Exam 3: Wounds/Drains/Nutrition/Hygiene Flashcards
Describe the four stages of a pressure injury.
Stage 1: Nonblanchable redness typically over boney prominance
Stage 2: Partial thickness - shallow open ulcer without slough (may be a blister)
Stage 3: Full-thickness - SQ may be visible, but not deeper tissue. Slough may be present but doesn’t obscure
Stage 4: Full thickness - bone, tendon, or muscle may be exposed. Slough or eschar may be present but doesn’t obscure
Describe an unstageable pressure injury and a deep tissue injury.
Unstageable - full-thickness loss where depth is completed obscured by slough or eschar (typ. either 3 or 4)
Deep tissue - Depth unknown. Discolored, intact skin or blister from pressure or shear (painful, firm, mushy, boggy, different temp)
What are four complications of wound healing? Describe each and know the nurse responsibilities.
Infection
Dehiscense
Evisceration
Hemorrhage
How does nutrition aid in wound healing?
Need protein in the diet to be able to rebuild from a wound
Describe the components of the Braden scale?
Sensory Perception - the ability to respond meaningfully to pressure-related discomfort.
Moisture - Presence and duration of moisture on the skin
Activity - Degree of physical activity that the patient is currently capable of
Mobility - Ability to change and control body position
Nutrition - usual food intake pattern
Friction & Shear - whether or not a pt requires assistance to move puts them at risk of these injuries
What are interventions that are used based on the client’s Braden scale results?
Implement turning schedule
Moisturize skin daily and PRN
Obtain PT consult for activity
level, out of bed, foot drop risk as
indicated
Control moisture
Nutrition consult
Minimize shear on bed and chair
surfaces
Pressure redistribution bed; low
air loss if Braden Moisture
subscale less than 3
Patient/Caregiver Education
What are the signs and symptoms of a wound infection?
Redness, warm, painful, unable to use, streaking, fever
What are priority interventions for an immobile client to prevent a skin injury?
Turn team
Positioning devices
Cleaning incontinence quickly
Lifting devices to avoid friction/shear
What are the components of incontinence management?
Frequent position changes
Using an incontinence cleaner
Applying a moisture barrier ointment
What is the purpose of irrigation and debridement?
Clean out the wound of any debris/foreign body/necrotic tissue and to be able to visualize the wound and its depth/damage
Describe slough tissue
Yellow, stringy substance attached to wound bed
Usually must be removed before wound can heal
Describe eschar tissue
Brown, black tissue
Indicates necrosis
Usually must be removed for healing to occur
Describe granulation tissue
Red, moist, beefy; indicates progression to healing
What are documentation requirements when charting wounds?
Location
Size
Tunneling and undermining
Color of ulcer base
Drainage
Use standard measurements
Primary or secondary intention
Describe the various classifications of drainage seen in a wound drain?
Amount – color – odor – consistency
• Serous – clear, watery plasma
• Purulent – thick, yellow, green, tan or brown (pus)
• Sanguineous – bright red, indicates active bleeding (bloody)
• Sero-sanguineous – pale, red, watery; mixture of serous and
sanguineous
Describe the various types of drains.
Jackson-Pratt (JP) drains: closed drainage system with a bulb that exerts a low pressure to pull fluid out of the wound; can hold 25-50 mL of fluid
Hemovacs: “evacuator unit,” closed drainage system that exerts a low pressure to pull fluid out of the wound; can hold up to 500 mL of fluid
Penrose drain: lies underneath dressing; at time of placement, a pin or clip is placed through the drain to prevent it from slipping further into the wound; wound heals from inside out
