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Chapter 35 Potter &

Skin Integrity and Wound Care

________________ is the term used to describe impaired skin integrity resulting form pressure. pressure ulcer
A patient experiencing decreased mobility, inadequate nutrition, decreased sensory perception, or decreased activity is a risk for ________________ development. pressure ulcer
________________ occurs when capillary blood flow is obstructed, as in the case of pressure. tissue ischemia
________________ is an area of skin that appears red and warm and will turn lighter in color following fingertip palpation. blanchable hyperemia
________________ is redness that persists after palpation and indicates tissue damage. nonblanchable hyperemia
________________ is the force exerted against the skin while the skin remains stationary and the boy structures move. shear
________________ is an injury to the skin that has the appearance of an abrasion. friction
________________ on the skin increases the risk of ulcer formation. moisture
Poor nutrition, specifically severe ________________, causes soft tissue to become susceptible to breakdown. protein deficiency
Low ________________ cause edema or welling, which contributes to problems with oxygen transport and the transport of nutrients. protein levels
In patients with ________________, hypoalbuminemia(serum albumin level below 3 g/100 mL) leads to a shift of fluid from the extracellular fluid volume to the tissues, resulting in edema. severe protein loss
serum albumin level below 3 g/100 mL hypoalbuminemia
total protein level below 5 g/100 mL total protein
________________ increases the affected tissue's risk for pressure ulcer formation. edema
________________ is generalized ill health and malnutrition, marked by weakness and emaciation. cachexia
extreme thinness emaciation
A patient with an ________________ usually has a fever. infection
Infection and fever increase the ________________ of the body, making already hypoxic tissue more susceptible to ischemic injury. metabolic needs
Skin structure changes with ________________, causing a loss of dermal thickness and an increase in the risk of skin tears. age
________________ are at highest risk for development of pressure ulcers. older adults
60% to 90% of all pressure ulcers occur in patients over ________________ years of age. 65
Pressure exerted against the skin surface causes ________________, usually a bone and the surface of the bed compress the skin. pressure ulcers
When the intensity of the pressure exerted to the capillary exceeds ________________, this occludes the vessel, causing ischemic injury to the tissues it normally feeds. 12 to 32 mm Hg
The ulcer appears a s defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones the ulcer appears with persistent red, blue, or purple hues and the skin intact. stage I
Partial-thickness skin loss involving epidermis, dermis, or both; the ulcer is superficial and presents as an abrasion, blister, or shallow crater (skin is broken). stage II
Full-thickness skin loss involving damages to, or necrosis of, subcutaneous tissue that extends down to, but not through, underlying fascia; the ulcer presents as a deep crater with or without undermining of surrounding tissue. stage III
Full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures. stage IV
dead, dry tissue eschar
A wound with little or no tissue loss, such as a clean surgical incision, heals by ________________. primary intention
when skin edges are close together approximate
A wound involving loss of tissue such as a severe laceration or a chronic wound such as a pressure ulcer heals by ________________. secondary intention
The wound heals with a layer of ________________ at the edges and base, and several day s after the initial wounding the wound edges are brought together with sutures or adhesive closures. granulation tissue
________________ are the first response to a partial-thickness wound repair, bringing white blood cells to the site. erythema and edema
The inflammatory response of a partial-thickness wound repair appears ________________. red and swollen
During the inflammatory response of a partial-thickness wound repair, the ________________, or discharge, if allowed to dry, brings the white blood cells to the area and a scab will form. exudate
The inflammatory response of a partial-thickness wound repair occurs for approximately ________________. 24 hours
Peak epithelial proliferation occurs within ________________ after injury. 24 to 72 hours
peak epithelial proliferation epidermal cell migration across a wound
Wounds kept in a moist environment will heal in approximately ________________ (as opposed to 7 days when kept dry) b/c new epithelial cells migrate across a moist surface. 4 days
With ________________ , the epidermis thickens, anchors to adjacent cells, and resumes normal function and looks pink, dry, and fragile. dermal repair
During full-thickness wound repair, the first event of ________________ is hemostasis. inflammatory phase
________________ cause coagulation and vasoconstriction within inflammatory phase during full-thickness wound repair. platelets
The ________________ during full-thickness wound repair lasts approximately 3 days in an acute clean wound, such as a surgical incision. inflammatory phase
The key events in the ________________ of full-thickness wound repair are production of new tissue, epithelialization, and contraction. proliferative phase
The ________________ of full-thickness wound repair, which lasts up to 1 year, reorganizes the collagen to produce a more elastic, stronger collagen for the scar tissue. remodeling phase
The tensile strength of the scar tissue during the remodeling phase of full-thickness wound repair is never more than ________________ of the tensile strength in non-wounded tissue. 80%
Bleeding from an acute wound is normal during and immediately after initial trauma, but ________________ usually occurs within several minutes. hemostasis
hemostasis cessation of bleeding by vasoconstriction and coagulation
collection of clotted blood hematoma
________________ prevents healing by increasing tissue damage and altering the healing process. bacterial wound infection
A contaminated or traumatic wound infection develops within ________________. 2 to 3 days
A surgical wound infection develops within ________________. 4 to 5 days
________________ of a wound infection include fever, general malaise, and an elevated white blood cell count. systemic signs
________________ is the partial or total separation of layers of skin and tissue above the fascia in a wound that is not healing properly. dehiscence
________________ have a high risk for dehiscence because of constant strain on their wounds and the poor vascularity of fatty tissue. obese patients
Dehiscence occurs most often in ________________ after a sudden strain such as coughing, vomiting, or sitting up in bed. abdominal surgical wounds
When ________________ drainage increases from a wound, be alert for dehiscence. serosanguineous
________________ occurs when wound layers separate below the fascial layer, and visceral organs protrude through the wound opening. evisceration
A ________________ is an abnormal opening between two organs or between an organ and the skin. fistula
________________ increase the risks of infection, fluid and electrolyte imbalances, and skin breakdown fro chronic drainage. fistulas
In the ________________, some patients require well-though-out modifications of wound care techniques. immediate postoperative period
Skin assessment for the patient with intact darkly pigmented skin: appears ________________ than surrounding skin--purplish, bluish, eggplant. darker
Skin assessment for the patient with intact darkly pigmented skin: use ________________ light versus fluorescent lamps. natural or halogen
Skin assessment for the patient with intact darkly pigmented skin: ________________ is taut, shiny, or indurated (edema occurs w/more than 15 mm dia.) tissue consistency
Skin assessment for the patient with intact darkly pigmented skin: assess for for firm or ________________ feel. boggy
Skin assessment for the patient with intact darkly pigmented skin: skin may feel initially ________________, but subsequently may feel ________________. warmer; cooler
Use ________________ such as creams, ointments, pastes, and film forming skin protectants as needed to protect and maintain intact skin. incontinence skin barriers
Use ________________ to transfer patients in bed. lift sheets
Maintain head of bed at , or below ________________ or at the lowest level of elevation consistent with the patient's medical condition. 30 degrees
Avoid ________________ over bony prominences. vigorous massage
When you notice ________________, document location, size, and color, and reassess the area after 1 hour. hyperemia
Turning time - arrhythmia time = next turning time
If you suspect ________________, outlining the affected area with a marker makes reassessment easier. nonblancable hyperemia
Nonblanchable hyperemia is an early indicator of ________________, but damage to the underlying tissue is sometimes more progressive. impaired skin integrity
________________ is associated with overall morbidity and mortality. malnutrition
Inadequate caloric intake causes ________________ and a decrease in subcutaneous tissue, allowing bony prominences to compress and restrict circulation. weight loss
The ________________ is less tolerant to pressure, friction, and shear b/c of decreased elasticity from normal aging. older adult's skin
The major change in aging skin is dryness, which affects as many as ________________ of patients over the age of 64. 59% to 85%
The thinning of the dermis and flattening of the dermal-epidermal junction that occur in aging predispose the older adult's skin to ________________. tearing
abrasion loss of dermis
An ________________ is usually superficial with little bleeding but some weeping. abrasion
plasma leakage from damaged capillaries abrasion
A ________________ is damage to the dermis and epidermis and is a torn, jagged wound. laceration
The depth and location of the ________________ affect the extent of bleeding, with serous bleeding possible in lacerations greater than 5 cm (2 inches) long or 2.5 cm (1 inch) deep. laceration
________________ bleed in relation to the depth and size of the wound. puncture wounds
Internal bleeding and infection are the ________________ of puncture wounds. primary dangers
3 steps of assessing a puncture wound: 1. inspect the wound for ________________. contaminant material
3 steps of assessing a puncture wound: 2. assess the ________________ of the wound and the need for suturing or surface protection. size
3 steps of assessing a puncture wound: 3. If from a dirty penetrating object, ascertain if patient has had a ________________ injection within the last year. tetanus toxoid
________________ provide an excellent environment for bacterial growth. saturated dressing
When you plan a dressing change, give the patient an analgesic at least ________________ before exposing a wound. 30 minutes
Risk for malnutrition: age: < ________________ years or > ________________ years. 18; 64
Risk for malnutrition: age: weight ________________ loss in 1 to 6 month. 5 to 10%
Risk for malnutrition: albumin: < ________________ mg/dl 3.0
Risk for malnutrition: total protein ________________ mg/dl 5.0
ecchymosis superficial bleeding under the skin or a mucous membrane; a bruise
A simple method for estimating the volume of ________________ is to report the number and type of dressings used and saturated over an interval of time. wound drainage
Types of wound drainage: serous clear, watery plasma
Types of wound drainage: sanguineous fresh bleeding
Types of wound drainage: serosanguineous pale, more watery, a combination of plasma and red cells, may be blood-streaked
Types of wound drainage: purulent thick, yellow, green, brown, indicating the presence of dead or living organisms and white blood cells
Note the character and amount of drainage if there is a ________________. collecting device
Notify the ________________ of any sudden decrease that indicates a blocked drain or an increase indication bleeding or infection. physician or health care provider
When a wound exhibits swelling, separtion of its edges, or redness in the periwound area, it is important to evaluate for the presence of ________________. cellulitis
Use ________________ to detect localized areas of tenderness or collection of drainage. light palpation
Pain assessment is an important component of ________________ for detecting complications and planning for future wound care. wound assessment
Never collect a wound culture sample from ________________, b/c resident colonies of bacteria grow in exudate. old drainage
To collect an ________________, wipe a sterile swab from a culturette tube onto clean, healthy-looking tissue, return the swab to the culturette tube, cap the tube, and crush the inner ampule so that the medium for organism growth coats the swab tip. aerobic specimen
Nursing diagnoses relevant to wound care: risk for ________________ infection
Nursing diagnoses relevant to wound care: impaired ________________ physical mobility
Nursing diagnoses relevant to wound care: ________________ bed mobility impaired
Nursing diagnoses relevant to wound care: imbalanced nutrition: ________________ less than body requirements
Nursing diagnoses relevant to wound care: ________________ pain acute
Nursing diagnoses relevant to wound care: ________________ pain chronic
Nursing diagnoses relevant to wound care: situational low ________________ self-esteem
Nursing diagnoses relevant to wound care: impaired ________________ skin integrity
Nursing diagnoses relevant to wound care: risk for impaired ________________ skin integrity
Nursing diagnoses relevant to wound care: ineffective ________________ tissue perfusion
________________ for predicting pressure sore risk Braden Scale
A score of ________________ on the Braden Scale indicates at risk for pressure sores. 16
A score of ________________ on the Braden Scale indicates at high risk for pressure sores. <=9
Do not ________________ reddened areas b/c reddened areas indicate tissue injury. massage
When cleansing the skin, use a ________________ agent. mild cleansing
A ________________ will provide skin protection form the irritating effects of stool or urine and will allow you to clean the next incontinent episode easily. moisture barrier
Most underpads and briefs have a ________________ that holds moisture against skin. plastic outer lining
Diapers and underpads will ________________ the skin if left under patients for prolonged periods of time. irritate
A standard turning interval of ________________ will not prevent pressure sore development in some patients such as an immobilized patient. 1 to 2 hours
The WOCN recommends reducing ________________ by keeping the patient's head of bed below the 30-degree angle, using assistive devices when turning or transferring patients, using the bed gatch or footboard, and using the 30-degree lateral position. shear
When the patient is able to sit int he chair, reposition the patient every ________________. hour
Assist or teach patients with the ability to shift weight every ________________. 15 minutes
________________ decrease teh amount of pressure exerted over bony prominences by maximizing contact (allowing the body to touch the entire surface) and thereby redistributing weight over a large area. support surfaces
When using a ________________, make sure there are minimal layers of bed linens between the patient and the surface. support surface
Place ________________ on a pressure reduction/relief surface and not on an ordinary hospital mattress. at-risk individuals
Avoid using foam rings, donuts, and sheepskin for ________________. pressure reduction
________________ concentrate the pressure to the surrounding tissue. foam rings and donuts
The patient must receive ________________ to achieve wound healing. systemic support
________________ is necessary to support new blood vessels and collagen synthesis. protein intake
Certain medications and medical conditions influence ________________. wound healing
B/c ________________ causes problems with wound healing, blood glucose control is essential. hyperglycemia
A ________________ environment is necessary to promote healing. stable wound
To maintain a ________________ it is important to control infection and promote cleansing, debridement, exudate management, control of dead space, and wound protection. stable environment
Assess the patient with a ________________ for signs and symptoms of a wound infection: redness, warmth of surrounding tissue, odor, and the presence of exudate. pressure ulcer
Cleanse pressure ulcers at each ________________ to promote removal of wound debris and bacteria from the wound surface. dressing change
________________ slows wound healing b/c it becomes a source for infection and a barrier for epithelialization. necrotic tissue
Cleanse dirty wounds with ________________. irrigation
Clean wounds require only gentle flushing with ________________. normal saline solution
A ________________ supports wound healing. moist wound environment
Excessive ________________ will macerate the wound edges and interfere with wound healing. wound moisture
Allow a ________________ to bleed to remove dirt and other contaminants. puncture wound
If a ________________ is in a patient's body, do not remove the object. penetrating object
Gentle ________________ of a wound removes contaminants that serve a sources of infection. cleansing
________________ causes bleeding or further injury. vigorous cleaning
Ideally a ________________ provides a moist environment to promote normal epidermal cell migration. dressing
The proper dressing will absorb ________________ to prevent polling of exudate that promotes bacterial growth. drainage
The proper dressing prevents ________________ from coming into contact with intact skin. wound drainage
A dressing ________________ wound exposure to microorganisms. discourages
If a wound has minimal drainage, the natural formation of a ________________ eliminates the need for a dressing. fibrin seal
A pressure dressing promotes ________________ by exerting localized, downward pressure over an actual or potential bleeding site. hemostasis
A pressure dressing fosters ________________ by eliminating dead space in underlying tissues. normal healing
Assess skin color, pulses in distal extremities, patient comfort, and any changes in sensation to ensure pressure dressings do not interfere with ________________. circulation
A ________________ promotes healing by allowing the wound to heal by primary intention and absorbing minimal oozing of wound drainage. dry dressing
The purpose of a ________________ dressing is to act as a sponge, absorbing excessive wound drainage, while providing a moist environment. moist gauze
________________ is the most common dressing type. gauze
________________ does not interact with wound tissues and thus causes little wound irritation. gauze
________________ are useful in debriding wounds. wet-to-dry or moist-to-dry
The process of softening a solid by steeping in a fluid. maceration
________________ dressings are clear sheets coated on one side with an adhesive. transparent film
Transparent film dressings are used as a ________________ in wounds with minimal tissue loss that have very little wound draingage. primary dressing
You change a transparent film dressing when the seal is ________________. broken
________________ dressings are made of gelling agents and have an adhesive wound surface. hydrocolloid
________________ form a gel as they interact with the wound surface. hydrocolloids
________________ dressings are available in sheets or in a gel in a tube (amorphous). hydrogel
Hydrogels maintain moisture in some wounds for ________________. 1 to 3 days
A new treatment for chronic wounds is the wound ________________. vacuum assisted closure
Wound closure applies ________________ to the wound to promote and accelerate healing. negative pressure
add dressings w/o removing existing ones as needed reinforce dressing prn
An order to "reinforce dressing prn" is common immediately after ________________, when the physician or health car provider does not want accidental disruption of the suture line or loss of hemostasis. surgery
Use tape, ties, or bandages and cloth binders to secure a ________________ over a wound site. dressing
To avoid repeated removal of tape from sensitive skin, secure dressings with reusable ________________. Montgomery ties
Whenever cleansing a wound, clean from the ________________ contaminated area to the ________________ contaminated. least; most
Do not use povidone-iodine (Betadine0, hydrogen peroxide, and acetic acid (vinegar) to irrigate a ________________. They kill ________________, a key component in wound healing. clean, granular wound; fibroblasts
When ________________, allow the solution to flow from the least contaminated to the most contaminated area. irrigating
Administer the prescribed solution at ________________ to enhance comfort and provide local cleansing application. body temperature
When irrigating clean wounds, use sterile technique and an irrigation system with a safe pressure (________________) to prevent trauma to the newly formed granulation tissue. 4 to 15 psi
An example of a safe wound cleansing and irrigation system is a 35-mL syringe and a 19-gauge needle, which has a ________________. psi of 8
________________ are threads or wires made of silk, steel, cotton, nylon, and polyester (Dacron) and are used to sew body tissues together. sutures
________________ are convenient, portable units that connect to tubular drains within a wound bed and exert a safe, constant, low-pressure vacuum to remove and collect drainage. drainage evacuators
Before applying a bandage or binder, perform the following steps: 1. Inspect the ________________ for abrasions, edema, discoloration, or exposed wound edges. skin
Before applying a bandage or binder, perform the following steps: 2. Cover exposed wounds or open abrasion with a ________________. sterile dressing
Before applying a bandage or binder, perform the following steps: 3. Assess the condition of ________________, and change if they are soiled. underlying dressings
Before applying a bandage or binder, perform following steps: 4. Assess skin of ________________ & parts that will be distal to bandage for signs of circulatory impairment to provide a means for comparing changes in circulation after bandage application. underlying body parts
________________ impair chest expansion. breast binder
The local application of ________________ to an injured body part provides therapeutic benefits. heat and cold
Systemic responses occur through ________________ (sweating or vasodilation) or mechanisms promoting heat conservation (vasocontriction or piloerection) and heat production (shivering). heat loss mechanisms
________________ generally is therapeutic. heat
If ________________ is applied for 1 hour or more, a reflex vasoconstriction reduces blood flow as the body attempts to control heat loss from the area. heat
Continuous exposure to ________________ damages epithelial cells, causing redness, localized tenderness, and even blistering of the skin. heat
Prolonged exposure of the skin to ________________ results in a reflex vasodilation. cold
Factors influencing heat & cold tolerance: 1. duration of application - a person is better able to tolerate ________________ to any temperature extremes. short exposures
Factors influencing heat & cold tolerance: 2. Body part - The neck, inner aspect of the wrist and forearm, and perineal regions are ________________ sensitive to temperature variations. The foot & the palm of the hand are ________________ sensitive. more; less
Factors influencing heat & cold tolerance: 3. Damage to body surface - Exposed skin layers are ________________ sensitive to temperature variations. more
Factors influencing heat & cold tolerance: 4. Prior skin temperature - The ________________ responds best to minor temperature adjustments. body
Factors influencing heat & cold tolerance: 5. Body surface area - A person is ________________ of temperature changes over a large area of the body. less tolerant
Factors influencing heat & cold tolerance: 6. Age & physical condition - The very young and old are ________________ sensitive to heat & cold. most
If the patient has ________________, it is unwise to apply heat to large portions of the body b/c massive vasodilation will disrupt blood supply to vital organs. cardiovascular problems
Cold is ________________ if the site of injury is edematous or the patient has impaired circulation or is shivering (may intensify shivering and reduce blood flow). contraindicated
The patient who has had rectal surgery or an episiotomy during childbirth or who has painful hemorrhoids or vaginal inflammation will benefit from a ________________, a bath in which only the pelvic area is immersed in warm fluid. sitz bath
heat therapy: vasodilation improves blood flow to injury body part; example: arthritis or degenerative joint disease
heat therapy: reduced blood viscosity promotes delivery of nutrients and removal of wastes; example: localized joint pain or muscle strains
heat therapy: reduced muscle tension promotes muscle relaxation; example: menstrual cramping
heat therapy: increased tissue metabolism provides local warmth; example: hemorrhoidal, perianal, and vaginal inflammation
heat therapy: increased capillary permeability promotes movement of waste products and nutrients; example: local abscesses
cold therapy: vasoconstriction reduces blood flow to injured site, preventing edema formation; example: immediately after direct trauma (e.g., sprains, strains, fractures, muscle spasms)
cold therapy: local anesthesia reduces localized pain; example: superficial laceration or puncture wound
cold therapy: reduced cell metabolism reduces oxygen needs of tissues; example: minor burn
cold therapy: increased blood viscosity promotes blood coagulation at injury site; example: after injections
cold therapy: decreased muscle tension relieves pain; example: arthritis or joint trauma
Conditions that increase risk of injury from heat and cold application: very young; older adults thinner skin layers increase risk of burns; ________________ have reduced sensitivity to pain
Conditions that increase risk of injury from heat and cold application: open wounds, broken skin subcutaneous tissue is more sensitive to temperature variations
Conditions that increase risk of injury from heat and cold application: areas of edema or scar formation there is reduced sensation to temp. & pain stimuli b/c of scar formation
Conditions that increase risk of injury from heat and cold application: peripheral vascular disease (e.g., diabetes, arteriosclerosis) body's extremities are less sensitive to temp. & pain stimuli b/c of circulatory impairment & local tissue injury; cold application further compromises blood flow
Conditions that increase risk of injury from heat and cold application: confusion or unconsciousness there is reduced perception of sensory or painful stimuli
Conditions that increase risk of injury from heat and cold application: spinal cord injury alterations in nerve pathways prevent reception of sensory or painful stimuli
high pressure over short time; low pressure over long time same results - potential pressure ulcers
A ________________ occurs when problems with sensory reception pr perception exist. sensory deficit
________________ occurs when inadequate quality or quantity of stimuli impairs perception. sensory deprivation
When a person receives multiple sensory stimuli, the brain has difficulty distinguishing the stimuli that causes a ________________ to occur. sensory overload
a common progressive hearing disorder in older adults presbycusis
gradual decline in ability of the lens to accommodate or to focus on close objects; reduces ability to see near objects clearly presbyopia
examples of medications reported to cause ototoxicity antibiotics, diuretics, analgesics/NSAIDs, antineoplastic agents
gustatory taste
proprioception position and movement in space
olfactory smell
Created by: chaptravelman