tissue integrity

true or false: A contaminated or traumatic wound may show sign of infection within 24 hours. A surgical wound infection usually develops postoperatively with 14 days.

false

stage 3 pressure ulcer

full thickness skin loss involving damage or necrosis of subcutaneous tissue. Doesn't involve fascia.

stage 4 pressure ulcer

full thickness with extensive destruction, tissue necrosis, damage to muscle, bone, or supporting structures undermining and sinus tracts may occur.

complications of wound healing

hemorrhage, infection, dehiscence, evisceration

nutritional interventions

improve wound healing through increased protein and calories

maturation stage

21 days-2 years: collagen fibers continue to reorganize stretch, doesn't have the same strength as the tissue being replaced, also less pigmentation.

Which of the following patients would be expected to benefit from a moist-to-dry dressing? A) A 24 year-old patient with an open, infected wound from a spider bite. B) A 7 year-old with abrasions on the knees C) A 50 year-old with a postoperative knee replacement incision D) A 30 year-old who had a large cyst removed and now has some necrotic tissue present in the crater type wound.

A and D Moist to dry dressings are best used with necrotic, infected wounds requiring debridement. Moist dressings are often used for abrasions and postoperative incisions when minimal drainage is anticipated.

When teaching a patient about wound healing, the nurse should tell the patient which of the following? A) Inadequate nutrition delays wound healing and increases the risk of infection. B) Chronic wounds heal more efficiently in a dry, open environment, so leave them open to air whenever possible. C) Long-term steroid therapy diminishes the inflammatory response and speeds wound healing. D)Fat tissue heals more readily because there is less vascularization.

A) Rationale: Inadequate nutrition, including proteins, carbohydrates, lipids, vitamins, and minerals delays tissue repair and increases risk for infection. Both full thickness and partial thickness wounds heal more efficiently in a moist, protected environment. Long term steroid therapy may diminish the inflammatory response and reduce the healing potential. Fat tissue has less blood supply, which decreases transport of nutrients and cellular elements required for healing.

When should wound drainage be cultured? A) When there is a change in color, amount, or odor of drainage. B) If the patient complains of pain. C) When the drain is removed. D) If the nurse empties the drainage evacuator without applying sterile gloves.

A) Wound drainage should be cultured when infection is suspected, as indicated by the drainage appearing to be purulent, a change in the amount or color of the wound drainage, or when a foul odor of the drainage is noted. It is appropriate for the nurse to wear clean gloves to empty the drainage evacuator.

Which of the following are functions of dressings? (Select all that apply) A To promote hemostasis B To keep the wound bed dry C Wound debridement D To prevent contamination E To increase circulation

A,C,D Dressings provide several functions, which include debridement, maintaining a moist wound environment, protecting from outside contamination and further injury, preventing the spread of microorganisms, increasing patient comfort, and promoting hemostasis by controlling bleeding. Dressing are unable to increase circulation.

Identify contributing factors to pressure ulcer formation. (Select all that apply.) a)Malnutrition b)Middle age c)Decreased sensory perception/mobility d)Stress e)Anemia f)Excessive sweating g)Ethnic background

A,C,D,E,F Three pressure-related forces contribute to the development of a pressure ulcer: intensity of pressure (how much pressure is applied), duration of pressure (how long the pressure is applied), and tissue tolerance (the ability of the tissue to redistribute the weight).

Identify prevention strategies for pressure ulcers. (Select all that apply.) a)Use a moisture barrier ointment; apply after each incontinent episode. b)Reposition patient at least every 4 hours: use a written schedule. c)When the patient is in the side-lying position, use the 30 degree lateral position d)Place patient on a pressure reducing support surface. e)Maintain the head of the bed at 45 degrees f)Massage the reddened bony prominences. g)Oral supplements should be instituted if patient is found to be undernourished.

A,C,D,G Patients should be repositioned every 2 hours in order to reduce the duration and intensity of pressure. The 30 degree lateral position avoids direct contact of the trochanter with the support surface. Placing the patient on a pressure-reducing support reduces the amount of pressure exerted against the tissues.

A patient states that she is unable to get her transparent dressing to stay in place. What instruction should the nurse provide the patient? A) "If you are having difficulty with your dressing changes, we can see if the doctor will give you a referral to a home care agency." B) "Make sure that you have a margin of 1-1.5 inches around the wound, and that the skin is thoroughly dry before applying the dressing. C) "This type of dressing requires frequent changing because they do not stay in place." D) You are probably applying it incorrectly, or perhaps you are too anxious about having to perform the dressing change." E) "There are many options on the market. Why don't you use a non-adhesive-backed transparent dressing instead."

B If the transparent dressing does not stay in place, the size of the dressing should be evaluated for adequate (1-1.5 inches) margin, and the skin should be thoroughly dried before reapplication. The patient requires further instruction, not necessarily a referral, regarding interventions to aid in dressing adherence. The dressing coming off is a unexpected outcome. Blaming the patient is non-therapuetic.

The nurse is observing the patient's wife perform the moist-to-dry dressing change. Which actions, if made by the patient's wife, indicate that further instruction is needed? (Select all that apply.) a) Premedicates for pain. b)Packs wound tightly c)Leaves contact or primary dressing dripping moist. d)When removing the old dressing the wife leaves the dressing dry, even when it sticks slightly.

B and C Inner gauze should be moist in order to absorb drainage and adhere to debris. The wound should be loosely packed to facilitate wicking of drainage into the absorbent, outer layer of the dressing. The wound should never be over packed because this can cause wound trauma when the dressing is removed.

Which of the following are common sites for the development of pressure ulcers? (Select all that apply.) a)Sternum b)Heels c)Sacrum d)Ears e)Lateral malleoli f)Trochanters g)Ischial tuberosities

B,C,E,F,G Common sites for the development of pressure ulcers include the sacrum, heels, elbows, lateral malleoli, trochanters, and ischial tuberosities.

Sanguineous

Bright red; indicates active bleeding

The nurse is caring for a patient who had knee replacement surgery 5 days ago. The patient's knee appears red and is very warm to the touch. The patient requests pain medication. Which of the following would be a correct explanation of what the nurse is noticing? A) These are expected findings for this postoperative time period. B) The patient may become dependent upon pain medication. C) The nurse should observe the patient more closely for wound dehiscence. D) The patient is demonstrating signs of a postoperative wound infection.

D) The risk for infection is greatest 4 to 5 days postoperative. Symptoms of wound infection include fever, tenderness and pain at the wound site, an elevated white blood cell count, and may appear inflamed at the edges of the wound. If drainage is present, it is odorous and purulent, which causes a yellow, green, or brown color, depending upon the causative organism.

Serosanguineous

Pale, red, watery

first intention

Type of wound healing typical of an incision. primary skin edges are approximated and closed. low risk of infection. quick healing. inflammation decreases w/in 24 hrs, wound resurfaced in 4-7 days.

factors that increase risk of pressure ulcer formation

alterations in mobility alterations in sensory perception alterations in level of consciousness presence of moisture poor nutrition (decreased protein needed to heal) fecal or urinary incontinence

A patient has a 4 day old, post-operative incision. Which would be a normal finding when changing the dressing? a) Small amount of serous drainage b) Moderate amount of sanguineous drainage c) Small amount of serosanguineous drainage D Small amount of purulent drainage

a) Small amount of serous drainage

fistula

abnormal passageway between two organs or between an internal organ and the body surface

preventive skin care

aimed at controlling external pressure over bony prominences and keeping skin clean, well lubricated and hydrated, and free of excess moisture

open wound

break in skin or mucus membranes

principle of cleansing a wound

center of wound to outwards or direction from least contamination, such as from wound incision to surrounding skin

serous

clear, watery plasma

when inspecting a wound dressing for drainage you will include:

color amount consistency odor

Purulent

containing pus, thick, yellow, green, tan, or brown

consequences of pressure ulcers

contribute to pt discomfort decrease pt function increase length of stay in acute /extended care settings increase cost of care

principles of wound first aid

control of bleeding cleaning protection

process of wound healing

day 1-3: inflammatory stage day 3-21: proliferation stage day 21-2 years: maturation stage

inflammatory stage

day 1-3: involving redness and swelling to an area of tissue trauma including a moderate amount of serous exudate, injured blood vessels initially constrict and platelets gather to control bleeding

proliferation stage

day 3-21: begins at wound edges and wound appendages, involves the migration of epithelial cells across the wound bed, other main activities include: new vessels appearing, tissue granulation and epithelialization occur

signs of normal wound healing include

decreased inflammation absence or decreasing pain at site decreasing redness no heat at site site warm and dry w/out exudate

wound assessment includes

description of appearance of the wound base, size, presence of exudate, and periwound skin condition

pressure ulcer definition

localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction

factors that decrease the risk of pressure ulcer formation

meticulous, ongoing assessment of skin identification and elimination or minimizing of risk factors preventive skin care proper positioning

factors that may affect timely wound healing

nutrition friction and shear tissue perfusion age malnutrition obesity impaired oxygenation smoking drugs diabetes / medical conditions radiation

stage 1 pressure ulcer

observable, pressure related alteration of intact skin, may include changes in skin temp, tissue consistency (bogginess), or sensation (pain or itching)

Dehiscence

partial or total separation of wound layers

stage 2 pressure ulcer

partial thickness skin loss involves epidermis and / or dermis. superficial and presents as a blister, abrasion, or shallow crater

contributing factors to the development of pressure ulcers

pressure, shear, friction

age related changes that increase risk of pressure ulcers

reduced skin elasticity decreased collagen thinning of underlying muscle and tissues flattened skin multiple medical problems polypharmacy decreased inflammatory response decreased wound healing decreased subcutaneous tissue

proper positioning

reduces the effects of pressure and guards against shearing force

intentional wound

resulting from therapy

partial thickness wound

shallow wounds involving loss of the dermis and possibly partial loss to the dermis (heal by regeneration)

stages of pressure ulcer development

stage 1: non blanching redness stage 2: partial thickness stage 3: full thickness- skin stage 4: full thickness- tissue

true or false: Healing by primary intention is expected when the edges of a clean surgical incision are sutured or stapled together, tissue loss is minimal or absent, and the wound is uncontaminated by microorganisms.

true

second intention

type of wound healing where wound is left open until it fills by scar tissue. wound edges are not approximated. healing occurs by granulation and contraction of wound edges.

when applying dressings on a clean chronic wound

use medical asepsis, not surgical asepsis

factors that increase wound infection risk

wound contains dead or necrotic tissue foreign bodies lie on or near wound reduced blood supply to wound

third intention

wound has become contaminated and is left open to drain, but closed later by suturing after the infection has subsided.

Evisceration

wound separation with protrusion of organs

clean wound

wound without pathogenic agents