Podcast
Questions and Answers
Which of the following assessments is not typically included as part of a comprehensive skin assessment?
Which of the following assessments is not typically included as part of a comprehensive skin assessment?
- Evaluation of bony prominences for pressure points
- Assessment of the patient's dietary intake for nutritional deficiencies (correct)
- Observation for blanchable and non-blanchable areas
- Determination of skin integrity in areas exposed to adhesive tape or medical devices
A low score on the Braden Scale indicates what about a patient's risk for pressure ulcers?
A low score on the Braden Scale indicates what about a patient's risk for pressure ulcers?
- The patient has a lower risk of developing pressure ulcers.
- The Braden Scale score is unrelated to pressure ulcer risk.
- The patient has a higher risk of developing pressure ulcers. (correct)
- The patient only has a risk if they have impaired sensory perception.
Which of the following is the correct sequence of phases in wound healing?
Which of the following is the correct sequence of phases in wound healing?
- Remodeling, proliferation, inflammation, hemostasis
- Hemostasis, inflammation, proliferation, remodeling (correct)
- Proliferation, remodeling, hemostasis, inflammation
- Inflammation, hemostasis, remodeling, proliferation
During the inflammatory phase of wound healing, which physiological change is not expected?
During the inflammatory phase of wound healing, which physiological change is not expected?
In the proliferative phase of wound healing, what is the primary process contributing to the filling of the wound bed?
In the proliferative phase of wound healing, what is the primary process contributing to the filling of the wound bed?
What is the ultimate goal of wound healing?
What is the ultimate goal of wound healing?
What is meant by 'tunneling' in a wound assessment?
What is meant by 'tunneling' in a wound assessment?
When assessing a wound, which factor is least important to document?
When assessing a wound, which factor is least important to document?
What color is granulation tissue typically?
What color is granulation tissue typically?
What is slough composed of in a wound bed?
What is slough composed of in a wound bed?
Why is it generally necessary to remove eschar from a wound?
Why is it generally necessary to remove eschar from a wound?
A patient's wound is producing a thick, yellow-green exudate. What type of exudate is this?
A patient's wound is producing a thick, yellow-green exudate. What type of exudate is this?
What type of exudate would be expected from a surgical incision that is beginning to heal without complications?
What type of exudate would be expected from a surgical incision that is beginning to heal without complications?
Which type of wound healing is characterized by wound edges that are closely approximated with minimal tissue loss?
Which type of wound healing is characterized by wound edges that are closely approximated with minimal tissue loss?
A wound left open to heal, fills with granulation tissue is what type of healing?
A wound left open to heal, fills with granulation tissue is what type of healing?
In tertiary intention wound healing, why is there a delay in closing the wound?
In tertiary intention wound healing, why is there a delay in closing the wound?
Which of the following is not considered a major complication of wound healing?
Which of the following is not considered a major complication of wound healing?
What is the key difference between dehiscence and evisceration?
What is the key difference between dehiscence and evisceration?
How does excessive fluid accumulation in a wound bed typically impact wound healing?
How does excessive fluid accumulation in a wound bed typically impact wound healing?
What is the primary function of a Jackson-Pratt (JP) drain?
What is the primary function of a Jackson-Pratt (JP) drain?
How does polypharmacy potentially affect wound healing?
How does polypharmacy potentially affect wound healing?
Which of the following is not a risk factor for pressure ulcer development?
Which of the following is not a risk factor for pressure ulcer development?
What is the key characteristic of a Stage 1 pressure ulcer?
What is the key characteristic of a Stage 1 pressure ulcer?
A pressure ulcer is characterized by partial-thickness skin loss with a shallow open ulceration, without slough or bruising. Which stage is this?
A pressure ulcer is characterized by partial-thickness skin loss with a shallow open ulceration, without slough or bruising. Which stage is this?
In which stage of a pressure ulcer would you expect to see exposed bone, tendon, or muscle?
In which stage of a pressure ulcer would you expect to see exposed bone, tendon, or muscle?
An unstageable pressure ulcer is characterized by what feature?
An unstageable pressure ulcer is characterized by what feature?
What visual characteristic is associated with a suspected deep tissue injury?
What visual characteristic is associated with a suspected deep tissue injury?
Which of the following is not a recommended strategy for preventing pressure ulcers?
Which of the following is not a recommended strategy for preventing pressure ulcers?
When a patient is in an upright position in a chair, what is generally the recommended maximum duration before repositioning to prevent pressure ulcers?
When a patient is in an upright position in a chair, what is generally the recommended maximum duration before repositioning to prevent pressure ulcers?
To minimize pressure on the sacrum and buttocks, how high should the head of the bed (HOB) be raised?
To minimize pressure on the sacrum and buttocks, how high should the head of the bed (HOB) be raised?
Which of the following nutrients is least important for wound healing?
Which of the following nutrients is least important for wound healing?
Why is hydrogen peroxide generally not recommended for cleaning wounds?
Why is hydrogen peroxide generally not recommended for cleaning wounds?
Which of the following vitamins is essential for collagen synthesis during wound healing?
Which of the following vitamins is essential for collagen synthesis during wound healing?
What is the rationale for offering pain medication before debridement?
What is the rationale for offering pain medication before debridement?
Which type of debridement relies on the body's own enzymes to break down necrotic tissue?
Which type of debridement relies on the body's own enzymes to break down necrotic tissue?
Maggot therapy is an example of which type of debridement?
Maggot therapy is an example of which type of debridement?
What key information should be included when documenting a wound assessment?
What key information should be included when documenting a wound assessment?
When irrigating a wound, in which direction should the solution flow?
When irrigating a wound, in which direction should the solution flow?
What is the primary purpose of vacuum-assisted closure (VAC) therapy?
What is the primary purpose of vacuum-assisted closure (VAC) therapy?
When is wound packing typically indicated?
When is wound packing typically indicated?
What size syringe is generally used for wound irrigation?
What size syringe is generally used for wound irrigation?
The application of heat to open wounds can provide what therapeutic effect?
The application of heat to open wounds can provide what therapeutic effect?
When conducting a comprehensive skin assessment, why is it crucial to assess areas with adhesive tape or devices?
When conducting a comprehensive skin assessment, why is it crucial to assess areas with adhesive tape or devices?
A patient with limited mobility and poor nutritional intake has a Braden Scale score of 12. How should this score guide nursing interventions?
A patient with limited mobility and poor nutritional intake has a Braden Scale score of 12. How should this score guide nursing interventions?
During the inflammatory phase of wound healing, how does the body's response contribute to the overall healing process?
During the inflammatory phase of wound healing, how does the body's response contribute to the overall healing process?
In the proliferative phase of wound healing, how do new blood vessels contribute to the tissue repair?
In the proliferative phase of wound healing, how do new blood vessels contribute to the tissue repair?
In the maturation phase of wound healing, what changes occur in the newly formed skin to increase its strength and flexibility?
In the maturation phase of wound healing, what changes occur in the newly formed skin to increase its strength and flexibility?
Why is an accurate assessment of wound depth crucial when documenting a wound?
Why is an accurate assessment of wound depth crucial when documenting a wound?
What does the presence of granulation tissue in a wound bed indicate about the healing process?
What does the presence of granulation tissue in a wound bed indicate about the healing process?
Why is it important to differentiate between serous, serosanguineous, and purulent exudate when assessing a wound?
Why is it important to differentiate between serous, serosanguineous, and purulent exudate when assessing a wound?
A surgical wound is closed using sutures, leading to minimal scarring. Which type of wound healing is exemplified in this situation?
A surgical wound is closed using sutures, leading to minimal scarring. Which type of wound healing is exemplified in this situation?
A patient's surgical wound initially closed by primary intention begins to separate, and is left open to heal with granulation tissue filling the gap. Which type of wound healing is occurring?
A patient's surgical wound initially closed by primary intention begins to separate, and is left open to heal with granulation tissue filling the gap. Which type of wound healing is occurring?
In tertiary intention wound healing, what is the primary reason for delaying the closure of the wound?
In tertiary intention wound healing, what is the primary reason for delaying the closure of the wound?
Following an abdominal surgery, a patient reports a sudden 'popping' sensation, and upon examination, the nurse observes the wound edges have separated with some bowel protruding. What complication does this signify?
Following an abdominal surgery, a patient reports a sudden 'popping' sensation, and upon examination, the nurse observes the wound edges have separated with some bowel protruding. What complication does this signify?
How does excessive moisture in a wound bed impede the healing process?
How does excessive moisture in a wound bed impede the healing process?
What is the primary rationale for using a Jackson-Pratt (JP) drain in a surgical wound?
What is the primary rationale for using a Jackson-Pratt (JP) drain in a surgical wound?
How does polypharmacy potentially complicate wound healing in older adults?
How does polypharmacy potentially complicate wound healing in older adults?
How does impaired sensory perception increase the risk of pressure ulcer development?
How does impaired sensory perception increase the risk of pressure ulcer development?
What key characteristic distinguishes a Stage 1 pressure ulcer from normal skin?
What key characteristic distinguishes a Stage 1 pressure ulcer from normal skin?
In a Stage 3 pressure ulcer, what tissues are exposed?
In a Stage 3 pressure ulcer, what tissues are exposed?
What visual characteristic defines an unstageable pressure ulcer?
What visual characteristic defines an unstageable pressure ulcer?
What underlying physiological process leads to the development of a suspected deep tissue injury (sDTI)?
What underlying physiological process leads to the development of a suspected deep tissue injury (sDTI)?
To reduce the risk of pressure ulcers, what is the recommended maximum angle for raising the head of the bed (HOB)?
To reduce the risk of pressure ulcers, what is the recommended maximum angle for raising the head of the bed (HOB)?
Why is adequate protein intake essential for wound healing?
Why is adequate protein intake essential for wound healing?
What role does Vitamin A play in promoting wound healing?
What role does Vitamin A play in promoting wound healing?
Why is Zinc important for optimal wound healing?
Why is Zinc important for optimal wound healing?
Why is adequate hydration important for effective wound healing?
Why is adequate hydration important for effective wound healing?
What is the rationale for avoiding the use of hydrogen peroxide on open wounds?
What is the rationale for avoiding the use of hydrogen peroxide on open wounds?
Which of the following vitamins is crucial for collagen synthesis, and deficiencies in this vitamin can impair wound healing?
Which of the following vitamins is crucial for collagen synthesis, and deficiencies in this vitamin can impair wound healing?
Why is it important to administer pain medication prior to wound debridement?
Why is it important to administer pain medication prior to wound debridement?
Which type of debridement relies on the body's own enzymes and moisture to break down necrotic tissue?
Which type of debridement relies on the body's own enzymes and moisture to break down necrotic tissue?
Maggot therapy, where sterile maggots are applied to a wound, is an example of which type of debridement?
Maggot therapy, where sterile maggots are applied to a wound, is an example of which type of debridement?
What is the recommended direction to clean a wound during irrigation to prevent contamination?
What is the recommended direction to clean a wound during irrigation to prevent contamination?
What is the primary mechanism by which Vacuum-Assisted Closure (VAC) therapy promotes wound healing?
What is the primary mechanism by which Vacuum-Assisted Closure (VAC) therapy promotes wound healing?
In what type of wound is packing indicated?
In what type of wound is packing indicated?
What gauge of needle is generally recommended when using a 35ml syringe for wound irrigation?
What gauge of needle is generally recommended when using a 35ml syringe for wound irrigation?
How does local application of heat to an open wound affect the wound environment?
How does local application of heat to an open wound affect the wound environment?
What should the nurse document about the edges of a wound?
What should the nurse document about the edges of a wound?
When assessing a wound, which of the following best describes 'tunneling'?
When assessing a wound, which of the following best describes 'tunneling'?
What color is typically associated with healthy granulation tissue in a wound bed?
What color is typically associated with healthy granulation tissue in a wound bed?
What is the composition of slough commonly found in a wound bed?
What is the composition of slough commonly found in a wound bed?
What is the primary reason eschar needs to be removed from a wound?
What is the primary reason eschar needs to be removed from a wound?
A patient's wound is producing a clear, watery exudate. How would this type of exudate be classified?
A patient's wound is producing a clear, watery exudate. How would this type of exudate be classified?
When performing a skin assessment, which area requires extra attention due to increased risk of skin breakdown?
When performing a skin assessment, which area requires extra attention due to increased risk of skin breakdown?
A patient scores low on the 'moisture' component of the Braden Scale. What does this indicate about their risk for pressure ulcers?
A patient scores low on the 'moisture' component of the Braden Scale. What does this indicate about their risk for pressure ulcers?
During the inflammatory phase of wound healing, which cellular activity is most crucial for preventing infection?
During the inflammatory phase of wound healing, which cellular activity is most crucial for preventing infection?
In the proliferative phase, granulation tissue fills the wound bed. Which component is primarily responsible for the structural integrity of this tissue?
In the proliferative phase, granulation tissue fills the wound bed. Which component is primarily responsible for the structural integrity of this tissue?
Following a surgical incision, epithelialization begins to cover the wound. What is the primary purpose of this process?
Following a surgical incision, epithelialization begins to cover the wound. What is the primary purpose of this process?
What finding would indicate a failure to achieve the ultimate goal of wound healing?
What finding would indicate a failure to achieve the ultimate goal of wound healing?
When assessing a wound with suspected tunneling, what is the most accurate method for determining the depth and direction of the tunnel?
When assessing a wound with suspected tunneling, what is the most accurate method for determining the depth and direction of the tunnel?
During wound assessment, the periwound skin is found to be macerated. How would this affect ongoing care?
During wound assessment, the periwound skin is found to be macerated. How would this affect ongoing care?
You observe pink tissue in the wound bed. How would you proceed?
You observe pink tissue in the wound bed. How would you proceed?
A wound is covered in a thick layer of yellow tissue. What is your immediate action?
A wound is covered in a thick layer of yellow tissue. What is your immediate action?
Why is debridement of eschar essential for promoting wound healing?
Why is debridement of eschar essential for promoting wound healing?
A patient presents with a wound exuding thick, yellow drainage. What is the most likely cause.
A patient presents with a wound exuding thick, yellow drainage. What is the most likely cause.
A surgical wound is closed with sutures, and the skin edges are well-approximated. By what intention will this wound heal?
A surgical wound is closed with sutures, and the skin edges are well-approximated. By what intention will this wound heal?
Wound edges that are not approximated, resulting in a cavity that must fill with granulation tissue. By what intention will it heal?
Wound edges that are not approximated, resulting in a cavity that must fill with granulation tissue. By what intention will it heal?
A patient's surgical wound was initially closed, but due to infection, the wound is left open to heal. After the infection clears, the wound is surgically closed. What type of healing is this?
A patient's surgical wound was initially closed, but due to infection, the wound is left open to heal. After the infection clears, the wound is surgically closed. What type of healing is this?
A patient reports his surgical incision has separated and he can see loops of bowel protruding. What has happened?
A patient reports his surgical incision has separated and he can see loops of bowel protruding. What has happened?
Why does excessive fluid accumulation in a wound bed impede the healing process?
Why does excessive fluid accumulation in a wound bed impede the healing process?
What type of pressure-redistribution surface relies on air-filled cells to cyclically inflate and deflate, thereby alternating pressure on different areas of the body?
What type of pressure-redistribution surface relies on air-filled cells to cyclically inflate and deflate, thereby alternating pressure on different areas of the body?
A patient with a stage 3 pressure ulcer is prescribed a high-protein diet. What is the primary rationale for this nutritional intervention?
A patient with a stage 3 pressure ulcer is prescribed a high-protein diet. What is the primary rationale for this nutritional intervention?
What is the primary rationale for using sterile saline for wound irrigation rather than hydrogen peroxide?
What is the primary rationale for using sterile saline for wound irrigation rather than hydrogen peroxide?
Flashcards
Components of skin assessment?
Components of skin assessment?
Evaluation of skin, Braden Scale, and wounds.
Key areas during skin assessment?
Key areas during skin assessment?
Areas of bony prominences, skin under adhesive, blanching, and moisture.
Braden Scale
Braden Scale
Evaluates sensory perception, moisture, activity, mobility, nutrition, friction, and shear. Lower scores indicate higher risk.
Stages of wound healing?
Stages of wound healing?
Signup and view all the flashcards
Hemostasis
Hemostasis
Signup and view all the flashcards
Inflammatory stage
Inflammatory stage
Signup and view all the flashcards
Proliferative stage
Proliferative stage
Signup and view all the flashcards
Epithelialization
Epithelialization
Signup and view all the flashcards
Maturation
Maturation
Signup and view all the flashcards
Goal for wound healing?
Goal for wound healing?
Signup and view all the flashcards
Wound Assessment Elements
Wound Assessment Elements
Signup and view all the flashcards
Granulation tissue
Granulation tissue
Signup and view all the flashcards
Slough
Slough
Signup and view all the flashcards
Eschar
Eschar
Signup and view all the flashcards
Exudate
Exudate
Signup and view all the flashcards
Serous exudate
Serous exudate
Signup and view all the flashcards
Purulent
Purulent
Signup and view all the flashcards
Serosanguineous
Serosanguineous
Signup and view all the flashcards
Sanguineous
Sanguineous
Signup and view all the flashcards
Primary intention wound
Primary intention wound
Signup and view all the flashcards
Secondary intention wound
Secondary intention wound
Signup and view all the flashcards
Tertiary wound healing
Tertiary wound healing
Signup and view all the flashcards
Wound Healing Complications
Wound Healing Complications
Signup and view all the flashcards
Dehiscence
Dehiscence
Signup and view all the flashcards
Evisceration
Evisceration
Signup and view all the flashcards
Too much fluid
Too much fluid
Signup and view all the flashcards
JP drain
JP drain
Signup and view all the flashcards
Polypharmacy
Polypharmacy
Signup and view all the flashcards
Risk factors of pressure ulcers
Risk factors of pressure ulcers
Signup and view all the flashcards
Stage 1 ulcer
Stage 1 ulcer
Signup and view all the flashcards
Stage 2 ulcer
Stage 2 ulcer
Signup and view all the flashcards
Stage 3 ulcer
Stage 3 ulcer
Signup and view all the flashcards
Stage 4
Stage 4
Signup and view all the flashcards
Unstageable pressure ulcer
Unstageable pressure ulcer
Signup and view all the flashcards
Suspected deep tissue injury
Suspected deep tissue injury
Signup and view all the flashcards
Prevention of pressure ulcers
Prevention of pressure ulcers
Signup and view all the flashcards
Upright position in chair
Upright position in chair
Signup and view all the flashcards
Raise HOB to
Raise HOB to
Signup and view all the flashcards
Nutrition wound healing
Nutrition wound healing
Signup and view all the flashcards
Hydrogen peroxide
Hydrogen peroxide
Signup and view all the flashcards
Autolytic debridement
Autolytic debridement
Signup and view all the flashcards
Mechanical debridement
Mechanical debridement
Signup and view all the flashcards
Chemical debridement
Chemical debridement
Signup and view all the flashcards
Wound Assessment
Wound Assessment
Signup and view all the flashcards
Irrigation method?
Irrigation method?
Signup and view all the flashcards
VAC
VAC
Signup and view all the flashcards
Wound packing
Wound packing
Signup and view all the flashcards
Syringe used
Syringe used
Signup and view all the flashcards
Heat
Heat
Signup and view all the flashcards
Study Notes
Skin Assessment
- Skin assessment includes using the Braden Scale and wound assessment techniques.
- During skin assessment, check bony prominences, areas under adhesive tape or devices, blanchable or non-blanchable areas, and moisture levels.
Braden Scale
- The Braden Scale assesses sensory perception, moisture, activity, mobility, nutrition, friction, and shear.
- Lower scores on the Braden Scale indicate a higher risk for pressure ulcers.
Stages of Wound Healing
- Hemostasis: Stoppage of bleeding.
- Inflammation: White blood cells are sent to kill germs and clean the wound, with redness, swelling, warmth, and pain occurring within 24 hours of injury.
- Proliferation: New blood vessels form, granulation tissue (collagen and extracellular matrix) fills the wound, and epithelialization resurfaces the area, occurring from 3-24 days.
- Epithelialization: New skin cells grow over a wound to form a protective layer.
- Maturation: The wound fully closes, and the new skin becomes stronger.
- The goal for wound healing is to achieve intact skin.
Wound Assessment
- Wound assessment includes checking wound location, type of tissue in the wound base, depth of tissue involvement (staging), wound healing process, wound dimensions, exudate description, periwound area, and any drains.
- Tunneling in a wound refers to tracts of different depths.
- Granulation tissue is pink tissue that normally forms during wound healing.
- Slough is yellow, stringy, or mucoid material coming out of wounds.
- Eschar is dead tissue that needs to be removed to help wound healing.
Exudate Types
- Exudate is fluid that leaks out of an infected wound.
- Serous exudate is clear and watery plasma.
- Purulent exudate is thick and can be yellow, green, tan, or brown.
- Serosanguineous exudate is pale, red, and watery.
- Sanguineous exudate is bright red, indicating active bleeding.
Wound Healing Types
- Primary intention wound healing occurs when wound edges are closed, well-approximated, with little tissue loss and minimal scarring.
- Secondary intention wound healing happens when wound edges are not approximated, there is tissue loss or contamination, and granulation tissue is present, potentially involving tunneling.
- Tertiary wound healing involves leaving a wound open for several days, then approximating the edges; closure is delayed until the risk of infection is resolved.
Complications of Wound Healing
- Complications include hemorrhage, infection, dehiscence (bursting open of a wound), and evisceration (protrusion of organs).
- Too much fluid decreases wound healing.
- A JP (Jackson-Pratt) drain is a suction drain with tubing inside the body and a bulb reservoir.
Risk Factors of Pressure Ulcers
- Risk factors include impaired sensory perception, impaired mobility, alterations in level of consciousness, shear, friction, and moisture.
Pressure Ulcer Stages
- Stage 1: Intact skin with redness/irritation that is unblanchable.
- Stage 2: Loss of dermal layer, shallow open ulceration, no sloughing or bruising, blistering, serum-filled or serosanguineous filled.
- Stage 3: Loss of subcutaneous fat; bone, tissue, and tendon are not exposed.
- Stage 4: Exposed bone, tendon, and muscle; possible bone infection.
- Unstageable: Ulcer base is covered by slough and/or eschar in the wound bed.
- Suspected Deep Tissue Injury: Purple or maroon localized area of discolored intact skin or blood-filled blistering caused by damage to soft tissue from pressure or shear force, and is often painful.
Prevention of Pressure Ulcers
- Nutritional status, controlling incontinence, frequent position changes, and support beds/surfaces are all strategies of prevention.
- Limit upright position in a chair to two hours.
- Raise the head of the bed to 30 degrees.
Nutrition for Wound Healing
- Protein, Vitamin A (for regeneration), Zinc (for preventing infection), Vitamin C (for collagen synthesis), and fluids are important.
- All cells need water, so staying hydrated helps support wound healing.
Wound Care Principles
- Do not use hydrogen peroxide to clean wounds.
- Offer pain medications before debriding.
Types of Debridement
- Autolytic: Uses the body's own enzymes to break down necrotic tissue.
- Mechanical: Uses outside forces to remove dead tissue (e.g., maggots).
- Chemical: Topical enzymes are applied to induce changes that break down necrotic tissue.
Wound Assessment and Documentation
- Assess wound dimensions (length x height x depth), edges (clean, well-approximated, crusting), and presence of inflammation or exudate.
- Irrigate from least to most contaminated areas, cleaning away from the wound.
- Vacuum-Assisted Closure (VAC): A machine removes fluid and debris to increase wound healing.
- Wound packing is used for deep wounds.
- A 35 ml syringe with a 19-gauge needle is used for wound irrigation.
Heat Application
- Therapeutic heat application causes vasodilation and is beneficial for open wounds, hemorrhoids, and wound debridement.
Studying That Suits You
Use AI to generate personalized quizzes and flashcards to suit your learning preferences.
