Understanding Wound Healing and Pressure Ulcers, Exams of Nursing

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Wound Care terms and answers 2024 Primary Function of Skin Disruption\ CORRECT ANSWER IS Protection from trauma (mechanical, thermal, chemical, radiant) What are the results of impaired skin integrity?\ CORRECT ANSWER IS Loss of body fluids and risk for infection Skin Lesion\ CORRECT ANSWER IS Pathological or traumatic discontinuity of TISSUE Etiology: Skin Lesions\ CORRECT ANSWER IS Mechanical injuries, pathological changes, allergies, bites Primary Lesion\ CORRECT ANSWER IS Initial or first lesion to occur ex: mosquito bite Secondary Lesion\ CORRECT ANSWER IS Change in the primary lesion ex: scab that develops after you have scratched the mosquito bite Wound\ CORRECT ANSWER IS Disruption in the structure and function of the skin from bodily injury or disease Intentional Wounds\ CORRECT ANSWER IS Wounds that occur from surgical procedures or treatments Unintentional Wound\ CORRECT ANSWER IS Wound that occurs from accidental injuries or trauma, adverse effects of health care Open Wound\ CORRECT ANSWER IS An injury in which the skin is INTERRUPTED or disrupted, EXPOSING the tissue beneath. Closed Wound\ CORRECT ANSWER IS Bruising underneath the skin Clean Wound\ CORRECT ANSWER IS Wound that is created with CLEAN surgical instruments; Microbes have not entered the wound. Contaminated Wound\ CORRECT ANSWER IS Wound with presence of microorganisms, dirt, debris, exudate Acute Wound\ CORRECT ANSWER IS Wound that heals in orderly and timely process; i.e. surgical incision Chronic Wound\ CORRECT ANSWER IS Wound that heals slowly and has an insidious onset; i.e. DPU Types of Wounds\ CORRECT ANSWER IS Open vs Closed Clean vs Contaminated Acute vs Chronic RYB Classification System\ CORRECT ANSWER IS Based on WOUND BED COLOR Red Wound Bed Color\ CORRECT ANSWER IS Granulating tissue (clean, healthy tissue) Yellow Wound Bed Color\ CORRECT ANSWER IS Slough (fibrous material of exudate) ;wound is not ready to heal yet Eschar Wound Bed\ CORRECT ANSWER IS Necrotic tissue (thick, leathery); tissue is nonhealing and needs to be removed Exudate\ CORRECT ANSWER IS Fluid and cells that have escaped from blood vessels during the inflammatory process Exudate: Serous\ CORRECT ANSWER IS Clear, plasma thats escaping from wound bed Exudate: Sanguinous\ CORRECT ANSWER IS Bloody drainage Exudate: Serosanguinous\ CORRECT ANSWER IS Mixture of plasma and RBCs Exudate: Purulent\ CORRECT ANSWER IS Pus, liquification of necrotic tissue (body is getting rid of debris) Types of Wound Healing\ CORRECT ANSWER IS Primary Intention vs Seconday Intention vs Tertiary Intention Primary Intention\ CORRECT ANSWER IS ~Wound edges are approximated (closed) by sutures, staples ~NO blood, debris, exudate ~Healing occurs in approx 14 days ~↓ risk for infection ~Little tissue lost, ↓ scarring Secondary Intention\ CORRECT ANSWER IS ~ i.e. chronic wounds, DPUs ~edges CANNOT be approximated ~Wound bed will fill with granulating tissue ~↑ risk of infection, tissue loss, contractures ~longer healing times Tertiary Intention\ CORRECT ANSWER IS ~Occurs with contaminated wounds ~Keeping a wound open for 3 to 5 days to let healing begin Fistula\ CORRECT ANSWER IS An abnormal passageway between an organ and external surface; Forms because tissue does not close, abcess, infection, injury or radiation Dehiscence\ CORRECT ANSWER IS Separation of wound edges; Obesity is main factor Evisceration\ CORRECT ANSWER IS Protrusion of the internal organs; EMERGENCY!!!! ~Cover bowel with NS and sterile dressing ~Check VS, IV access ~Semi-fowlers position Factors Affecting Wound Healing\ CORRECT ANSWER IS Pg 23 Braden Scale\ CORRECT ANSWER IS Used to assess risk for impaired skin integrity; 6 subscales: sensory perception, moisture, activity, mobility, nutrition, friction Areas to Assess: Bony prominences, nares, tongue, lips, drainage tubes, orthopedic devices Lower the score-> Higher the risk Assessment of Wound\ CORRECT ANSWER IS Location Size (L x W x D, face of clock) Color (wound bed) Surrounding skin (periwound) Temperature Drainage Wound Closure Pain Drainage: C.O.T.A\ CORRECT ANSWER IS C - Color (may identify the type of organism) Yellow - staph Greenish-blue - pseudomonas Beige - proteus Brownish - aerobic bacteria O - Odor T - Thickness A - Amount Wound Assessment: R.E.E.D.A\ CORRECT ANSWER IS R - Redness (erythema) E - Edema (induration) E - Echymosis (black and blue discoloration or bruising) D - Drainage A - Approximation Adequate Nutrition: Intervention for Wound Healing\ CORRECT ANSWER IS Carbs, Fats, Calories - wound regeneration Copper, Vitamin A and B complex IRON - O₂transport PROTEIN - Collagen synthesis Vitamin C - Collagen synthesis, capillary repair Zinc - Collagen synthesis, immunity Irrigation: Intervention for Wound Healing\ CORRECT ANSWER IS Solutions: can damage newly developing cells (temporary) Normal Saline (preferred solution; physiologically compatible with our tissue) ~Cleansing around in incision or drain → always irrigate or wipe ~Clean from center → outward (Wound bed is the CLEANEST) Purpose of Dressing\ CORRECT ANSWER IS ~PROTECTION from contamination ~GAURD from injury ~Compression ~Medication application ~ABSORB drainage ~Debridement ~MAINTAIN MOIST ENVIRONMENT(enhances wound epitheliazation, helps wound heal faster with less scar tissue) Wound Care Products\ CORRECT ANSWER IS Gauze Transparent Dressings Hydrocolloid Dressings Hydrogel Alginates Exudate Absorbers Foam Gauze\ CORRECT ANSWER IS ~CHEAP, used with debridement ~Indications: Prevents trauma, decreases infection and exudate, moist environement for wound bed to heal ~Contraindications: Adheres to wound bed (take away new cells that are forming) Dry Sterile Dressings\ CORRECT ANSWER IS Used for post-op or surgical wounds (absorb drainage) Wet to Dry Dressing\ CORRECT ANSWER IS Used LARGER OPEN wounds; Pack with damp gauze; absorbs exudate and as dressing DRYS out, it will debride wound (remove dead tissue) Wet to Moist Dressing\ CORRECT ANSWER IS The preferred method of healing; Works through 'autolytic debridement' Autolytic Debridement\ CORRECT ANSWER IS Uses body's ability to digest devitalized tissue; Allows macrophages and neutrophils to ↓ necrotic tissue (BODY HEALS ITSELF) Transparent Dressing\ CORRECT ANSWER IS VAPOR permeable but impermeable to BACTERIA; Allows VISUALIZATION of the wound Indications: superficial wounds, LIGHT exudate Contraindications: not for infected wounds with heavy exudate i.e.Tegaderm Hydrocolloid Dressing\ CORRECT ANSWER IS NON-PERMEABLE to WATER VAPOR and O₂; Creates a hypoxic wound bed, moist environment, promotes autolytic debridement Indications: PARTIAL thickness, LIGHT exudate Contraindications: not for heavy exudate i.e. Duoderm Hydrogel\ CORRECT ANSWER IS Used to maintain a moist environment; POLYMER GELS Indications: COOL wounds, used in BURNS, PARTIAL thickness wounds Contraindications: cannot be used with heavy exudate i.e. Elasto-Gel Alginates\ CORRECT ANSWER IS Made from SEAWEED; ABSORBS exudates and aids in debridement Indications: PARTIAL or FULL thickness wounds, absorbs 20x its weight Contraindications: can be DRYING i.e. Aquacell Exudate Absorbers\ CORRECT ANSWER IS CONFORMS to wound surface and ELIMINATES dead space; promotes debridement