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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
DTI
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.
26
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?
Unstageable Stage 3 or 4 Do not use DTPI to describe vascular, traumatic, neuropathic, or derm conditions
27
Tunneling
Patient head = 12 oclock
28
Sanguineous
Thin, bright, red
29
Serosanguineous
Thin, watery, clear pale red to pink
30
Serous
Thin, watery clear
31
Purulent
Thick, opaque tan to yellow
32
Foul Purulent
Thick opaque yellow to green with offensive odor
33
Amount of Wound- None
Wound Tissues dry
34
Scant
Wound tissues very moist, drainage
35
25% dressing
Small = wound tissues wet, drainage Less than 25%
36
Moderate
Wound tissues wet, drainage involves 25 to 75% dressing
37
Large = Wound tissues filled with
Fluids above 75%
38
Nonadherent
Easily separated from wound base; loosely adherent = pulls away from wound, but attached to the wound base.
39
Firmly Adherent
Does not pull away from wound
40
Slough
usually lighter in color, thinner and stringy in consistency can be yellow, gray, white, green, and brown
41
Eschar
Usually darker in color, thicker and hard consistency black or brown color.
42
Granulation Tissue
Beefy Red, granular, bubbly in appearance should be differentiated from a smooth red wound bed color of tissue or full dusky
43
Epithelialization
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
Foreign Bodies
Wound Edges Defined or undefined edges attachment
45
Rolled under
Epibole Macerated softened by liquid
46
Fibrotic
Fibrous connective tissue present Callused Hardened Border round shaped, square, and irregular
47
Surrounding Tissue
Color edema Firmness Intact Induration Pallor lesions texture scar rash staining mositure
48
Indicators of Infection
Fever streaking redness Increased drainage odor warmth elevated WBC induration malaise edema weeping Increased pain Discoloration
49
Tubes or Drains
NC NG tube Foley Catheter Rrectal Tube ET tube PEG Tube
50
Wound Management
Nursing Assessment Evaluate Mobility Evaluate Circulatory Status Evaluate Neurologic status Evaluate Nutrition, hydration Braden Scale
51
What are risk Factors for developing pressure ulcers?
Immobility Impaired sensory perception or cognition Decreased tissue perfusion Decreased nutritional status Friction, shear Increased moisture
52
Braden Scale
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
Braden Risk Assessment Scale
6 to 23 Lower score - Higher risk Higher score- Less risk
54
Wound Healing
Nursing Interventions Mobilize the client Nutrition Hydrate Hygiene Monitor Skin Dressing Changes
55
Irrigation
Use of solution to provide turbulence to wound to promote hydration, removal of deep debris and allow for visualization of wound.
56
Debridement
Removal of unhealthy tissue from a wound to promote healing Surgical and Santyl - Enzyme Debridement
57
Dressing
Sterile covering to promote wound healing by protecting the wound from further harm
58
Hydrocolloid
Used for burns Light to moderate draining wounds , necrotic wounds, under comprrssion wraps, pressue ulcers, and venous ulcers
59
Hydrogel
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
Aliginate used for moderate to high amounts of wound drainage, venous ulcers, packing wounds, and pressure ulcers in stage 3 or 4.
True
61
Collagen
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
Negative Pressure Wound Therapy
Using vacuum dressing to enhance and promote wound healing
63
Use of Foam Dressing
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
Name of Different Wound Therapies
Foam Dressing with Negative Pressure Compression Dressing Pressure Dressings Optimal Nutrition Royal Jelly Probiotics Skin Grafts Maggots Hyperbaric Oxygen Therapy Acupuncture Hydrogels
65
Wound Therapy Experimentations
Nanoparticle Therapy Laser Silk Wound Care Mats Self Repairing Material Bamboo Wound Care Dressings Q Peptide Scar Reducing Compound Nanofiber Devices Stem Cells
66
Dehiscence
Wound Rupture along surgical incision Caused by poor stitching, diabetes, obesity, Ehlers- Danlos syndrome, picking at surgical incision
67
Evisceration
Ejection or exposure of viscera (internal organs)
68
Ways to Prevent Ulcers
Improve Nutrition Improve mobility Improve Sensory Perception Improve Tissue Perfusion Reduce pressure, friction, and shear Repositioning Minimize Moisture
69
Nursing Diagnosis
Acute Pain Impaired Skin Integrity Disturbed Body Image Deficient Fluid Volume Deficient Knowledge
70
Superficial
Epidermis layer Dry Red and blanches to touch 3-6 days healing None
71
Superficial Partial Thickness
Epidermis and upper portion of dermis Moist blisters, blanches to touch 7-20 days Potential pigment changes
72
Deep Partial Thickness
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
Full Thickness
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
Rules of Nines
Measurement of % of affected surface area Assists in determining fluid replacement
75
Face/ Scalp or Back of Head
4.5
76
Ant RUE and Post LUE
4.5
77
Abdomen or Buttocks
9
78
ANT RLE LLE or Post LLE RLE
9
79
Parkland Formula
LR 4ml/ kg/ %TBSA Burn
80
Treatment
Pain Management Fluid and Electrolyte Replacement Antimicrobial Ointments Silver Compounds Wound Debridement Skin Grafts Psychosocial Support
81
Brooke
LR 1.5 ml/ kg/ % TBSA BURN Colloid 0.5 ml/ kg/% TBSA BURN

ADN002 MED SURG (18 decks)

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