Help
Options
Didn't know it?
click below
click below
Knew it?
click below
click below
Don't Know
Remaining cards (0)
Know
retry
shuffle
restart
0:00
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.
Normal Size Small Size show me how
Normal Size Small Size show me how
NUR151-WoundCare1
Wound Care and Skin Integrity
| Question | Answer |
|---|---|
| Epidermis | Several layers - top layer is dead cells, no blood vessels or nerves – when we bleed, the vessels are down further, Nutrients/fluid diffuse into it |
| Dermis | Appendages consist of hair follicles, sebaceous glands & sweat glands (2 types: Eccrine and Apocrine) - mostly CT which helps w/scar formation, hold hair follicles, sweat glands, & keep us together |
| Skin is useful how? | 1st line of defense, Prevents excess fluid loss, Provides sensory perception – sense pain, Synthesis & activation of Vit D on exposure to sm amounts of UV |
| Skin changes in older adults | FOCUS on Older Adults, Lose adipose tissue – cushion, Sensory perception not as strong, Skin elasticity is reduced –tents easily |
| What is a wound | Break in integrity of skin/mucus membrane caused by surgery, trauma, disease |
| Partial thickness wounds | shallow involving loss of epidermis and possible partial loss of dermis |
| Example of partial thickness wounds | papercut, scrape, blister, abrasion |
| __ can regenerate – scab forms and skin regenerates | Epidermis |
| Full thickness wounds | extend into the dermis or deeper – surgical, gunshot, stabbing, deep laceration, decub ulcer |
| Full thickness wounds heal by | scar formation |
| Inflammation phase of partial thickness wound | Lasts about 24hours, Redness & swelling, serous exudate – clear/watery |
| Epithelial Proliferation of partial thickness | superficial wounds - epithelial cells regenerate & migrate across wound surface from edges –only migrate across moist surface – good tissue looks “red and beefy” |
| Open to air resurfacing | 7 days – moist is 4 days |
| 3 stages of partial thickness wound healing | Inflammation (24 hours), Epithelial proliferation, & Reestablishment of epithelial layers |
| 3 stages of full thickness wound healing | Inflammation (around 3 days), Proliferation (Granulation) phase 3 – 24 days, Remodeling Phase (7 days – mo or years) |
| Reestablishment of Epithelial Layers | Initial resurfacing very thin, appears pink & dry, Must re-establish epithelial layers over time |
| Full thickness inflammation phase | Inflammation phase |
| Fibrin clot serves as | matrix for cellular repair |
| Proliferation (Granulation) phase of full thickness wound repair | 3-24d - fills w/granulation tissue & surface re-epithelialized - Immature CT (fibroblasts) migrate to site & secrete collagen - wound appears pink, grainy - budding capillaries – this a good thing! |
| Remodeling Phase/Scar contracture of full thickness wound repair | 7d- mo. or yrs. - Remodeling of collagen, contraction & strengthening of scar, Appears pale, avascular |
| Scar tissue is not as strong as regular tissue making it | at risk for opening up again due to skin breakdown |
| Assessing wound - note wound appearance | redness, swelling, warmth, tenderness, presence of granulation or necrotic tissue |
| Slough | yellowish & stringy |
| Eschar | black or brown – Necrotic tissue must be removed so that granulation tissue can regenerate. |
| Undermining | when wound descends further under the skin |
| Tunneling | abnormal passageway in the tissue – wound tunnels to an organ like a bowel - Don’t know how deep they go - have to heal by secondary intention- heal from the inside out. |
| Measure Size of wound how often | One a day – Once a week – depends on extent/severity - Most are measured 1 – 2 times per week - measure in cm - use only sterile q-tips in the wounds |
| Measurements of wounds are done how? | head to toe = length, side to side = width, depth at deepest point |
| Gently clean wound w/normal saline or commercial wound cleanser only Why? | Removes debris, toxins, necrotic tissue w/o damaging healthy tissue |
| Chemical debridement | collagenase, papain-urea, Dakin’s solution,sterile maggots |
| Mechanical debridement | Wet to dry dressings - Wound irrigation 8psi w/ 35ml syringe & 19g needle or 18g angiocath – squirt inside wound, Whirlpool |
| Autolytic | occlusive or semi-occlusive dressing promotes body’s softening of Eschar - transparent or hydrocolloid dressings |
| Stable means | it is dry, adherent, intact without erythema or fluctuance -area not stable/mushy |
| stable eschar on the heels serves | as the body’s natural cover and should not be debrided |
| Choose type of dressing based on | purpose, type of wound, amount of exudate – you follow physician’s orders, - choose dressing that allows for proper absorbency |
| Purpose of Dressings | Protects wound from microorganisms, Aids in hemostasis, Provides moist environment, Suports or splints site, Promotes thermal insulation |
| Gauze | woven & non-woven - Wet to moist - Wet to dry – used for packing & delivery of solutions to wound |
| Non-adherent dressings | Adaptic, Vaseline, Telfa – doesn’t pull off the granulation tissue – used a lot on surgical incisions. Shiny |
| Transparent films | Tegaderm, Biocclusive – cover IV sites and wounds – used on partial thickness – minimal exudate |
| Hydrocolloids | Duoderm, Comfeel – used on the coccyx area a long – want to cover the are so it doesn’t become infected – minimal tomoderate exudate – autolysis promoter |
| Absorptive dressings | Kerlix fluffs (using multiple ones together makes a “kluff”), ABDs, Surgipads |
| Foams | Lyofoam, Curafoam – absorbs moderate to heavy exudate – maintains moist environment - semipermeable |
| Hydrogels | Supply moisture to dry wound- Cover w/gauze or hydrocolloid |
| Alginates | Sorban, AlgiDerm – supplied in a dry form – look like filaments of cotton – they turn into jelly when exposed to moisture – absorbs moderate to heavy exudate |
| Antimicrobial | Prisma |
| What would you use to dress Stage I pressure Ulcer? | None, transparent, hydrocolloid – protects from shear – resolves slowly w/o epidermal loss |
| What would you use to dress Stage II pressure Ulcer? | Composite film (limits shear), hydrocolloid, hydrogel (provoids moist environ) – heals through reepithelialization |
| What would you use to dress Stage III pressure Ulcer? | Hydrocolloid, hydrogel w/foam, calcium alginate, gauze, growth factors – Heals through granulation and reepithelialization |
| What would you use to dress Stage IV pressure Ulcer? | Hydrogel, Calcium alginate gauze, growth factors Adherent film, gauze, enzymes – Heals through granulation and reepithelialization |
| Red wound examples | skin tears, pressure ulcers (stage II), partial-thickness or 2-deg burns, surgical allowed to heal by secondary intention |
| Red wound appearance | Clean, pink or red w/ granulating tissue |
| What kind of dressing might be used if red wound is superficial | bandaid, gauze, hydrocolloid (duoderm) |
| If red wound is deeper and has moderate drainage? | gauze dressing – wound vacs are good w/red wounds |
| What does yellow wound look like? | presence of slough – yellowish or greenish in color and necrotic tissue |
| What kind of dressing might be used for yellow wound? | absorption dressing - calcium alginate, foam, hydrogel - absorbs exudate and cleanses the wound surface |
| Thick black necrotic tissue | eschar |
| What type of wounds usually have Eschar? | full-thickness or third-degree burns, pressure ulcers (stages III and IV) and gangrenous ulcers |
| Best way to remove Eschar? | Surgical debridement – other ways – Mechanical, Enzymatic ointments, Dressings to promote softening – Hydrogel, Wet to dry dressings – pull off when dry to debride |
| Protein is important for | wound remodeling and wound healing also helps fight infection – collagen formation |
| Zinc | Collegen Formation, protein synthesis, cell membrane, host defenses |
| Vit C | Collagen synthesis, capillary wall integrity, fibroblast function, immunologic, antioxidant |
| Vit A | Epithelialization, wound closure, inflammatory response, angiogenesis, collagen formation – can reverse steroid effects on skin & delayed healing |
| Inflammatory Response to Cell Injury | Vascular Response – 1 generally occur simultaneously w/cellular, 2 Cellular Response, 3 Formation of exudate, 4 Healing |
| Vascular Response Phase | Hemostasis (vasoconstriction), release of histamine, WBCs & other chemicals (vasodialation), Increased capillary permeability –edema |
| Cellular Response | Specialized WBCs (first neutrophils, then monocytes) move to site of injury to clean debris |
| Leukocytosis is | Increase in white blood count |
| CBC Differential | Part of it is the WBC count and see the specific WBCs to see if they have increased |
| Exudate Formation | Caused by release of chemical mediators, Function of drainage |
| Nature and amount of exudate depends on | tissue involved, type of wound, intensity & duration of inflammation –longer it lasts = more exudate, presence of microorganisms –look for color, amount, consistency |
| Serous | mild inflammation – blister - Serum - watery, low protein |
Created by:
Ladystorm