Epidermis
e. Top layer of the skin
Dermis
f. Inner layer of the skin that provides tensile strength and mechanical support
Collagen
a. Tough, fibrous protein
Pressure ulcer
b. Localized injury to the skin and underlying tissue over a body prominence
Blanching
d. Normal red tones of light-skinned patients are absent
Darkly pigmented skin
c. Does not blanch
Identify the pressure factors that contribute to pressure ulcer development. (3)
a. Pressure intensity
b. Pressure duration
c. Tissue tolerance
Identify the risk factors that predispose a patient to pressure ulcer formation. (6)
a. Impaired sensory perception
b. Impaired mobility
c. Alteration in level of consciousness
d. Shear
e. Friction
f. Moisture
Staging systems for pressure ulcers are based on he depth of tissue destroyed. Briefly describe each stage.
Stage I
Stage I. Intact skin with nonblanchable redness of a localized are over a bony prominence
Staging systems for pressure ulcers are based on he depth of tissue destroyed. Briefly describe each stage.
Stage II
Stage II. Partial-thickness skin loss involving epidermis, dermis, or both
Staging systems for pressure ulcers are based on he depth of tissue destroyed. Briefly describe each stage.
Stage III
Stage III. Full-thickness with tissue loss
Staging systems for pressure ulcers are based on he depth of tissue destroyed. Briefly describe each stage.
Stage IV
Stage IV. Full-thickness tissue loss with exposed bone, tendon, or muscle
Define the following terms related to wound healing.
Granulation tissue
Red, moist tissue composed of new blood vessels, which indicates wound healing
Define the following terms related to wound healing.
Slough
Stringy substance attached to wound bed that is soft, yellow, or white tissue
Define the following terms related to wound healing.
Eschar
Black or brown necrotic tissue
Define the following terms related to wound healing.
Exudate
Describes the amount, color, consistency, and odor of wound drainage
Describe the physiological process involved with would healing.
Primary intention
Wound that is closed by epithelialization with minimal scar formation
Describe the physiological process involved with would healing.
Secondary intention
Wound is left open until it becomes filled by scar tissue; chance of infection is greater
Identify the three components involved in the healing process of a partial-thickness wound. (3)
a. Inflammatory response
b. Epithelial proliferation (reproduction)
c. Migration with reestablishment of the epidermal layers
Explain the four phases involved in the healing process of a full-thickness wound.
Hemostasis
Injured blood vessels constrict, and platelets gather to stop bleeding; clots form a fibrin matrix for cellular repair
Explain the four phases involved in the healing process of a full-thickness wound.
Inflammatory phase
Damaged tissues and mast cells secrete histamine (vasodilates) with exudation of serum and WBC into damaged tissues
Explain the four phases involved in the healing process of a full-thickness wound.
Proliferative phase
With the appearance of new blood vessels as reconstruction progresses, the proliferative phase begins and lasts from 3 to 24 days. The main activities during this phase are the filling of the wound with granulation tissue, contraction of the wound, and re
Explain the four phases involved in the healing process of a full-thickness wound.
Remodeling
Maturation, the final stage, may take up to I
year; the collagen scar continue to reorganize and gain strength for everal months.
Briefly explain the following complications of wound healing.
Hemorrhage
Bleeding from a wound site; occurs after
hemostasis indicate a slipped surgical suture, a dislodged clot, infection, or erosion of a blood vessel by a foreign object (internal or external)
Briefly explain the following complications of wound healing.
Hematoma
Localized collection of blood underneath the tissue
Briefly explain the following complications of wound healing.
Health care-associated infection
Second most common nosocomial infection; purulent material drains from the wound (yellow, green, or brown, depending on the organism)
Briefly explain the following complications of wound healing.
Dehiscence
A partial or total separation of wound layers; risks are poor nutritional status, infection, or obesity
Briefly explain the following complications of wound healing.
Evisceration
Total separation of wound layers with protrusion of visceral organs through a wound opening requiring surgical repair
The Braden Scale was developed for assessing pressure ulcer risks. Identify the subscales of this tool. (6)
a. Sensory perception
b. Moisture
c. Activity
d. Mobility
e. Nutrition
f. Friction or shear
List the factors that influence pressure ulver formation. (5)
a. Nutrition
b. Tissue perfusion
c. Infection
d. Age
e. Psychosocial impact of wounds
Explain the following factors that place a patient at risk for a pressure ulcer.
Mobility
Potential effects of impaired mobility; muscle tone and strength
Explain the following factors that place a patient at risk for a pressure ulcer.
Nutritional status
Malnutrition is a major risk factor; a loss of 5% of usual weight, weight less than 90% of lDW, or a decrease of 10 Ib in a brief period
Explain the following factors that place a patient at risk for a pressure ulcer.
Body fluids
Continuou exposure of the skin to body fluids, especially gastric and pancreatic drainage, increases the risk for breakdown.
Explain the following factors that place a patient at risk for a pressure ulcer.
Pain
Adequate pain control and patient comfort will increase mobility, which in turn reduce risk.
Identify the following types of emergency setting wounds.
Abrasion
Is superficial with little bleeding and is considered a partial-thicknes wound
Identify the following types of emergency setting wounds.
Laceration
Sometimes bleeds more profusely depending on depth and location (>5 cm or 2.5 cm in depth)
Identify the following types of emergency setting wounds.
Puncture
Bleed in relation to the depth and size, with a high risk of internal bleeding and infection
Explain how the nurse assesses the following.
Wound appearance
Whether the wound edge are closed, the condition of tissue at the wound base; look for complications and skin coloration
Explain how the nurse assesses the following.
Character of wound drainage
Amount, color, odor, and consistency of drainage, which depends on the location and the extent of the wound
Complete the table below describing the types of wound drainage.
Type: Serous
Appearance: ?
Clear, watery plasma
Complete the table below describing the types of wound drainage.
Type: Purulent
Appearance: ?
Thick, yellow, green, tan or brown
Complete the table below describing the types of wound drainage.
Type: Serosanguineous
Appearance: ?
Pale, pink, watery; mixture of clear and red fluid
Complete the table below describing the types of wound drainage.
Type: Sanguineous
Appearance: ?
Bright red; indicates active bleeding
Explain how the nurse assesses the following.
Drains
Observe the security of the drain and its location with respect to the wound and the character of the drainage; measure the amount.
Explain how the nurse assesses the following.
Wound closures
Surgical wound are closed with staples, sutures, or wound closures. Look for irritation around staple or suture site and note whether the closures are intact.
List the potential or actual nursing diagnosis related to impaired skin integrity. (8)
a. Risk for Infection
b. Imbalanced Nutrition: Less than Body
Requirement
c. Acute or Chronic Pain
d. Impaired Skin Integrity
e. Impaired Physical Mobility
f. Risk for Impaired Skin Integrity
g. Ineffective Tissue Perfusion
h. Impaired Tissue Integrity
List possible goals to achieve wound improvement. (3)
a. Higher percentage of granulation tissue in the
wound base
b. No further skin breakdown in any body location
c. An increase in the caloric intake by 10%
Identify the three major areas of nursing interventions for preventing pressure ulcers. (3)
a. Skin care
b. Mechanical loading and support devices
c. Education
List the principles to address to maintain a healthy wound environment. (6)
a. Manage infection.
b. Cleanse the wound.
c. Remove nonviable tissue.
d. Manage exudates.
e. Maintain the wound in moist environment.
f. Protect the wound.
Explain the rationale for debriding a wound.
Removal of nonviable necrotic tissue to rid the ulcer of a source of infection, enable visualization of the wound bed, and provide a clean base necksary for healing
Identify the four methods of debridement.
a. Mechanical
b. Autolytic
c. Chemical
d. Sharp or surgical
First aid for wounds includes the following. Briefly explain each one.
Hemostasis
Control bleeding by applying direct pressure in the wound site with a sterile or clean dressing, usually after trauma, for 24 to 48 hours
First aid for wounds includes the following. Briefly explain each one.
Cleansing
Gentle cleansing rather than vigorous cleansing with NS (physiological and will not harm tissue)
First aid for wounds includes the following. Briefly explain each one.
Protection
Applying sterile or clean dressings and immobilizing the body part
List the purposes of dressings. (7)
a. Protects a wound from microorganism
contamination
b. Aids in hemostasis
c. Promote healing by absorbing drainage and
debriding a wound
d. Support or splints the wound site
e. Protects the patient from seeing the wound
f. Promote thermal insulation of t
List the clinical guidelines to use when selecting the appropriate dressing. (6)
a. Use a dressing that will continuously provide a
moist environment.
b. Perform wound care using topical dressings as
determined by assessment.
c. Choose a dressing that keep the surrounding
skin dry.
d. Choose a dressing that controls exudates.
e. Consi
List the advantages of a transparent film dressing. (6)
a. Adheres to undamaged skin
b. Serves as a barrier to external fluid and bacteria but allows the wound surface to breathe
c. Promote a moist environment
d. Can be removed without damaging underlying
tissues
e. Permits viewing
f. Does not require a second
List the function of hydrocolloid dressings. (7)
a. Absorbs drainage through the use of exudate absorbers
b. Maintains wound moisture
c. Slowly liquefies necrotic debris
d. Impermeable to bacteria
e. Self-adhesive and molds well
f. Act as a preventative dressing for high-risk
friction areas
g. May be le
List the advantages of the hydrogel. (4)
a. Soothing and reduces pain
b. Provides a moist environment
c. Debrides the wound
d. Does not adhere to the wound base and is easy
to remove
List the guidelines to follow during a dressing change procedure. (4)
a. Assessment of the skin beneath the tape
b. Performing thorough hand hygiene before and
after wound care
c. Wear sterile gloves
d. Removing or changing dressings over closed
wounds when they become wet or if the patient
has signs and symptoms of infecti
Summarize the principles of packing a wound.
Assess the size, depth, and shape of the wound; dressing (moist) needs to be flexible and in contact with all of the wound surface; do not pack tightly (overpacking causes pressure): do not overlap the wound edges (maceration of the tissue).
Briefly describe how the wound vacuum-asssisted closure (wound VAC) device works.
Applies localized negative pressure to draw the edge of a wound together by evacuating wound fluids and stimulating granulation tissue formation and reduces the bacterial burden of a wound and maintain a moist environment
Identify three principles that are important when cleaning an incision. (3)
a. Cleanse in a direction from the least contaminated area to the surrounding skin.
b. Use gentle friction when applying solutions locally to the skin.
c. When irrigating, allow the solution to flow from the least to the most contaminated area.
Summarize the principles of wound irrigation.
Use of an irrigating syringe to flush the area with a constant low-pressure flow of solution of exudates and debris. Never occlude a wound opening with a syringe.
Explain the purpose for drainage evacuation.
Portable units that connect tubular drain lying within a wound bed and exert a safe, constant low- pressure vacuum to remove and collect drainage
Explain the benefits of binders and bandages. (6)
a. Creating pressure over a body part
b. Immobilizing a body part
c. Supporting a wound
d. Reducing or preventing edema
e. Securing a splint
f. Securing dressings
List the nursing responsibilities when applying a bandage or binder. (4)
a. Inspecting the skin for abrasions, edema,
discoloration, or exposed wound edges
b. Covering exposed wounds or open abrasions with a sterile dressing
c. Assessing the condition of underlying dressings and changing if soiled
d. Assessing the skin for und
Describe the physiological response to the following.
Heat applications
Improve blood flow to an injured part; if applied for more than 1 hour, the body reduces blood flow by reflex vasoconstriction to control heat loss from the area
Describe the physiological response to the following.
Cold applications
Diminishes swelling and pain, prolonged results in reflex vasodilation
List the factors that influence heat and cold tolerance. (7)
a. A person is better able to tolerate short exposure to temperature extremes.
b. More sensitive to temperature variations: neck, inner aspect of the wrist and forearm, and perineal region
c. The body responds best to minor temperature adjustments.
d. A p
Explain the rationale for the following types of applications.
Warm, moist compresses
Improve circulation, relieve edema, and promote consolidation of pus and drainage.
Explain the rationale for the following types of applications.
Warm socks
Promote circulation, Iessens edema, increases
muscle relaxation, and provide a means to debride wounds and apply medicated solutions
Explain the rationale for the following types of applications.
Sitz baths
The pelvic area is immersed in warm fluid, causing wide vasodilation
Explain the rationale for the following types of applications.
Commercial hot packs
Disposable hot packs that apply warm, dry heat to an area
Explain the rationale for the following types of applications.
Cold, moist, and dry compresses
Relieves inflammation and swelling
Explain the rationale for the following types of applications.
Cold soaks
Immersing a body part for 20 minutes
Explain the rationale for the following types of applications.
Ice bags or collars
Used for muscle prawn, localized hemorrhage, or hematoma
List the questions to ask if the identified outcomes were not met. (3)
a. Was the etiology of the skin impairment addressed?
b. Was wound healing supported by providing the wound base with a moist, protected environment?
c. Were issues such as nutrition assessed and a plan of care developed?
Mr. Post is in a Fowler position to improve his oxygenation status. The nurse notes that he frequently slides down in the bed and needs to be repositioned. Mr. Post is at risk for developing a pressure ulcer on his coccyx because of:
1. Friction
2. Macera
3. The force exerted parallel to the skin resulting from both gravity pushing down on the body and resistance between the patient and the surface.
Which of the following is not a subscale on the Braden scale for predicting pressure ulcer risk?
1. Age
2. Activity
3. Moisture
4. Sensory perception
1. Age is not a sub scale. Perception, moisture, activity, mobility, nutrition, friction, and shear are the subscale
Which of these patients has a nutritional risk for pressure ulcer development?
1. Patient A has an albumin level of 3.5.
2. Patient B has a hemoglobin level within normal limits.
3. Patient C has a protein intake of 0.5g/kg/day.
4. Patient D has a body we
3. The recommended protein intake for adults is 0.8g/kg; a higher intake of up to 1.8g/kg/day is necessary for healing.
Mr. Perkins has a stage II ulcer of his right heel. What would be the most appropriate treatment for this ulcer?
1. Apply a heat lamp to the area for 20 minutes twice daily.
2. Apply a hydrocolloid dressing and change it as necessary.
3. Apply a calcium a
2. See Table 48-8, p. 1203, for choice and rationale for dressing for ulcer stages.