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3802 #3
Circulation Part 1: Wound Care
| Question | Answer |
|---|---|
| The first four out of seven functions of the integumentary system are: | 1. protection, barrier 2. insulation 3. receives sensory stimuli 4. controls heat regulation |
| The last three out of seven functions of the integumentary system are: | 5. excretion 6. method of medication administration 7. displays emotions and physical identity |
| T or F Thinning of dermal layers is not an age related change | F- thinning of dermal layers is an age related change |
| T or F increased elasticity is an age related changes | F decreased elasticity is an age related change |
| T or F decreased sensation is an age related change | T |
| T or F less padding over bony prominences is an age related change | True |
| Four common age related changes include: | 1. thinning of dermal layers 2. decreased elasticity 3. decreased sensation 4. less padding over bony prominences |
| The replacement of lost cells and tissues with cells of the same type | tissue regeneration |
| healing as a result of lost cells being replaced by connective tissue | tissue repair |
| Tissue repair occurs by _____, _____ or _____ intention | - primary - secondary - tertiary |
| A surgical wound heals by _____ intention when the skin edges are approximated, or close, scarring is minimal, and the risk of infection is low | primary |
| A wound involving loss of tissue, such as a burn, pressure ulcer, or severe laceration, heals by ____ intention because the wound is left open until it becomes filled by scar | secondary |
| A surgical incision wound that is sutured or stapled is an example of ____ intention | primary |
| Pressure ulcers and surgical wounds that have tissue loss are examples of ____ intention | secondary |
| T or F nutritional deficiencies delay would healing | True |
| T or F adequate blood supply and corticosteroid drugs are factors that delay would healing | False- inadequate blood supply delays would healing |
| T or F infection delays wound healing | True |
| T or F Poor general health and mechanical friction are factors that delay would healing | True |
| decrease vascularization due to ____ is a factor that delays wound healing | obesity |
| T or F Anemia does not delay wound healing | False- anemia delays wound healing |
| T or F Diabetes mellitus delays wound healing | True |
| Nurtional Therapy to promote wound healing should include: | 1. high fluid intake 2. diet high in protein 3. Vitamins A, C, zinc |
| What should you primarily use to clean a wound | normal saline |
| The following should be assessed on a wound? | 1. location 2. size 3. draiange 4. color of wound 5. pain 6. tunneling 7. undermining |
| pocketing beneath the skin | tunneling |
| breakdown of SQ tissue around the wound | undermining |
| removal of nonviable, necrotic tissue | debridement |
| type of debridement - use of wet to dry dressing; not commonly used because it devitalized and viable tissue are both removed | mechanical debridement |
| type of debridement - uses synthetic dressing over a wound to allow eschar to be self-digested by the action of enzymes that are present in wound infections | autolytic debridement |
| type of debridement - use of topical enzyme prepartion, Dakin's solution, or sterile maggots | chemical debridement |
| type of wound drainge - clear, watery plasma | serous |
| type of wound drainage - thick, yellow, green, tan, or brown | purulent |
| type of wound drainage - pale, red, watery: mixture of clear and red fluid | serosanguineous |
| type of wound drainage - bright red: indicates active bleeding | sanguineous |
| Wound Classification - typically indicates granulation tissue: wound is in the inflammatory or proliferation phase of wound healing; protect the wound and keep in moist | Red (pale pink to beefy red) |
| If a wound is red in color what two phases could it potentially be in? | inflammatory or proliferation |
| Wound Classification - indicates presence of slough (dead but moist tissue); actively generates wound fluid and may need to be debrided; may need treatment of infection | yellow (page ivory to various shades of yellow green brown) |
| Wound Classification - indicates the presence of dead tissue that is dehydrated; may be covered with eschar; the wound cannot be assessed until the eschar is removed; eschar is an excellent medium for facterial proliferation | black (black/brown, tan) |
| Can a wound be assessed with the presence of eschar? | NO |
| Necrotic tissue should always be removed with the exception of what are of the body? | heel- debridement could cause infection and lead to osteomylitits |
| To confirm a wound infection, common diagnostic procedure and test are | - swab culture (by nurse) - biopsy (done only by MD) |
| prior to taking a wound culture, the wound must be cleaned with | normal saline |
| ___ is caused by compression of soft tissue between two hard surfaces | pressure ulcer |
| factors that dictate severity of pressure ulcer include: | 1. pressure intensity 2. pressure duration 3. tissue intolerance |
| occlusion of capillary closing pressure is a cause of | pressure ulcers |
| Pressure ulcers causes the tissue to become | ischemic and die |
| T or F decreased mobility and poor nutrition contribute to pressure ulcers | True |
| T or F fecal and urinary continence have no affect on development of pressure ulcers | False |
| Decreased sensory perception can lead to ___ | pressure ulcers |
| Complete or partial arterial blockage may lead to tissue necrosis and / or ulceration - not caused by pressure -ex. PVD - common in feet | Arterial Ulcer |
| _____are wounds that are thought to occur due to improper functioning of valves in the veins usually of the legs and are not caused by pressure. | Venous ulcers (or varicose ulcers) |
| To prevent pressure ulcers, ensure pt avoid pressure of the ____ if pt is on his/her side | trochanter |
| To prevent pressure ulcers, limit what position while patient is in bed? | limit the sitting position; limit time HOB is elevated to avoid pressure on sacral area |
| T or F You should massage areas that are susceptible to pressure ulcers | False- this creates shearing and/or friction; two causes of pressure ulcers |
| While a pt is sitting chair, how often should the nurse shift their weight | every 15 minutes |
| due to high glucose levels and poor circulation, diabetic pts are at increased risk for developing ______ on the feet | pressure ulcers |
| Treatment for Wounds with the following guidlines 5-6 days/wk X 1 month very flammable wear cotton gown | Hyperbaric Oxygen Therapy |
| T or F Stages of Pressure Ulcers can go backwards | False |
| Stage __ Pressure Ulcer and Interventions - skin is intact, but will have nonblanching redness -releive pressure, change mattress, ambulate patient | Stage I |
| Stage __ Pressure Ulcer - affects dermis and epidermis - top layer of skin is broken, shallow - protect skin with dressing | Stage II |
| Stage ___ Pressure Ulcer - wound continues to open and affect SQ | Stage III |
| Stage ___ Pressure Ulcer - wound continues all the way through the fascia and beyond | Stage IV |
| - skin feels spongy in this area of the body when skin begins to break down | heel |
| most common type of debridement is ____; fastest method of heeling | surgical |
| ice is used to vasoconstriction | heat is used for vasoconstriction |
| T or F Tissue regeneration does not cause scarring | True |
| T or F corticosteroids prolong healing process | True |
| Benefits of VAC therapy | 1. removes fluids 2. removes infectios materials 3. helps protect the wound environment 4. helps promote perfusion 5. helps draw wound edges together 6. promotes moist wound healing environment |
Created by:
Black88cat
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