Skin Integrity and Wound Care Study Guide, Exams of Nursing

Download Skin Integrity and Wound Care Study Guide and more Exams Nursing in PDF only on Docsity! NR224 Exam 2 Study Guide CH 48: Skin Integrity and Wound Care 1. Describe the dermis and the epidermis.  Dermis: The dermis, the inner layer of the skin, provides tensile strength; mechanical support; and protection for the underlying muscles, bones, and organs. It differs from the epidermis in that it contains mostly connective tissue and few skin cells.  Collagen (a tough, fibrous protein), blood vessels, and nerves are found in the dermal layer. Fibroblasts, which are responsible for collagen formation, are the only distinctive cell type within the dermis.  Epidermis: The epidermis, or the top layer, has several layers. The stratum corneum is the thin, outermost layer of the epidermis. It consists of flattened, dead, keratinized cells. The cells originate from the innermost epidermal layer, commonly called the basal layer.  Cells in the basal layer divide, proliferate, and migrate toward the epidermal surface. After they reach the stratum corneum, they flatten and die. 1185This constant movement ensures replacement of surface cells sloughed during normal desquamation or shedding. 2. What are three pressure related factors that contribute to pressure ulcers? Why?  Three pressure-related factors which contribute to pressure ulcer development:  1. Intensity  2. Duration  3. Tissue Tolerance  These can be caused by:  Major cause is PRESSURE!  Impaired mobility  Decreased/impaired sensory perception  Fecal and/or urinary incontinence  Poor nutrition  Aging skin  Presence of a cast  Alteration in the level of consciousness  Moisture  3. Describe the following terms: a. Granulation tissue: Granulation tissue is red, moist tissue composed of new blood vessels, the presence of which indicates progression toward healing. b. Slough: Soft yellow or white tissue (stringy substance attached to wound bed), and it must be removed by a skilled clinician or with the use of an appropriate wound dressing before the wound is able to heal. c. Eschar: Black, brown, tan, or necrotic tissue,which needs to be removed before healing can proceed. d. Exudate: Fluid, cells, or other substances that have been discharged from cells or blood vessels slowly through small pores or breaks in cell membranes. e. Necrotic tissue: pertaining to the death of tissue in response to disease or injury. 4. Describe friction & shear.  Friction: Effects of rubbing or the resistance that a moving body meets from the surface on which it moves; a force that occurs in a direction to oppose movement.  Shear: Force exerted against the skin while the skin remains stationary and the bony structures move. Occurs when there is a change in position due to gravity. Muscle and bone slide in the direction of body movement. Tissue damage occurs deep in the tissues causing undermining of the dermis. It affects the epidermis/top layer of skin (unlike shear injuries). 5. What is the Braden scale and why do we use it?  The interpretation of the meaning of the total numerical scores differs with each risk- assessment scale relevant to their population.  Lower numerical scores on the Braden Scale indicate that the patient is at high risk for skin breakdown.  A benefit of the predictive instruments is to increase a nurse's early detection of patients at greater risk for ulcer development.  Once you identify these patients, institute appropriate interventions to maintain skin integrity and implement prevention strategies 12. How often should a patient get a tetanus shot? Every 10 years 13. Describe the following wound drainages: a. Serous: clear, watery plasma b. Serosangineous: pale, pink, watery: mixture of clear and red fluid c. Sanguineous: bright red; indicates active bleeding d. Purulent: thick yellow, green, tan, or brown 14. What characteristics do we note about wound drainage? a. C: Color b. O: Odor c. C: Consistency d. A: Amount 15. What nutrient & element is important for wound healing? a. Protein b. _Petrolatum___ (this is found in A&D ointment for diaper rashes) 16. When are montgomery ties utilized?  To avoid repeated removal of tape from sensitive skin, secure dressings with pairs of reusable Montgomery ties  Another method to protect the surrounding skin on wounds that need frequent dressing changes is to place strips of hydrocolloid dressings on either side of the wound edges, cover the wound with a dressing, and apply the tape to the dressing.  To provide even support to a wound and immobilize a body part, apply elastic gauze, elastic stretch net, or binders over a dressing. 17. What is the purpose of a wet to dry dressing?  When used to pack a wound, the gauze is saturated with the solution (usually normal saline), wrung out (leaving the gauze only moist), unfolded, and lightly packed into the wound. Unfolding the dressing allows easy wicking action. The purpose of this type of dressing is to provide moisture to the wound yet to allow wound drainage to be wicked into the dry cover gauze pad.  It has the following advantages:  Adheres to undamaged skin  Serves as a barrier to external fluids and bacteria but still allows the wound surface to “breathe” because oxygen passes through the transparent dressing (Guest et al., 2011)  Promotes a moist environment that speeds epithelial cell growth  Can be removed without damaging underlying tissues  Permits viewing a wound  Does not require a secondary dressing a. Why do we not saturate these dressings before we remove them?  Inner gauze needs to be moist, not dripping wet, to absorb drainage and adhere to debris. Excessively moist dressings result in moisture-associated skin damage (maceration) in periwound skin 18. Describe a hydrocolloid dressing and when it is used.  Hydrocolloid dressings are dressings with complex formulations of colloids and adhesive components. They are adhesive and occlusive. The wound contact layer of this dressing forms a gel as wound exudate is absorbed and maintains a moist healing environment. Hydrocolloids support healing in clean granulating wounds and autolytically debride necrotic wounds; they are available in a variety of sizes and shapes.  This type of dressing has the following functions:  Absorbs drainage through the use of exudate absorbers in the dressing  Maintains wound moisture  Slowly liquefies necrotic debris  Is impermeable to bacteria and other contaminants  Is self-adhesive and molds well  Acts as a preventive dressing for high-risk friction areas  May be left in place for 3 to 5 days, minimizing skin trauma and disruption of healing  The hydrocolloid dressing is useful on shallow-to–moderately deep dermal ulcers. Hydrocolloid dressings cannot absorb the amount of drainage from heavily draining wounds, and some are contraindicated for use in full-thickness and infected wounds. Most hydrocolloids leave a residue in the wound bed that is easy to confuse with purulent drainage. 19. Describe a Jackson Pratt (JP) drain and when it is used?  A Jackson-Pratt (JP) drain is a type of drain that is placed in an incision during surgery. The drain is made up of a hollow tube that is connected to an egg-shaped bulb. The hollow tube begins inside the incision and exits the body. Attached to the end of the tube outside of the body is the collection bulb. This bulb collects fluid from the incision a. Should the bulb be compressed or no? Why?  The JP drain helps drain excess blood and fluid from under the skin and the incision site. When you squeeze the egg-shaped bulb, fluid is sucked out. If the bulb is not squeezed tightly, the fluid will not drain. 20. Describe a wound vac, how it works and when it is used.  a device that helps in wound closure by applying localized negative pressure to draw the edges of a wound together a. If it is sounding an alarm, always check for air leaks first! 21. What is wound dehiscence?  Separation of wound edges at suture line. Signs and symptoms include increased drainage and appearance of underlying tissues. This usually occurs 6-8 days after surgery.  Caused by: Malnutrition, obesity, preoperative radiation to surgical site, old age, poor circulation to tissues, and unusual strain on suture line from coughing or positioning. 22. What is wound evisceration?  Protrusion of internal organs and tissues through incision. Incidence usually occurs 6-8 days after surgery a. What are the nursing interventions if a wound does eviscerate? 31. If a client is experience orthopnea while lying flat in bed, what intervention can we recommend to improve their condition short term?  The number of pillows used usually helps to quantify the orthopnea (e.g., two- or three- pillow orthopnea). Also ask if the patient must sleep in a recliner chair to breathe easier. 32. What are the clinical signs and symptoms of hypoxia?  Hypoxia is inadequate tissue oxygenation at the cellular level. It results from a deficiency in oxygen delivery or oxygen use at the cellular level. It is a life-threatening condition. Untreated it produces possibly fatal cardiac dysrhythmias.  The clinical signs and symptoms of hypoxia include apprehension, restlessness, inability to concentrate, decreased level of consciousness, dizziness, and behavioral changes.  The patient with hypoxia is unable to lie flat and appears both fatigued and agitated.  Vital sign changes include an increased pulse rate and increased rate and depth of respiration.  During early stages of hypoxia the blood pressure is elevated unless the condition is caused by shock.  As the hypoxia worsens, the respiratory rate declines as a result of respiratory muscle fatigue. 33. What is the first sign of hypoxia that you will observe in a patient? High blood pressure 34. What clinical manifestations of hypoxia are found late stages?  Cyanosis, blue discoloration of the skin and mucous membranes caused by the presence of desaturated hemoglobin in capillaries 35. What do you do if you get an abnormal pulse ox reading that does not match your physical assessment? a. Example: a SPO2 reading of 76% for a client who’s breathing is unlabored at a rate of 12 without evidence of hypoxia  Check the probe to ensure it is positioned properly and that is nothing blocking the probe 36. Who should receive a flu vaccine?  Annual flu vaccines are recommended for all people 6 months and older.  Patients with chronic illnesses (heart, lung, kidney, or immunocompromised), infants, older adults, and pregnant women can get very sick; thus they should be immunized.  Close contacts of infants under 6 months should also be immunized.  Seasonal flu vaccine protects against influenza viruses that research indicates will be the most common during that year.  The vaccine is also recommended for people in close or frequent contact with anyone in the high-risk groups. 37. Who should receive the pneumonia vaccine?  Pneumococcal vaccine (PCV13) is routinely given to infants in a series of four doses and is recommended for patients at increased risk of developing pneumonia.  This includes all adults over 65 years of age, those with chronic illnesses or who are immunocompromised (such as HIV/AIDS), any adult who smokes or has asthma, and those living in special environments such as nursing homes or long-term care facilities 38. What are the different oxygen devices? What liters per minute do they require? Which ones are used for oxygen support, which ones are used for oxygen and ventilation support? Delivery system O2 delivered Advantages Disadvantages Nasal cannula (low flow) 1-6 L/min: 24%-44% Safe and simple Easily tolerated Effective for low concentrations Does not impede eating or talking Inexpensive, disposable Unable to use with nasal obstruction Drying to mucous membranes Can dislodge easily May cause skin irritation or breakdown around ears or nares Patient's breathing pattern (mouth or nasal) affects exact FiO2 Simple face mask (low flow) 6-12 L/min: 35%- 50% Useful for short periods such as patient transportation Contraindicated for patients who retain CO2 May induce feelings of claustrophobia Therapy interrupted with eating and drinking Increased risk of aspiration Partial and nonrebreather masks (low flow) 10-15 L/min: 60%- 90% Useful for short periods Delivers increased FiO2 Easily humidifies O2 Does not dry mucous membranes Hot and confining; may irritate skin; tight seal necessary Interferes with eating and talking Bag may twist or kink; should not totally deflate Oxygen- conserving cannula (Oxymizer) (low flow) 8 L/min: up to 30%- 50% Indicated for long-term O2 use in the home Allows increased O2 concentration and lower flow Cannula cannot be cleaned More expensive than standard cannula Venturi mask (high flow) 24%-50% Provides specific amount of oxygen with humidity added Administers low, constant O2 Mask and added humidity may irritate skin Therapy interrupted with eating and drinking Specific flow rate must be followed 39. What is the purpose of percussion?  Percussion detects the presence of abnormal fluid or air in the lungs. It also determines diaphragmatic excursion. 40. What is the importance of an incentive spirometer?  Obstruction of urine flow through the ureters such as by a kidney stone can cause a backflow of urine (urinary reflux) into the ureters and pelvis of the kidney, causing distention (hydroureter/hydronephrosis) and in some cases permanent damage to sensitive kidney structures and function. c. Bladder  The urinary bladder is a hollow, distensible, muscular organ that holds urine.  When empty, the bladder lies in the pelvic cavity behind the symphysis pubis.  In males the bladder rests against the rectum, and in females it rests against the anterior wall of the uterus and vagina.  The bladder has two parts, a fixed base called the trigone and a distensible body called the detrusor.  The bladder expands as it fills with urine.  Normally the pressure in the bladder during filling remains low, and this prevents the dangerous backward flow of urine into the ureters and kidneys.  Backflow can cause infection. In a pregnant woman the developing fetus pushes against the bladder, reducing capacity and causing a feeling of fullness. d. Urethra  Urine travels from the bladder through the urethra and passes to the outside of the body through the urethral meatus.  The urethra passes through a thick layer of skeletal muscles called the pelvic floor muscles. These muscles stabilize the urethra and contribute to urinary continence.  The external urethral sphincter, made up of striated muscles, contributes to voluntary control over the flow of urine  The female urethra is approximately 3 to 4 cm (1 to 1.5 inch) long, and the male urethra is about 18 to 20 cm (7 to 8 inches) long  The shorter length of the female urethra increases risk for urinary tract infection (UTI) because of close access to the bacteria-contaminated perineal area. 44. What hormone comes from the kidneys and stimulates production of RBCs?  Erythropoietin, produced by the kidneys, stimulates red blood cell production and maturation in bone marrow. 45. How does renin increase your blood volume and blood pressure?  The kidneys play a major role in blood pressure control via the renin-angiotensin system (i.e., release of aldosterone and prostacyclin)  In times of renal ischemia (decreased blood supply), renin is released from juxtaglomerular cells.  Renin functions as an enzyme to convert angiotensinogen (a substance synthesized by the liver) into angiotensin I.  Angiotensin I is converted to angiotensin II in the lungs.  Angiotensin II causes vasoconstriction and stimulates aldosterone release from the adrenal cortex.  Aldosterone causes retention of water, which increases blood volume.  The kidneys also produce prostaglandin E2 and prostacyclin, which help maintain renal blood flow through vasodilation.  These mechanisms increase arterial blood pressure and renal blood flow 46. Describe the symptoms of cystitis (UTI).  irritation of the bladder (cystitis) characterized by urgency, frequency, incontinence, suprapubic tenderness; and foul-smelling cloudy urine a. How do symptoms differ across the lifespan?  Older adults may experience a change in mental status called delirium. In some cases there will be obvious blood in the urine (hematuria). If infection spreads to the upper urinary tract (pyelonephritis), patients may also experience fever, chills, diaphoresis, and flank pain 47. What are possible causes of a UTI?  indwelling catheter  any instrumentation of the urinary tract  urinary retention  urinary and fecal incontinence  poor perineal hygiene practices. 48. What foods increase the acidity of the urine, decreasing the risk of UTI’s?  Grains  Sugars  Fish  Certain dairy foods  High-protein foods  Sweetened beverages and sodas 49. Describe the symptoms of pyelonephritis.  If infection spreads to the upper urinary tract (pyelonephritis), patients 1105may also experience fever, chills, diaphoresis, and flank pain 50. Describe ways a patient could get a UTI in the hospital.  Catheter-associated UTIs (CAUTIs) are an ongoing problem for hospitals because they are associated with increased hospitalizations, increased morbidity and mortality, longer hospital stays, and increased hospital costs 51. Describe the clinical manifestations of urinary retention.  Urinary retention is the inability to partially or completely empty the bladder. Acute or rapid- onset urinary retention stretches the bladder, causing feelings of pressure, discomfort/pain, tenderness over the symphysis pubis, restlessness, and sometimes diaphoresis. Patients may have no urine output over several hours and in some cases experience frequency, urgency, small-volume voiding, or incontinence of small volumes of urine 52. If a patient has a Foley, how would you obtain a sterile specimen?  If the patient has an indwelling catheter, collect a specimen by using sterile aseptic technique through the special sampling port found on the side of the catheter.  Usually does not leak urine at night when sleeping  Urge or Urgency Urinary Incontinence: Involuntary passage of urine often associated with strong sense of urgency related to an overactive bladder caused by neurological problems, bladder inflammation, or bladder outlet obstruction  In many cases bladder over activity is idiopathic; cause is not known  Caused by involuntary contractions of the bladder associated with an urge to void that causes leakage of urine  May experience one or all of the following symptoms:  Urgency  Frequency  Nocturia  Difficulty or unable to hold urine once the urge to void occurs  Leaks on the way to the bathroom  Leaks larger volumes of urine, sometimes enough to wet outer clothing  Dribbles small amounts on the way to the bathroom  Strong urge/leaks when one hears water running, washes hands, drinks fluids  Reflex Urinary Incontinence: Involuntary loss of urine occurring at somewhat predictable intervals when patient reaches specific bladder volume related to spinal cord damage between C1 to S2  Diminished or absent awareness of bladder filling and the urge to void  Leakage of urine without awareness  May not completely empty the bladder because of dyssynergia of the urinary sphincter; inappropriate contraction of the sphincter when the bladder contracts, causing obstruction to urine flow  CAUTION: At risk for developing autonomic dysreflexia, a life-threatening condition that causes severe elevation of blood pressure and pulse rate and diaphoresis 55. How can we help to prevent incontinence? 2 ways a. KEGELS! b. Urge-suppression strategies 56. What is the normal urinary output for the average adult?  Normal urinary output:1200 to 1500 mL  Hourly output of less than 30 mL for longer than 2 consecutive hours is cause for concern.  Similarly, you need to report consistently high volumes of urine (polyuria) (i.e., over 2000 to 2500 mL daily). 57. A patient must void at least __30_ ml/hr, or we have to call the physician. 58. Describe a 24-hour urine collection.  In most 24-hour specimen collections discard the first voided specimen and then start collecting urine.  Patient voids into a clean receptacle; and the urine is transferred to the special collection container, which often contains special preservatives.  Depending on the test, the urine container may need to be kept cool by setting it in a container of ice.  Each specimen must be free of feces and toilet tissue.  Missed specimens make the whole collection inaccurate. 59. When irrigating a catheter, how do we calculate urinary output?  If continuous bladder irrigation (CBI) is being used, amount of fluid draining from bladder should exceed amount of fluid infused into bladder. If output does not exceed irrigant infused, catheter obstruction (i.e., blood clots, kinked tubing) should be suspected, irrigation stopped, and prescriber notified. 60. When we are assessing urine, what are we looking at? (and smelling for unfortunately.)  Inspect the patient's urine for color, clarity, and odor. Monitor and document any changes.  Normal urine ranges in color from a pale straw color to amber, depending on its concentration. Urine is usually more concentrated in the morning or with fluid volume deficits. As the patient drinks more fluids, urine becomes less concentrated, and the color lightens. Patients taking diuretics commonly void dilute urine while the medication is active.  Normal urine appears transparent at the time of voiding. Urine that stands several minutes in a container becomes cloudy. In patients with renal disease, freshly voided urine appears cloudy because of protein concentration. Urine may also appear thick and cloudy as a result of bacteria and white blood cells. Early-morning voided urine may be cloudy because of urine held in the bladder overnight but will be clear on the next voiding.  Urine has a characteristic ammonia odor. The more concentrated the urine, the stronger the odor. As urine remains standing (e.g., in a collection device), more ammonia breakdown occurs, and the odor becomes stronger. A foul odor may indicate a UTI. Some foods such as asparagus and garlic can change the odor of urine. 61. If a patient has a Foley, how would you obtain a sterile specimen?  If the patient has an indwelling catheter, collect a specimen by using sterile aseptic technique through the special sampling port found on the side of the catheter.  Urine specimen collection: aspiration from a collection port in drainage tubing of indwelling catheter  Never collect the specimen from the drainage bag.  Clamp the tubing below the port, allowing fresh, uncontaminated urine to collect in the tube.  After wiping the port with an antimicrobial swab, insert a sterile syringe hub and withdraw at least 3 to 5 mL of urine  Using sterile aseptic technique, transfer the urine to a sterile container