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Fundamentals 2 Exam 4 Flashcards > Skin Integrity & Wound Care Flashcards > Flashcards

Skin Integrity & Wound Care Flashcards

1
Q

This is the largest organ of the body and protects the body from injury =

A

Skin

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2
Q

How do you assess a wound using your senses?

A

Sight:
Assess Location + Size Shape + Color + Exudate + Bleeding Necrosis

Feel:
Textural Changes

Smell:
Can tell about the presence of infectious organisms

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3
Q

What are all of the important things to assess about a wound?

A

Location

Measure length, width, and depth in centimeters

Any odor?

Describe drainage

Stage the ulcer

Describe surrounding tissue

Undermining or sinus tracts?

Describe wound bed tissue

Any clinical signs of infection?

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4
Q

What is Serous Exudate like?

A

Clear, Watery Serum

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5
Q

What is Purulent Exudate like?

A

Thick Yellow, Green, Tan, or Brown

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6
Q

What is Sanguineous Exudate like?

A

Bright Red

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7
Q

What is Serosanguineous Exudate like?

A

Pale, Red, Watery

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8
Q

What is Purosanguineous Exudate like?

A

Pus & Blood

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9
Q

What do you do for a Red wound?

A

Protect & Cover

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10
Q

What do you do for a Yellow wound?

A

Cleanse

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11
Q

What do you do for a Black wound?

A

Debride

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12
Q

What does the color of an open wound determine?

A

It determines the treatment

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13
Q

What do you do if there is more than one color present on a wound?

A

Treat the most serious first. Black, then Yellow, then Red.

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14
Q

Does the depth or size determine what kind’ve treatment you’d give for a wound?

A

No, just the color

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15
Q

Most common site for pressure ulcers =

A

Sacral Area

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16
Q

What is a Pressure Ulcer?

A

Localized injury to the skin and/or underlying tissue, caused by force or a combination of force and movement over bony prominences

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17
Q

Most Pressure Ulcers are-

A

Preventable + Heal by secondary intention

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18
Q

How many recognized stages of Pressure Ulcers are there?

A

4

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19
Q

How do Stage 3 and Stage 4 Pressure Ulcers heal?

A

By filling in with scar tissue (Not new dermis and subcutaneous tissue)

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20
Q

What is Granulation?

A

Scar Tissue

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21
Q

A stage 4 Pressure Ulcer is healing nicely. Can it be downgraded to a Grade 3 after a month passes?

A

No, Pressure Ulcers can not be downgraded

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22
Q

As a Stage 4 Pressure Ulcer heals, what should it be referred to as?

A

A healing / healed Stage 4 Pressure Ulcer (Because they can’t be downgraded)

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23
Q

What is a Stage 1 Pressure Ulcer like?

A

No tissue loss, but non-blanchable red skin over a bony prominence

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24
Q

Pressure ulcer with a loss of Epidermis tissue and possibly Dermis tissue =

A

Stage 2 Pressure Ulcer

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25
Q

Pressure ulcer with a loss of Epidermis, Dermis, and Hypodermis Tissue =

A

Stage 3 Pressure Ulcer

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26
Q

Full-thickness skin loss involving muscle, bone, or other supporting structures such as tendons or joint capsules. Undermining and sinus tracts may be present also =

A

Stage 4 Pressure Ulcer

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27
Q

Subcutaneous Tissue is the same thing as-

A

Hypodermis Tissue

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28
Q

A stage 2 pressure ulcer may be present as-

A

An Abrasion, a Blister, or a Very Shallow Crater

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29
Q

You have a pt with a pressure ulcer that you can’t visually see the wound bed and the depth is unknown. What would you call this pressure ulcer?

A

An Unstageable Pressure Ulcer

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30
Q

What can make a Pressure Ulcer Unstageable?

A

Full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar on the wound bed

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31
Q

What is Slough?

A

Yellow, Tan, Gray, Green, or Brown (Dead Tissue)

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32
Q

What is Eschar?

A

Tan, Brown, or Black (Dead Tissue)

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33
Q

Necrotic Tissue means the same thing as-

A

Dead Tissue

34
Q

What are the 3 phases of wound healing?

A

Inflammatory Phase
Proliferative Phase
Maturation (Remodeling) Phase

35
Q

This phase starts immediately after injury =

A

Inflammatory Phase

36
Q

How long does the Inflammatory Phase last?

A

3-6 Days

37
Q

What are the 2 processes that occur during the Inflammatory Phase?

A

Hemostasis

Phagocytosis

38
Q

Hemostasis =

A

The mechanism that leads to cessation of bleeding from a blood vessel

39
Q

Phagocytosis =

A

Cells ingesting and eliminating other cells

40
Q

Granulation =

A

Scarring

41
Q

What’s the second phase of wound healing called?

A

Proliferative Phase

42
Q

What does the Proliferative Phase of wound healing start?

A

Begins 3-4 days after injury, lasts until 21 days post-injury

43
Q

What are the processes that occur during Proliferative Phase?

A

Granulation

Epithelialization

44
Q

Epithelialization =

A

The formulation of epithelial tissue covering an injury

45
Q

What’s the last phase of wound healing?

A

The Maturation Phase

46
Q

When does the Maturation Phase start? When does it end?

A

Starts from about day 21, lasts 1-2 years post surgery

47
Q

What process occurs during the Maturation Phase?

A

The continued synthesis of Collagen

48
Q

What intrinsic factors affect wound healing?

A

Age (Kids heal faster, elderly heal slower)
Chronic Illness
Altered Sensation

49
Q

What extrinsic factors affect wound healing?

A

Meds, Chemotherapy, Stress, Illness, Diet

50
Q

What does the type of dressing for a wound depend on?

A

Location, size, and type of wound

Amount of exudate

Wound require debridement?

Wound infected?

Frequency of dressing change

Ease or difficulty of dressing application

Cost

51
Q

Why do we Irrigate a wound?

A

To remove debris, excess slough, necrotic tissue, bacteria, and other microbes

52
Q

To irrigate a wound, you should use a piston syringe with pressures of-

A

4-15 Pounds Per Square Inch (psi)

53
Q

How many psi can a 30-60 mL syringe with 19 G needles provide?

A

8 psi

54
Q

Can you delegate a wound irrigation to a UAP?

A

Nah

55
Q

What are the 4 types of Debridement?

A

Sharp Debridement / Surgical Debridement

Mechanical Debridement

Chemical Debridement

Autolytic Debridement

56
Q

Using a Scalpel or Scissors for Debridement is an example of-

A

Sharp Debridement / Surgical Debridement

57
Q

Using a Scrubbing or Wet-To-Dry Dressing for Debridement is an example of-

A

Mechanical Debridement

58
Q

Using an Enzyme Agent for Debridement is an example of-

A

Chemical Debridement

59
Q

Using the body’s own enzymes to break down Necrosis for Debridement is an example of-

A

Autolytic Debridement

60
Q

What is done for Negative Wound Therapy?

A

Sterile foam sponges placed in clean wound
Covered with transparent occlusive drape
Hole cut in drape to insert vacuum tubing
Negative pressure applied

61
Q

What can be done to prevent a Pressure Ulcer?

A

Nutrition
Good skin hygiene
Bathe
Lotion
Avoid skin trauma
Proper lifting & turning
Wrinkle free sheets
Provide Supportive devices
Turn & reposition frequently
Pressure reduction devices

62
Q

Used to identify clients at risk for pressure ulcer development =

A

Braden Scale

63
Q

How many subscales does the Braden Scale consist of?

A

6

64
Q

What are the subscales that the Braden Scale consists of?

A

Sensory Perception
Moisture
Activity
Mobility
Nutrition
Friction & Shear

65
Q

What score is a severe risk on the Braden Scale?

A

9

66
Q

What score is a high risk on the Braden Scale?

A

10-12

67
Q

What score is a moderate risk on the Braden Scale?

A

13-14

68
Q

What score is a mild risk on the Braden Scale?

A

15-18

69
Q

What lab data can be used to assess wound progression?

A

WBC Count + Hemoglobin + Platelet Count + Serum Protein + Albumin + Wound Cultures + Sensitivity Reports

70
Q

Decreased WBC’s =

A

Delayed wound healing + more risk of infection

71
Q

Low hemoglobin =

A

Less oxygen being delivered to tissues, delayed wound healing

72
Q

Low Platelet count =

A

Not enough coagulation, excessive bleeding, prolonged clot absorption

73
Q

What can a serum protein analysis provide?

A

An indication of the body’s nutritional reserves for rebuilding cells

74
Q

Low serum protein =

A

Less rebuilding cells, delayed wound healing

75
Q

Low albumin =

A

Indicates that the pt’s nutrition is bad.

Decreased wound healing time + more risk of infection

76
Q

A wound culture can analyze the presence of -

A

An Infection

77
Q

Sensitivity reports can indicate-

A

Which antibiotic is appropriate for healing

78
Q

Can you delegate obtaining a Wound Culture to a UAP?

A

Nope

79
Q

What do you need to do 30 minutes prior to obtaining a wound culture?

A

Administer Analgesics

80
Q

Aside from administering analgesics, what else do you need to do prior to obtaining a wound culture?

A

Cleanse the wound, determine if the wound culture is anaerobic or aerobic

81
Q

How do you obtain a wound culture?

A

Obtain by rotating swab back & forth over clean granulated wound tissue

82
Q

What is Debridement?

A

The removal of necrotic tissue or foreign tissue from a wound

Fundamentals 2 Exam 4 Flashcards (12 decks)

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