ch 48 skin integrity and wound care

Question 1

acute wound nursing care

Answer 1

require close monitoring (q 8 hr)

Question 2

chronic wound nursing care

Answer 2

every dressing change

Question 3

wound irrigation

Answer 3

mechanical -debrides necrotic tissue with pressure that can remove debris from wound bed without damaging health tissue
-19 gauge, 35 mL syrnge, 8 psi

Question 4

debridement

Answer 4

removal of nonviable, necrotic tissue

-mechanical, autolytic, chemical, sharp/surgical

Question 5

autolytic debridement

Answer 5

use of white blood cells and natural enzymens of the body

• use dressing that support moisture at wound surface
• -transparent film, hydrocolloid dressings

Question 6

chemical debridement

Answer 6

use of topical enzyme preparation

-Dakon’s solution, sterile maggots

Question 7

poor wound healing

Answer 7

shear force, friction, moisture, nutrition, tissue perfusion, infection, and age

Question 8

nutritional status implementations

Answer 8

dietician, enteral, 30-35 calories/kg, increased caloric intake, vitamin (C) and mineral suppliments, increased protein (1.8g/kg/day)

Question 9

comfort measures implementation

Answer 9

administer analgesic 30-60 min before dressing changes, careful removal of tape, gentle cleansing, careful manipulations of dressings and drains, careful turning and positioning

Question 10

primary intention wounds abnormal

Answer 10

1. incision line poorly approximated
2. drainage present more than 3 days after closure
3. inflammation increased in first 3-5 days after injury
4. no epitheliazation of wound edges by day 4

Question 11

secondary intention wounds abnormal

Answer 11

1. pale or fragile granulation tissue, gran tissue bed excessively dry or moist
2. purulent exudate present
3. necrotic or slough tissue present in wound base
4. epitheliazation not continuous; odor present; presence of fistulas, tunneling, undermining

Question 12

primary intention normal healing

Answer 12

clean, well-approximated edges

7-10 days resurfaces w epithelial tissue and edges close

Question 13

wound drainage

Answer 13

1 g of drainage equals 1 mL volume

Question 14

types of drainage 4

Answer 14

serous
sanguineous
serosanguinous
purulent

Question 15

moist applications advantages

Answer 15

1. reduces drying of skin and softens wound exudate
2. moist compress conform well to most body areas
3. moist heat penetrates deep into tissue layers
4. does not promote sweating or insensible fluid loss

Question 16

dry applications advantages

Answer 16

1. less risk to burns than moist heat
2. does not cause skin maceration
3. retains temp longer because no evaporation

Question 17

evisceration treatment

Answer 17

total separation of wound layers

• emergent surgical repair
• place sterile gauze soaked in sterile solution over extruding tissues
• make pt NPO
• observe for signs of shock

Question 18

transparent dressing

Answer 18

protects from shear and friction
traps moisture, providing moist environment
stage 1 pressure ulcer

Question 19

surgical wounds healing by primary intention

Answer 19

remove dressings once drainage stops

Question 20

wound healing by secondary intention

Answer 20

dressing material becomes a means for providing moisture to the wound or helping in debridement

Question 21

6 purposes of dressings

Answer 21

1. protects from contamination
2. aids in hemostasis
3. promotes healing by absorbing drainage and debridement
4. supports or splints
5. thermal insulation
6. provides moist environment

Question 22

hydrocolloid dressings

Answer 22

support healing in clean granulating woundsand autolytically debride necrotic wounds
-shallow to mod deep dermal ulcers (stage 2, 3)

Question 23

hydrogel

Answer 23

gauze or sheet impregnated w water or glycerine-based amorphous gel

• partial to full thickness, deep wounds w exudate, necrotic, burns, radiation damage (stage 2, 3, 4)
• soothing for painful wounds

Question 24

foam and alginate

Answer 24

large amount of exudate and wounds that need packing

-not to be used in dry wounds and require secondary dressing

Question 25

stage 1

Answer 25

resolves slowly without epidermal loss over 7-14 days

Question 26

stage 2

Answer 26

heals through reepithelialization

Question 27

stage 3

Answer 27

heals through granulation and reepithelialization

Question 28

stage 4

Answer 28

heals through granulation and reepithelialization

Question 29

Vacuum-Assisted closure- VAC

Answer 29

device that uses applied localized negative pressure to draw edges of wound together (negative pressure wound therapy -NPWT)

Question 30

bandages and binders 6 therapeutic benefits

Answer 30

1. create pressure
2. immobilize
3. supporting wound
4. reduce or prevent edema
5. secure a splint
6. secure dressings

Question 31

goals and outcomes

Answer 31

intact skin integrity
signs of healing
maintains intact skin over pressure points