominence or related to a medical or other device

Injury can be present as intact skin or as open ulcer

May be painful

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9
Q

Common places for pressure ulcers

A

Head
Shoulder
Sacrum
Heel

Pressure sore forms when pressure forces a bony prominence to compress underlying soft tissue.

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10
Q

Stage 1

A

Area is reddish and may be hard and warm
No skin lost

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11
Q

Stage 2

A

Sore extends into, but not through the skin layers. Skin partially lost.

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12
Q

Stage 3

A

Skin Layers are completely lost. Necrosis of subcutaneous tissue may extend to but not through the fascia.

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13
Q

Stage 4

A

Necrosis beyond the fascia causing extensive damage to muscle and bone

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14
Q

Pressure and Shear is affected by what?

A

Microclimate
Nutrition
Perfusion
Co morbidities
Condition of soft tissue

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15
Q

Which agency has elements for pressure ulcers?

A

JACO

Use nursing skills and judgement and write care plan to prevent them as well.

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16
Q

Blanchable Redness

A

Not staged or considered a pressure ulcer

Warning sign to stage 1

Pressing on reddened area and skin becomes white for at least a brief period of time

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17
Q

Stage 1

A

Non blanchable erythema of intact skin

Intact skin with a localized area of non blanchable erythema. May be different in darker pigmented skin

Presence on blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes.

Color changes do NOT include purple or maroon discoloration; these may indicate deep tissue pressure injury

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18
Q

Stage 2

A

Pressure injury. Partial Thickness skin loss with exposed dermis

Wound bed is viable pink or red with blisters. Adipose not visible and deeper tissues are not visible.

No granulation eschar and slough

Injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel

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19
Q

Stage 2 should not be used to describe what?

A

MASD
IAD
ITD
MARSI
Traumatic Wounds- Skin tears, burns, and abrasions

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20
Q

Stage 3

A

Full Thickness loss

Adipose visible
and granulation and epibole is present are often present

epibole is rolled wound edges

Depth of tissue damage depends on anatomical position

Muscle or bone not exposed

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21
Q

If slough and eschar obscures the extent of tissue loss this is…

A

Unstageable Pressure Injury

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22
Q

Stage 4

A

Full Thickness skin and tissue Loss

Exposed bone muscle tendon or cartilage

Slough and eschar may be visible

Rolled edges and tunneling often occur

Slough obscures the extent of the tissue loss this is unstageable injury

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23
Q

Unstageable

A

Slough and eschar are covering the stages of 3 and 4

Obscured full thickness and tissue loss

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24
Q

Stable Eschar

A

Dry adherent intact without erythema or flatulence on the heel or ischemic limb should not be softened or removed

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25
Q

DTI

A

Deep Tissue Pressure Injury

Persistent nonblanch deep red, maroon or purple discoloration

Blood filled blister with deep red or purple color

Pain and temperature often precede skin color changes

Injury results from intense or prolonged pressure and shear forces at the bone muscle interface.

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26
Q

Wound may evolve rapidly to reveal the actual extent of tissue injury or may resolve without tissue loss

If necrotic tissue, subq, granulation, fascia, muscle, or other underlying tissues indicates what?

A

Unstageable Stage 3 or 4

Do not use DTPI to describe vascular, traumatic, neuropathic, or derm conditions

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27
Q

Tunneling

A

Patient head = 12 oclock

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28
Q

Sanguineous

A

Thin, bright, red

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29
Q

Serosanguineous

A

Thin, watery, clear pale red to pink

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30
Q

Serous

A

Thin, watery clear

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31
Q

Purulent

A

Thick, opaque tan to yellow

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32
Q

Foul Purulent

A

Thick opaque yellow to green with offensive odor

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33
Q

Amount of Wound- None

A

Wound Tissues dry

34
Q

Scant

A

Wound tissues very moist, drainage

35
Q

25% dressing

A

Small = wound tissues wet, drainage
Less than 25%

36
Q

Moderate

A

Wound tissues wet, drainage involves 25 to 75% dressing

37
Q

Large = Wound tissues filled with

A

Fluids above 75%

38
Q

Nonadherent

A

Easily separated from wound base; loosely adherent = pulls away from wound, but attached to the wound base.

39
Q

Firmly Adherent

A

Does not pull away from wound

40
Q

Slough

A

usually lighter in color, thinner and stringy in consistency can be yellow, gray, white, green, and brown

41
Q

Eschar

A

Usually darker in color, thicker and hard consistency black or brown color.

42
Q

Granulation Tissue

A

Beefy Red, granular, bubbly in appearance should be differentiated from a smooth red wound bed color of tissue or full dusky

43
Q

Epithelialization

A

Appear as deep pink, then pearly/ pink and light purple from the edges in full thickness wound or may form islands in the wound base with superficial wounds

44
Q

Foreign Bodies

A

Wound Edges

Defined or undefined edges attachment

45
Q

Rolled under

A

Epibole

Macerated softened by liquid

46
Q

Fibrotic

A

Fibrous connective tissue present

Callused Hardened

Border round shaped, square, and irregular

47
Q

Surrounding Tissue

A

Color
edema
Firmness
Intact
Induration
Pallor
lesions
texture
scar
rash staining
mositure

48
Q

Indicators of Infection

A

Fever
streaking
redness
Increased drainage
odor
warmth
elevated WBC
induration
malaise
edema
weeping
Increased pain
Discoloration

49
Q

Tubes or Drains

A

NC NG tube Foley Catheter Rrectal Tube ET tube PEG Tube

50
Q

Wound Management

A

Nursing Assessment

Evaluate Mobility
Evaluate Circulatory Status
Evaluate Neurologic status
Evaluate Nutrition, hydration
Braden Scale

51
Q

What are risk Factors for developing pressure ulcers?

A

Immobility
Impaired sensory perception or cognition
Decreased tissue perfusion
Decreased nutritional status
Friction, shear
Increased moisture

52
Q

Braden Scale

A

Scores patient by:

Sensory Perception
Moisture
Activity
Mobility
Nutrition
Friction and Shear

Lower the score means higher chance of developing a pressure sore

6 is lowest.
20 is highest

53
Q

Braden Risk Assessment Scale

A

6 to 23

Lower score - Higher risk
Higher score- Less risk

54
Q

Wound Healing

A

Nursing Interventions
Mobilize the client
Nutrition
Hydrate
Hygiene
Monitor Skin
Dressing Changes

55
Q

Irrigation

A

Use of solution to provide turbulence to wound to promote hydration, removal of deep debris and allow for visualization of wound.

56
Q

Debridement

A

Removal of unhealthy tissue from a wound to promote healing

Surgical and Santyl - Enzyme Debridement

57
Q

Dressing

A

Sterile covering to promote wound healing by protecting the wound from further harm

58
Q

Hydrocolloid

A

Used for burns

Light to moderate draining wounds , necrotic wounds, under comprrssion wraps, pressue ulcers, and venous ulcers

59
Q

Hydrogel

A

Used for wounds with little to no excess of fluids, painful wounds, necrotic wounds, pressure ulcers, donor sites

2nd degree or higher burns and infected wounds

60
Q

Aliginate used for moderate to high amounts of wound drainage, venous ulcers, packing wounds, and pressure ulcers in stage 3 or 4.

A

True

61
Q

Collagen

A

Used for chronic or stalled wounds, ulcers, bed sores, transplant sites, surgical wounds, second degree or higher burns and wounds with large surface areas

62
Q

Negative Pressure Wound Therapy

A

Using vacuum dressing to enhance and promote wound healing

63
Q

Use of Foam Dressing

A

Used for first and second degree burns, chronic wounds, diabetic, venous, arterial and pressure ulcers, wounds suffering excessive drainage, acute or surgical wounds at risk for suffering isolation

64
Q

Name of Different Wound Therapies

A

Foam Dressing with Negative Pressure
Compression Dressing
Pressure Dressings
Optimal Nutrition
Royal Jelly
Probiotics
Skin Grafts
Maggots
Hyperbaric Oxygen Therapy
Acupuncture
Hydrogels

65
Q

Wound Therapy Experimentations

A

Nanoparticle Therapy
Laser
Silk Wound Care Mats
Self Repairing Material
Bamboo Wound Care Dressings
Q Peptide Scar Reducing Compound
Nanofiber Devices
Stem Cells

66
Q

Dehiscence

A

Wound Rupture along surgical incision

Caused by poor stitching, diabetes, obesity, Ehlers- Danlos syndrome, picking at surgical incision

67
Q

Evisceration

A

Ejection or exposure of viscera (internal organs)

68
Q

Ways to Prevent Ulcers

A

Improve Nutrition
Improve mobility
Improve Sensory Perception
Improve Tissue Perfusion
Reduce pressure, friction, and shear
Repositioning
Minimize Moisture

69
Q

Nursing Diagnosis

A

Acute Pain
Impaired Skin Integrity

Disturbed Body Image

Deficient Fluid Volume

Deficient Knowledge

70
Q

Superficial

A

Epidermis layer

Dry Red and blanches to touch

3-6 days healing

None

71
Q

Superficial Partial Thickness

A

Epidermis and upper portion of dermis

Moist blisters, blanches to touch

7-20 days

Potential pigment changes

72
Q

Deep Partial Thickness

A

Epidermis and most dermis, blood capillaries are destroyed; most hair follicles and nerves remain intact

Blisters; wet or waxy dry, variable colors does not blanch with pressure

More than 21 days

Scarring, risk for contractures

73
Q

Full Thickness

A

Epidermis, subcutaneous, and dermis

Waxy, charred or translucent color

Pain due to adjacent areas

Will not heal if more than 2% off body surface is affected

Severe scarring, high risk for contracture

74
Q

Rules of Nines

A

Measurement of % of affected surface area

Assists in determining fluid replacement

75
Q

Face/ Scalp or Back of Head

A

4.5

76
Q

Ant RUE and Post LUE

A

4.5

77
Q

Abdomen or Buttocks

A

9

78
Q

ANT RLE LLE or Post LLE RLE

A

9

79
Q

Parkland Formula

A

LR

4ml/ kg/ %TBSA Burn

80
Q

Treatment

A

Pain Management

Fluid and Electrolyte Replacement

Antimicrobial Ointments

Silver Compounds

Wound Debridement Skin Grafts

Psychosocial Support

81
Q

Brooke

A

LR
1.5 ml/ kg/ % TBSA BURN

Colloid
0.5 ml/ kg/% TBSA BURN

ADN002 MED SURG (18 decks)

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