Term
| When assessing the skin, what characteristics are you looking for? |
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Definition
| Color, temperature, tugor, moisture, and texture (smooth vs. rough; thick vs. thin; hard vs. soft) |
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Term
[image]
In your documentation, what would you want to include about this patient? What stage is this wound? |
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Definition
length and width
shape/pattern
depth
odor
drainage
Elevation (raised/flat/smooth)
stage 2 |
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Term
| What is the risk of a patient that sweats a lot? |
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Definition
| High levels of moisture on the skin is more likely to erode and therefore breakdown. |
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Term
| A patient that is placed on Bed rest w/ bathroom privileges is at a higher risk for pressure ulcers. Why? |
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Definition
| Because of the increased pressure on the tissue. |
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Term
| A well balanced diet is important for healthy skin. Why? |
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Definition
| Fluids contain nutrients that support the tissue as well as provides electrolytes and minerals. Protein is also very important for antibodies. |
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Term
| Why would an elderly adult may be unaware that they have a pressure area and thus develop a sore? |
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Definition
| Do to sensory losses to the tissue. Also, the patient may have diabetes, which causes the person to have the inability to sense tissue breakdown because of neuropathy. |
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Term
| What assessment tool do nurses use to determine the risk of infection/skin breakdown? |
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Definition
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Term
| What is a stage I pressure ulcer? |
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Definition
| Wounds are red but do not blanch and the skin is intact |
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Term
| What is a stage II pressure ulcer? |
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Definition
| Wounds which have a partial-thickness loss (epidermis and or dermis). Wound is superficial and may appear as an abrasion, blister, or shallow crater. |
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Term
| What is a stage III pressure ulcer? |
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Definition
| Wounds involve damage or death of tissue to subcutaneous tissue but not the fascia. There may be the appearance of a deep crater and may or may not have surrounding tissue damage. |
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Term
| what is a stage IV pressure ulcer? |
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Definition
| Wound that involves extensive destruction and death of tissue, may extend to the muscle bone or supporting structures. |
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Term
[image]
What stage is this wound? |
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Definition
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Term
[image]
What stage is this wound? |
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Definition
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Term
[image]
What stage is this wound? |
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Definition
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Term
| How does an elevated glucose effect a pressure wound? |
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Definition
| It can cause the wound to become worse more swiftly. |
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Term
| What is the most superficial layer of skin? |
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Definition
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Term
| what layer of the epidermis consists of mostly dead cells and skin? |
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Definition
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Term
| What is the second layer of skin? |
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Definition
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Term
| What tissue is present deep to the epidermis and dermis? |
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Definition
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Term
| What factors place patients at risk for impaired skin integrity? |
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Definition
| circulation, nutrition, age related changes, lifestyle and habits, condition of epidermis. |
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Term
| What does a petechiae lesion look like? |
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Definition
| Tiny punctate hemorrhages less than 2 mm round discrete, dark, red, purple or brown in color. |
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Term
| What does porpura look like? |
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Definition
| Confluent and extensive patch of petechiae and ecchymosis, flat macular hemorrhage. If petechiae larger than 0.5 cm in diameter they are known as purpura. |
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Term
| What is an intentional wound? |
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Definition
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Term
| What is an unintentional wound? |
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Definition
| trauma, gun shot, chest wound. |
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Term
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Definition
| wound that is produced by the tearing of soft body tissue. This type of wound is often irregular and jagged. |
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Term
| What is a puncture wound? |
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Definition
| wound is usually caused by a sharp pointy object such as a nail, animal teeth, or a tack. This type of wound usually does not bleed excessively and can appear to close up. |
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Term
| What is a "clean" intentional wound? |
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Definition
| Closed surgical wound not entering GI, Rasp., uninfected GU, genital, and/or oropharyngeal cavities. |
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Term
| what is a "clean-contaminated" intentional wound? |
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Definition
| surgery into resp. GU, and alimentary under controlled conditions. |
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Term
| What is a "contaminated" intentional wound? |
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Definition
| major break in aseptic technique, spillage from GI, or incision into infected areas. |
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Term
| What is a "open" intentional wound? |
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Definition
| surgical incision left open usually due to infected site or nature of surgery, with draining wound. |
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Term
| What is a "closed" intentional wound? |
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Definition
| part of body being injured by blunt object, a twisted limb, tearing of visceral organs. |
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Term
| What is the difference between an infected and a colonized wound? |
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Definition
| amount of bacterial organisms present. (an infected wound has more than a colonized) |
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Term
| What is the function of wound drainage? |
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Definition
| dilution of toxins produced by bacteria, dead cells. transports WBCs, proteins, and antibodies to site. removes debris, bacteria, and dead cells. |
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Term
| What is the appearance of serous wound drainage? |
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Definition
| watery in appearance, serum portion of blood. |
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Term
| What is the appearance of purulent wound drainage and what does it consist of? |
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Definition
| "pus" thick yellow,green,tan, or brown. severe inflammation w/infection, contains leukocytes, liquefied dead cells, dead and living bacteria |
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Term
| What is the appearance of sanguineous wound drainage and what does it consist of? |
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Definition
| pale, red, watery mixture of clear and red blood. large # RBC |
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Term
| What is the appearance of serosanguineous wound drainage? |
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Definition
| bloody, bright red. rainage is a mixture of serous and some blood tinged, seen with surgical incisions. |
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Term
| What are the types of closed suction wound drains? |
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Definition
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Term
| What are complications of a surgical wound? |
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Definition
| dehiscence, evisceration, infection, hemorrhage. |
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Term
| What is dehiscence, and what do you do if a patient has this? |
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Definition
| separation of a closed surgical site. Position patient so that there is no stress on incision, cover area w/sterile dressing, and call the doctor. |
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Term
| What is evisceration? What do you do if your patient has this? |
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Definition
| Seperation of a closed surgical incision, with bulging of internal organs. Do not try to put the viscera back, position patient so the incision has no stress, cover w/ sterile saline soaked gauze. Call Dr. STAT. |
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Term
| What is the primary intention of wound healing? |
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Definition
| Skin edges are approximated or closed together. |
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Term
| What is the secondary intention to wound healing? |
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Definition
| healing for wounds with tissue loss. (burns, pressure ulcers, severe uneven lacerations, or infected surgical area. skin is left open until scar tissue or granulated tissue forms. wet-moist dressings usually required. |
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Term
| What is the third intention of wound healing? |
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Definition
| Healing occurs when wound is closed at a later time, after the wound surfaces have already started to granulate. |
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Term
| What are some nursing diagnoses for a patient with a wound? |
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Definition
Risk for Infection: skin r/t
Impaired tissue integrity r/t
Impaired tissue perfusion
Acute Pain |
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Term
| What are some outcomes for a patient that has a wound? |
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Definition
Patient will be without signs/symptoms of infection throughout healthcare stay.
Wound size will decrease to...
Patient wound will heal by ....
Patient will state pain relief by… |
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Term
| What are the general care guidelines for wound and skin care? |
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Definition
| apply standard precautions, provide nutrition and fluids, use evidence-based practice in providing care, support and position the affected body part, and use hot or cold applications if indicated. |
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Term
| what are guidlines in obtaining a wound culture? |
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Definition
| Clean wound, zig-zag over wound, don't culture dead cells or pus/crust. |
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Term
| what is the purpose of using bandages and binders? |
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Definition
| support and cushion the area, secure a dressing, secure a splint, applies pressure, immobilizes an area, comfort |
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Term
| When giving a patient hot/cold treatments, what do you want to observe? |
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Definition
| pallor, redness, numbness, pain at treated site, comfort, safety, assess skin q 5-10min |
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Term
| What are gauze dressings used for? |
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Definition
| absorb exudate, pull drainage away from a wound. |
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Term
| What are hydrocolloid dressings used for? |
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Definition
| absorg exudate, maintain moisture, and break down necrotic tissue. (comes in granuaes, paste or wafer) stage 1-2 pressure ulcers. |
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Term
| What are hydrogel dressings used for? |
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Definition
| gel, or impregnated gause. same function as hydrocolloid, except in gel form. absorg exudate, maintain moisture, and break down necrotic tissue. |
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Term
| What is the function of transparent film dressings? |
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Definition
| promote a moist environment, protects the wound from outside contaminates and allows easy assessment of the wound. |
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Term
| What are foam dressings used for? |
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Definition
| To absorb moisture around drains or absorb moderate to heavy amounts of drainage in superficial or deep wounds. |
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Term
| What are alginate dressings used for? |
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Definition
| to pack a wound and are easy to remove. absorptive, comes in pastes, granules, sheets, or ropes. |
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Term
| what are common sites of pressure ulcers? |
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Definition
| heels, sacrum, lateral maleolus, greater trochanter, ischial tuberosities. |
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Term
| The greater the _______ and ______ the greater the risk for an ulcer. |
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Definition
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Term
| what is reactive hyperemia? |
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Definition
| body's response of vasodilation to the lack of blood flow to the tissues. If you press on a red area and it blanches, that is a good sign. hyperemia lasts less than one hour. |
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Term
| What does the braden scale evaluate? |
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Definition
| sensory, moisture, activity, mobility, nutrition, friction, and shear |
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Term
| What are pressure ulcer treatments? |
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Definition
| position q2, provide appropriate diet (vitamins a, b, c, k and high protein) frequently reassess, clean, dressing, specialty beds |
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Term
| what dressing would you use for a stage 1 pressure ulcer? |
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Definition
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Term
| what dressing would you use for a stage 2 pressure ulcer? |
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Definition
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Term
| What dressing would you use for a stage 3 pressure ulcer? |
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Definition
| Polyurethane foam, Hydrocolloid, Hydrogel, Calcium Alginate |
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Term
| What dressings would you use for a stage 4 pressure ulcer? |
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Definition
| Hydrocolloid, Hydrogel, Gauze roll |
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Term
| After the patient's first bandage is applied, who changes it? |
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Definition
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