Tissue Integrity and Wound Care

The registered nurse is teaching a nursing student about home care considerations to prevent the risk of pressure ulcers. Which statements made by the nursing student indicate effective learning? Select all that apply. Select all that apply 'I should educate the patient about the signs of wound infection.' 'I should discuss reactive surfaces that may increase pressure to the wound.' 'I should instruct the patient to dispose of the soiled dressings by incineration.' 'I should instruct the patient to evaluate the healing by using the pressure ulcer staging system.' 'I should instruct the patient to approach the registered nurse if the wound does not heal within 2 weeks.'

'I should educate the patient about the signs of wound infection.' 'I should discuss reactive surfaces that may increase pressure to the wound.'

what are the factors that influence pressure ulcer formation and wound healing?

-Nutrition -Tissue perfusion -Infection -Age -Psychosocial impact of wounds

what is the function of a hydrocolloid dressing? when should you use it? what are the side effects?

-adhesive dressings that contain a gel-forming agent that molds to body contours -maintains a moist environment by forming a gelatinous mass -used for autolytic debridement, absorption of minimal to moderate exudate side effects: some products leave residue in wound on removal and/or there is a potential for periwound maceration

What is compromised in a second degree burn? examples?

-can be superficial partial thickness injury that involves blisters -can be deep partial thickness injury that involves the entire dermis. appears waxy, white and is surrounded by superficial partial thickness injury -ex: more severe sun, heat, or friction exposure

what is important to remember when cleaning a wound?

-clean from least contaminated to the surrounding skin -use gentle friction -when irrigating, allow the solution to flow from the least to most contaminated area

what is a Jackson Pratt or a Hemovac?

-closed suction drain system used for serous or Serosanguinous drainage

when is purulent discharge common? when would you not want it?

-comes out of infected wound (ulcer, gangrene) -would not want this for a surgical incision because that indicates the sterile field turned infectious

what is a Pleur-X?

-drains pleural fluid in the lungs

What is compromised in a third degree burn? example?

-full thickness injury with destruction of the epidermis, dermis, and underlying subcutaneous tissue -bone and muscle may be destroyed -the wound appears dry and leathery -severe heat or friction exposure

what is the function of a Alginate dressing? when should you use it? what are the side effects?

-highly absorptive products -moderate to heavy wound exudate, full thickness wounds side effects: may contribute to wound desiccation if wound exudate is minimal and gel dries

What is a wound vac/PICO used for?

-negative pressure wound therapy -gangrene, ulcerations, trauma wound

how should you pack a wound?

-pack a wound loosely at the level of the skin -make sure to document how many gauze you used in the wound

What is compromised in a first degree burn? examples?

-partial thickness injury that involves the epidermis -no injury occurs to the dermis and subcutaneous tissue -normal skin barriers remain intact -ex: sunburns or minor heat or friction burns

what is the function of a gauze dressing? when should you use it? what are the side effects?

-protection for surgical wounds, moist to dry dressings, wound packing material side effects: may adhere to healthy tissue and cause injury on removal

what is the function of a hydrogel dressing? when should you use it? what are the side effects?

-provides moisture to wound bed -autolytic debridement -used for partial and full thickness wounds , dry-to-light exudate, necrotic wounds side effects: may cause third degree burns or heavily exudating wounds

what is the function of a foam (sacral) dressing? when should you use it? what are the side effects?

-used for absorption of moderate to heavy exudate, prevention/protection of pressure injuries -usually goes over bony prominences (elbow, knee, heel, sacrum) -do not need an order because it is preventative side effects: may promote wound dehydration

what is a pin rose drain?

-used for infected wounds, abscesses (appendix, abdomen)

what is dehiscence?

-when a wound fails to heal properly, the edges separate -Partial or total separation of the wound layers

What are the risk factors for pressure ulcer development?

1. Impaired sensory perception 2. Impaired mobility 3. Alteration in LOC 4. Shear 5. Friction 6. Moisture due to incontinence

what are the 4 stages of healing?

1. hemostasis -clots form to stop blood flow 2. inflammatory -scab 3. proliferative -filling of a wound and epithelialization 4. remodeling -freshly healed epidermis and dermis

how long does it take a moist wound to heal?

4 days

The nurse observes that a patient's ulcer is very slow to heal. Which action made by the nurse can help facilitate faster healing of the patient's wound? Obtaining necessary wound cultures Assessing the ulcer during each dressing Using liquid skin barrier on periwound skin Irrigating the wound with topical agents frequently

Assessing the ulcer during each dressing

Blanchable vs. nonblanchable

Blanchable: Skin blanches with pressure. Color returns immediately with release. THIS IS WHAT WE WANT Non-blanchable: No blanch, persistent redness in lightly pigmented skin. In darkly pigmented skin, a blanch response may not be visible.

what is the role of a blister?

Blisters protect the skin, popping it opens up the epidermis of the wound

Which type of gauze should be used for dressing a wound on the palm? Elastic net Precut gauze Topper dressing Hydrocolloid gauze

Elastic net

Which type of dressing would be most appropriate for a patient with a partial thickness, necrotic pressure ulcer with moderate drainage? Dry gauze Hydrocolloid dressing Calcium alginate dressing Transparent film dressing

Hydrocolloid dressing

A patient developed a pressure ulcer that was deep with the presence of exudates. Which type of dressing is provided to the patient? Film Foam Hydrogel Calcium alginate

Hydrogel

A nurse finds that a patient who has urinary incontinence scores 11 on the Braden Scale. Which nursing action is most appropriate to prevent this patient from developing pressure ulcers? Managing shear Managing moisture Providing nutritional intervention Providing foam wedges for positioning

Managing moisture

A patient developed a pressure ulcer after knee surgery due to restriction to bed. Which irrigating fluid should the nurse use to clean the ulcer? Normal saline Povidone iodine Hydrogen peroxide Sodium hypochlorite

Normal saline

The nurse determines the patient's risk of developing ulcers using the Braden Scale and finds the score to be 16. Which nursing interventions are appropriate for the patient to decrease the risk of skin breakdown? Select all that apply. Protecting the patient's heels Turning the patient frequently Providing pressure-redistribution surfaces Providing foam-wedges for 40-degree lateral position Applying a moisturizer to the patient's wound regularly

Protecting the patient's heels Turning the patient frequently Providing pressure-redistribution surfaces

A patient is diagnosed with moderate deep dermal ulcers. Why would the nurse provide a hydrocolloid dressing to this patient? SATA Reduces wound pain Minimizes skin trauma Permits viewing a wound Provides moist environment Slowly liquefies necrotic debris

Reduces wound pain Provides moist environment Slowly liquefies necrotic debris

what is slough?

Tan, yellow, or green scab like material that is dying off. Can be removed and irrigated but don't scrub.

While applying gauze dressing to a wound, the patient complains of severe pain. What could be the reason for the pain? The nurse did not use gloves to clean the wound site. The nurse did not remove the gauze dressings one at a time. The nurse did not perform hand hygiene before wearing gloves. The nurse did not use sodium hypochlorite for irrigating the wound.

The nurse did not remove the gauze dressings one at a time.

While treating a patient with negative-pressure wound therapy (NWPT) for radiation-damaged skin on the forearm, the nurse observes pressure ulcers on the elbow. Which nursing action is responsible for the patient's condition? The nurse placed the tubing over the elbow. The nurse removed the transparent film by stretching it horizontally. The nurse raised the tubing connectors above the level of the NWPT unit. The nurse kept the system in 'de vac' mode for 30 minutes before changing the dressing.

The nurse placed the tubing over the elbow.

The nurse observes that a patient with pressure ulcers has a score on the Braden Scale of 11. What would the nurse suspect from this observation? The patient is at high risk of development of pressure ulcers. The patient is at moderate risk of pressure ulcer development. The patient should be taken to the intensive care unit. The patient's condition can be managed in a few days.

The patient is at high risk of development of pressure ulcers. The Braden Scale provides a baseline for comparing increased or decreased risk for development of pressure ulcers that helps plan for interventions. If the score is 10 to 12, then the patient is at high risk of developing pressure ulcers; therefore, this patient is considered at a high risk of pressure ulcer development. If the score is 13 to 14, then the patient is at moderate risk of developing pressure ulcers. If the score is lower than 9, it indicates severe complication and the patient should be taken to the intensive care unit immediately. If the score is high, it indicates low risk, and the condition can be managed in a few days with minimal interventions.

what is tissue ischemia? what happens if it is left untreated?

Tissue ischemia is tissue that does not receive adequate blood supply. If left untreated causes tissue necrosis (death)

Which type of dressing is used for stage I pressure ulcers? Gauze sponges Hydrogel dressings Hydrocolloid dressings Transparent film dressings

Transparent film dressings

which types of pressure injuries will medicare or medicaid not pay for?

Will not pay the hospital for a stage 3 or stage 4 pressure injury that occurs at the hospital

what is wound irrigation?

Wound irrigation is the steady flow of a solution across an open wound surface to achieve wound hydration, to remove deeper debris, and to assist with the visual examination.

why would you use a transparent film dressing?

allows for assessment of skin breakdown (ex: stage 1 pressure injuries)

who are surgical dressings ordered by?

always ordered by a surgeon

what is a window pane dressing?

applying adhesive strips to frame a window around wound using four strips of tape - doesn't completely close wound off

why do hypovolemia, hypotension, vasoconstriction, edema, and hypoxia negatively affect wound healing?

because adequate perfusion and oxygenation are necessary for new vessel development, collagen synthesis, and development of tensile strength

what is eschar?

black full tissue destruction that can not be removed unless by a doctor

can dressing changes and/or irrigation be delegated?

cannot be delegated unless it's a chronic wound because it is more about maintenance and less about assessment

when should you put on a new pair of gloves when working with wounds and dressing changes?

change gloves after removing a dressing before putting on a new one if the dressing is a surgical dressing you need to replace old gloves with new sterile gloves

an acute sprain, closed fracture, or bruise best responds to what type of applications?

cold applications

what is a cell saver?

collects 1st post-op drainage and transfuges back into the patient, which allows for avoidance of a blood transfusion

what type of vacuum is used to remove and collect the drainage from a wound?

constant, low-pressure vacuum

the principles of wound first aid include..?

control of bleeding, cleaning, and protection

Removal of dead, damaged, or infected tissue

debridement

separates the dermis and epidermis

dermal-epidermal junction

inner layer of skin - contains collagen

dermis

what does a wound assessment determine?

determines progress toward pressure ulcer healing

what is the difference between a dirty wound and a clean wound?

dirty wound: caused in a noncontrolled environment (dog bite, trauma, skinned knee, infections, ulcers --> basically any community acquired thing) -use regular clean gloves when changing dressing clean wound: clean incision, clean close (appendicitis, abdomen --> a surgical wound) -use sterile gloves when changing dressing

what is the purpose of maggots?

eat the dead tissue (eschar)

Agents that soften skin or treat dry skin

emollient

top layer of skin

epidermis

Tissue that lines cavities and structure surfaces throughout the body

epithelium

how often should you reposition a patient in the bed to prevent the development of pressure ulcers?

every 2 hours

what are montgomery straps used for?

for skin integrity concerns for infants, children, and the elderly (abdomen)

when is a pressure injury considered unstageable?

full thickness tissue loss in which actual depth of an ulcer is completely obscured by slough or eschar

extends into the subcutaneous layer, and the depth and tissue type will vary depending on body location

full-thickness wounds

Connective tissue that forms on the surface of a healing wound

granulation

what does a purple or maroon color of the pressure injury indicate?

indicates damage of underlying tissue due to pressure or shear

what populations are at greatest risk for impaired tissue integrity? why are these populations at greater risk?

infants, children, older adults nutrition issues, decreased sensory perception and range of motion in older adults, and infants depend on other people so if they are in a hot tub of water they can scream it is hot, but they cannot get out of it without help

what is the scope of tissue integrity?

intact skin and tissue partial thickness injury full thickness injury

what type of solution do you irrigate a wound with? why?

irrigate with normal saline (0.9% sodium chloride) because it is isotonic hypotonic causes cell to swell hypertonic causes cell to shrink

what is the purpose of leeches?

leeches suck venous blood to help with collateral flow

what type of environment supports wound healing?

moist environment

do you suture dog bites? why or why not?

no, because it could cause infection

what is undermining?

occurs when the tissue under the wound edges becomes eroded, resulting in a a pocket beneath the skin at the wound's edge

what determines which type of dressing you use on a patient?

orders from a doctor or a wound care nurse

shallow in depth, moist and painful, and the wound base generally appears red

partial-thickness wound

What is the difference between primary, secondary, and tertiary intention processes of wound healing?

primary intention: -usually a surgical incision that heals from the outside-->in along suture lines, so risk of infection is low, PAPERCUT -edges are well approximated with sutures or stables (edges come together) wound is closed secondary intention: -ex: laceration with a knife, pressure ulcers -something that heals from the inside out on it's own tertiary intention: -intentional delay in closing a wound. On occasion, wounds are left open (covered by a sterile dressing) to allow an infection or inflammation to subside. Once the wound is closed with staples or sutures, the scarring in minimal.

what is granulation?

red healthy tissue that indicates healing. this is the tissue we want to see

What is debridement?

removal of dead tissue

What is epibole?

rolled or curled-under closed wound edges

What is ABCDE used for? What does it stand for? How often should it be performed?

screening for malignant melanoma should be done once a year unless you notice a change A-Asymmetry B-Border integrity (edges are notched or ragged) C-Color (various) D- Diameter (greater than 6 mm) E- Evolving

what is the difference between serous and serosanguinos drainage?

serous drainage is normal drainage that is clear, thin, and watery serosanguinos drainage is abnormal that is clear liquid mixed with blood

How do you classify pressure injuries (ulcers)? What are the stages?

stage 1: -intact skin with nonblanchable redness -usually localized over a bony prominence -discolored skin, warmth, edema, hardness, pain -may be difficult to detect in darker skinned patients stage 2: -partial thickness skin loss involving epidermis, dermis, or both -shallow, open ulcer with a red-pink wound bed and no slough or bruising stage 3: -full-thickness tissue loss with visible fat -bone, tendon, or muscle are NOT exposed -slough may be present and there may be undermining or tunneling Stage 4: -full-thickness tissue loss with exposed bone, muscle, or tendon -slough, eschar, undermining, or tunneling may be present

which stages of pressure injuries indicate significant tissue loss

stages 3 and 4

how long does it take a wound left open to the air (carpet burn) to heal? why?

takes 6-7 days because since it is left open, the wound is dry

What does the nonblanchable erythema indicate about the skin?

the skin is damaged

who always removes the first dressing after surgery?

the surgeon

the chances of wound infection are greater when..?

the wound contains dead or necrotic tissue, when foreign bodies lie on or near the wound, and when the blood supply and tissue defenses are reduced.

what is gangrene?

tissue death caused by a lack of blood supply. Symptoms may include a change in skin color to red or black, numbness, swelling, pain, skin breakdown, and coolness. The feet and hands are most commonly affected.

the state of structurally intact and physiologically functioning epithelial tissues such as the integument (including the skin and subcutaneous tissue) and mucous membranes.

tissue integrity

Elastic state of skin and tissue

turgor

Describe the scoring of the Braden Scale

up to 23 points = no risk < or = 9 --> severe risk 10-12 ---> high risk 13-14 ---> moderate risk 15-18 --> mild risk

what does the wet to dry principle mean? what does the wet to moist principle mean? which is the best practice, why?

wet to dry: pack the wound with wet gauze then remove when dry wet to moist: pack the wound with wet gauze then remove when moist wet to moist is the best practice because it allows for the wound to heal and keep the environment moist. wet to dry could cause tearing of unnecessary skin upon removal. do not let the gauze get all the way dry!

how soon do we want to see a wound begin to heal?

within 2 weeks

what is the 2nd most common healthcare infection?

wound infection

what is tunneling?

wound making a tunnel from one area to another -document how far it goes

is it a problem if a serous fluid becomes Serosanguinous?

yes, you do not want to go from serous backwards or have the fluid volume increase. You would need to call a doctor

what should you administer before dressing changes?

•Administer analgesic medications 30 to 60 minutes before dressing changes

How does a full-thickness wound heal?

•Hemostasis, inflammatory process, and maturation

what is evisceration?

•Organs come out of the wound •Get saline soaked gauze and put it on there, that patient NEEDS to go back to surgery because intestines are going to stick since it's dry so you need moisture

what is the purpose of dressings?

•Protects from microorganisms •Aids in hemostasis (stopping of blood flow-stops blood loss) •Promotes healing by absorbing drainage or debriding(remove damaged tissue from wound) a wound •Supports wound site •Promotes thermal insulation •Provides a moist environment

what is included in primary prevention for tissue integrity?

•Skin hygiene •Adequate nutrition •Avoidance of excessive sun exposure •Burn safety precautions •Dermal ulcer prevention

What is the Rule of Nines?

•You can estimate the body surface area on an adult that has been burned by using multiples of 9 •Head=9% •Chest/Abdomen (front)=18% •Upper/mid/low back & buttocks=18% •Each arm=9% •Groin=1% •Each leg=18% total (front=9%, back=9%) she will give a percentage of the patient burned with multiple choices so know which numbers correlate with which body part

how does a partial-thickness wound heal?

•inflammatory response, epithelial proliferation and migration, and reestablishment of the epidermal layers •Example: scrape, abrasion