Pressure Ulcers, Wounds, and Wound Management - ATI - Chapter 55 Flashcards by Leigh Rothgeb (2024)

Wounds are a result of injury to the ____.

skin.

Although there are many different methods and degrees of injury, the ______ of healing are essentially the same for most wounds.

basic phases

A pressure ulcer (formerly called a _______) is a specific type of tissue injury from unrelieved pressure or friction over bony prominences that results in ischemia and damage to the underlying tissue.

decubitus ulcer

The stages of wound healing

Inflammatory Stage
Proliferative Stage
Maturation or remodeling Stage

Inflammatory stage begins with the injury and lasts _____ days.

3-6 days

Controlling bleeding with vasoconstriction and retraction of blood vessels, and with ______ in the inflammatory stage.

clot formation

During the ______ stage oxygen, white blood cells, and nutrients are delivered to the area via the blood supply.

inflammatory stage

____ occurs along with fibrin formation during the inflammatory stage.

hemostasis

____ engulf microorgansims and cellular debris (phagocytosis) during the inflammatory stage.

macrophages

The ____ stage lasts the next 3 to 24 days in the wound healing process.

proliferative

During the proliferative stage lost tissue is replaced with ______ or ______ tissue or collagen.

connective or granulated

During the proliferative stage the wound’s edges are ____.

contracting

Resurfacing of new _______ occurs during the proliferative stage.

epithelial cells

____ stage occurs after day 21 and involves the strengthening of the collagen scar and the restoration of a more normal appearance.

maturation or remodeling stage

It can take more than a year to complete, depending on the extent of the original wound during the _____ stage.

maturation or remodeling stage

The types of the healing processes

primary intention
secondary intention
tertiary intention

primary intention

secondary intention

Tertiary intention

Factors affecting wound healing

Increased ___ delays healing.

age

A wound in a young, healthy client will heal faster than a wound in an older adult who has a chronic illness due to the _______ risk factor that affects wound healing.

overall wellness

_____ delays wound healing because the immune system function is to fight infection by destroying invading pathogens.

decreased leukocyte count

Age effects wound healing because of the following (8)

_____ interfere with the body’s ability to respond to and prevent infection.

some medication

what medications interfere with the body’s ability to respond to and prevent infection.

_______ do not get the nutrition they need which provides energy and elements for wound healing.

malnourished clients

______ provides circulation that delivers nutrients for tissue repair and infection control can effect wound healing.

tissue perfusion

_____ effect wound healing because Hgb is essential for oxygen delivery to healing tissues.

low Hgb levels

______ can effect wound healing because fatty tissue lacks blood supply.

obesity

______ such as diabetes mellitus and cardiovascular disorders, place additional stress on the body’s healing mechanisms which effect wound healing.

chronic diseases

_____ such as from vomiting or coughing, puts pressure on the suture line and disrupts the wound healing process.

wound stress

Wounds impair ____.

skin integrity

_____ is a localized protective response to injury or destruction of tissue.

inflammation

Wounds heal by various processes and in ______.

stages

Wound _____ result from the invasion of pathogenic micro-organisms.

infections.

Principles of wound care include assessment, _____, and protection.

cleansing

During assessment/data collection note the ______ of the open wounds.

color

A ____ wound means there is healthy regeneration of tissue.

red

A ____ colored wound means there is a presence of purulent drainage and slough.

yellow

A ____ wound means there is a presence of eschar that hinders healing and requires removal.

black

Assess the length, width, and ____ of wounds, and any undermining, sinus tracts or ______, and redness or swelling.

When assessing wounds use a ____ with 12:00 toward the client’s head to document the location of sinus tracts.

clock face

Use the RYB color guide for wound care:
Red = cover
Yellow = ____
Black = _____

With ___ wounds skin edges should be well-approximated.

closed wounds

________ is a result of the healing process and occurs during the inflammatory and proliferative phases of healing.

drainage (exudate)

Note the amount, odor, and _____ and color of drainage from a drain or on a dressing.

consistency

Not the _____ of the surrounding skin.

integrity

With each cleansing, observe the skin around a drain for ______ and breakdown.

irritation

For accurate measurement of drainage, ____ the dressing.

weigh

Note and document the _____ of dressings and frequency of dressing changes.

number

The portion of the blood (serum) that is watery and clear or slightly yellow in appearance (i.e. fluid blisters) is called _____

serous drainage

_____ drainage contains serum and red blood cells. It is thick and appears reddish. Brighter drainage indicates fresh bleeding; darker drainage indicates older _____.

_______ drainage contains both serum and blood. It is watery and appears blood-streaked or blood tinged.

serosanguineous drainage

____ drainage is the result of inflection.

purulent

______ drainage is a mixed drainage of pus and blood (i.e. newly infected wound)

purosanguineous

____ drainage is thick and contains white blood cells, tissue debris, and bacteria. It may have a foul odor, and its color such as yellow, tan, brown reflects the type of organism present (green for Pseuduomonoas aeroguinosa infection).

purulent

Types of wound closures (3)

staples
sutures
wound-closure strips

Note the location, quality, intensity, timing, setting, associated manifestations, and aggravating/relieving factors associated with any ____.

pain

In the assessment collect these (5) things

When they are asking about the _____ of a wound note if there are any drains or tubes.

status

A nursing intervention involving wound care requires you provide adequate hydration and meet _____ and calorie needs.

protein

Encourage an intake of ____ to ____ mL of fluid/day from food and beverage sources if not contraindicated (heart and chronic kidney disease).

2,000 to 3,000

A nursing intervention involving wound care involves _____ about good sources of protein (meat, fish, poultry, eggs, dairy products, beans, nuts, and grains.)

education

Note if serum ____ levels are low (below 3.5 g/dL) because of a lack of protein increases the risk for a delay in wound healing and infection.

albumin

Provide nutritional support (vitamin and mineral supplements, nutritional supplements, and enteral and parental nutrition). Most adult clients need at leas ____ kcal/day for nutritional support.

1500

For clean wounds, such as a surgical incision, cleanse from the ____ contaminated (the incision) toward the ____ contaminated (the surrounding skin).

Use gentle ____ when cleansing or applying solutions to the skin to avoid bleeding or further injury to the wound.

friction

Although the provider might prescribe other mild cleansing agents, ______solutions remain the preferred cleaning agent.

isotonic

Never use the same ____ to cleanse across an incision or wound more than once.

gauze

Do not use _____ or other products that shed fibers when you perform wound cleansing.

cotton balls

If irrigating, use a piston syringe or a _____ for deep wounds with small openings when cleaning a wound. Apply 5 to 8 psi of pressure. A ___ to ___ mL syringe with a 19 gauge needle provides approximately 8 psi. Use normal saline, lactated Ringer’s, or an antibiotic/antimicrobial solution.

When you perform wound cleaning remove sutures and ____.

staples

Administer ____ and monitor for effective pain management when performing wound cleansing.

analgesics

Administer _____ (topical,systemic) and monitor for effectiveness (reduced fever, increase in comfort, decreasing WBC count) when wound cleansing.

antimicrobials

Document the location and _____ of wound and incision, the status of the wound and type of drainage, the type of dressing and materials, client teaching, and how the client tolerated the procedure while performing wound cleansing.

type of

____ protect the wound from microbes.

protects

_____ absorbs exudate from the wound.

Woven gauze sponges

_____ does not stick to the wound bed. (type of wound dressing)

nonadherent material

_____ are used to mechanically debride a wound until granulation tissue starts to form in the wound bed. Must keep moist at all times to prevent pain and disruption of wound healing.

damp to damp 4 inch by 4 inch dressings

_____ are a temporary “second skin” ideal for small, superficial wounds.

self adhesive, transparent film

_____ is an occlusive dressing that swells in the presence of exudate; composed of gelatin and pectin, it forms a ____ at the wound’s surface to prevent evaporation of moisture from the skin.

Hydrocolloid maintains a ____ wound bed.

granulating

Hydrocolloid can stay in place up to _____.

7 days

_____ composition is mostly water. Gels after contact with exudate, promoting autolytic debridement and cooling. Rehydrates and fills dead space.

hydrogel

_____ is for infected, deep wounds, or necrotic tissue.

hydrogel

Hydrogel is not for moderately to heavily _____.

draining wounds

Hydrogel provides a _____ wound bed.

moist

Hydrogel can stay in place for _____ days.

3

Use of foam strips laid into the wound bed with an occlusive sealed drape applied and suction tubing is placed for negative pressure (suction) to occur once the tubing is connected to the _____ system therapy unit.

vacuum-assisted closure

A vacuum-assisted closure system decreases swelling, _____, and enhances healing in a moist protected environment.

speed tissue generation

____ is a partial or total rupture (separation) of sutured wound, usually with separation of underlying skin layers.

dehiscence

_____ is a dehiscence that involves the protrusion of visceral organs through a wound opening.

evisceration

Manifestations of dehiscence and evisceration (4)

Part of the prevention of dehiscence and evisceration is to take a thin, folded blanket or small pillow over surgical wounds when client ____ in order to support the wound.

coughs

Risk Factors for dehiscence and evisceration

Evisceration and dehiscence require ___.

emergency treatment

If eviscceration and dehiscence occurs call for help. Notify the provider immediately due to the need for ______. Stay with the client. Cover the wound and any protruding organs with ____ or dressings soaked with sterile normal saline solution to decrease the chance of bacteria invasion and drying of the tissues. Do not attempt to reinsert the organs. Position the client supine with the hips and ____ bent if possible. Observe for indications of shock. Maintain a calm environment. Keep the client _____ in preparation for returning to surgery.

surgical intervention
sterile towels
knees
NPO

_____ can be caused by clot dislodgement, broken stitch, or blood vessel damage.

hemorrhage

Internal bleeding (hemorrhage) will present with swelling or ____ in the area and sanguineous drainage.

distention

Hematoma is a local area of blood that appears as a _____.

red/blue bruise

Wound hemorrhage is an ____. Pressure dressing should be applied, with notification of the provider and monitoring of vital signs.

emergency

Risk factors for Infection

extremes in age (immature immune system, decrease in immune function)
impaired circulation and oxygenation (COPD, peripheral vascular disease)
wound condition and nature (gunshot wound vs. surgical incision)
impaired or suppressed immune system
malnutrition, such as with alcohol use disorder
chronic disease, such as diabetes mellitus or hypertension
poor wound care, such as breaches in aseptic technique

Manifestations with infection occur ___ to ___ days after injury or surgery.

3 to 11

Manifestations with infection (8)

One nursing intervention to prevent infection includes using aseptic technique when performing _____.

dressing changes.

One nursing intervention to prevent infection includes providing _____ to promote the immune response.

optimal nutrition

One nursing intervention to prevent infection includes providing adequate _____ to promote healing.

rest

One nursing intervention to prevent infection includes administering _____ after collecting specimens for culture and sensitivity testing.

antibiotic therapy

The National Pressure Ulcer Advisory Panel (NPUAP) classifies pressure ulcers in s____ stages/categories.

6

With suspected _____ the depth is unknown. Discoloration is apparent but the skin is intact from damage to underlying tissue.

deep tissue injury

Stage _____ is a non blanchable erythema.

1

Stage ____ is a partial thickness.

2

Stage ____ pressure ulcer is intact skin with an area of persistent, nonblanchable redness, typically over a bony prominence, that can feel warmer or cooler than the adjacent tissue. The tissue is swollen and has congestion, with possible discomfort at the site. With darker skin tones, the ulcer can appear ____ or ____.

Stage ___ involves the epidermis and the dermis. The ulcer is visible with reddish-pinkish bed without slough or bruising, superficial, and can appear as an abrasion, blister, or shallow crater. Edema persists. The ulcer can become infected, possibly with ____ and scant drainage.

Stage ____ pressure ulcers involve full thickness tissue loss.

4

Stage _____ pressure ulcers include damage to or necrosis of subcutaneous tissue. The ulcer can extend down to, but not through, underlying fascia. The ulcer appears as a deep crater with or without undermining or tunneling of adjacent tissue and without exposed muscle or bone. Drainage and ____ are common.

Stage ___ pressure ulcers involve full thickness skin loss.

3

Stage _____ pressure ulcers include destruction, tissue necrosis, or damage to muscle, bone, or supporting structures. There can be sinus tracts, deep pockets of infection, tunneling, undermining, eschar (black scab-like material), or slough (tan, yellow, or green scab-like material).

4

_____ pressure ulcers are full-thickness skin or tissue loss, but the depth is unknown.

unstageable/unclassified

_____ pressure ulcer’s stage cannot be determined because eschar or slough obscures the wound. the actual depth of injury is unknown.

unstageable/unclassified

The primary focus of prevention and treatment of pressure ulcers is to ____ the pressure and provide optimal nutrition and hydration.

relieve

During the assessment/data collection of pressure ulcers monitor all clients regularly for ____ status and for risk factors that contribute to impaired skin integrity.

skin-integrity

During the assessment/data collection of pressure ulcers use a _____ tool (Braden, Norton scales) for periodic systemic monitoring for skin breakdown risk.

risk assessment

Pressure ulcers are a significant source of ____ and mortality among older adults and those who have limited mobility.

morbidity

Risk factors for Pressure Ulcers (15)

Nursing interventions for Pressure Ulcers

avoid skin trauma
provide supportive devices
maintain skin hygiene
encourage proper nutrition

To avoid skin trauma (pressure ulcers), keep skin clean, dry and intact. Provide a firm, ____ foundation with wrinkle-free linens.

wrinkle-free

To avoid skin trauma (pressure ulcers), reposition the client in bed at least every ___ hours and every ____ in a chair. Document position changes.

To avoid skin trauma (pressure ulcers), keep the head of the bed at or below a ____- angle (or flat), unless contraindicated, to relieve pressure on the sacrum, buttocks, and heels.

30 degree

To avoid skin trauma (pressure ulcers), raise _____ off the bed to prevent pressure.

heels

To avoid skin trauma (pressure ulcers), ____- clients as soon and as often as possible.

ambulate

To avoid skin trauma (pressure ulcers), instruct client who are mobile to shift their weight ever _____ when sitting.

15 min

A nursing intervention to prevent pressure ulcers is to avoid skin trauma (pressure ulcers), keep clients from sliding down in bed, as this increases ______ that pull tissue layers apart and cause damage. Lift, rather than pull, clients up in bed or in a chair, because pulling creates friction that can damage the outer layer of skin (epidermis).

shearing forces

A nursing intervention to prevent pressure ulcers is to provide supportive devices. Use _________ and devices ( overlays; replacement mattresses; specialty beds; kinetic therapy; foam, gel, or air cushions).

pressure-reducing surfaces

A nursing intervention to prevent pressure ulcers is to ______ the skin frequently and document the client’s risk using a tool such as the Braden Scale.

inspect

A nursing intervention to prevent pressure ulcers is to ____ the skin with a mild cleansing agent, and pat it dry immediately following urine or stool incontinence.

clean

A nursing intervention to prevent pressure ulcers is to bathe with _____ water and avoid scrubbing.

tepid

A nursing intervention to prevent pressure ulcers is to apply ______ or alcohol-free barrier films to the skin of clients who have incontinence.

dimethicone-based moisture barrier creams

A nursing intervention to prevent pressure ulcers is to not use _____ or cornstarch to prevent friction or repel moisture due to their abrasive grit and aspiration potential.

powder

A nursing intervention to prevent pressure ulcers is to implement active and ____ exercises for clients who are immobile.

passive

A nursing intervention to prevent pressure ulcers is to not _____ bony prominences.

massage

A nursing intervention to prevent pressure ulcers is to provide adequate ______ and meet protein and calorie needs.

hydration (2,000 - 3,000 mL/day)

Note if serum albumin levels are low (less than ____) because a lack of protein puts the client at greater risk for skin breakdown, slowed healing, and infection.

3.5 g/dL

Provide _______ as indicated, such as vitamin and mineral supplements (especially A, C, zinc, copper) nutritional supplements, and enteral and parenteral nutrition.

nutritional support

When encouraging proper nutrition to prevent pressure ulcers monitory _____.

lymphocyte count

Lift, rather than ____, client up in bed or in a chair, because _____ creates friction that can damage the outer layer of skin (epidermis).

Treatment for deep tissue injury and stage 1 pressure ulcers involve relieving the ____ .

pressure

Treatment for deep tissue injury and stage 1 pressure ulcers involve the encouragement of frequent ______ and re-positioning.

turning

Treatment for deep tissue injury and stage 1 pressure ulcers involve the implementation of _______ such as air mattresses and foam mattresses.

pressure-reduction surfaces

Treatment for deep tissue injury and stage 1 pressure ulcers involve keeping the client dry, ______, and hydrated.

well-nourished

Treatment for stage 2 pressure ulcers involve maintaining a ______ healing environment (saline or occlusive dressing). Apply a _____ dressing.

Treatment for stage 2 pressure ulcers involve promoting natural healing while preventing the formation of ______.

scar tissue

Treatment for stage 2 pressure ulcers involve providing ______.

nutritional supplements

Treatment for stage 2, 3, and 4 pressure ulcers involve administering _____ for pain management.

analgesics

Treatment for stage 3 pressure ulcers involve cleaning and/or ____ the following; prescribed dressing, surgical intervention and proteolytic enzymes.

debriding

Treatment for stage 4 pressure ulcers involve performing nonadherent dressing changes every _____.

12 hours

Treatment for stage 4 pressure ulcers can include ______ or specialized therapy such as hyperbaric oxygen.

skin grafts

Treatment for stage 3 and 4 pressure ulcers involve providing nutritional ______.

supplements

Treatment for stage 3 and 4 pressure ulcers involve administering ________ (topical and or/systemic)

antimicrobials

Deterioration to higher-stage ulceration or infection can occur if you do not check the ulcer frequently and report an increase in the size or depth of lesion, changes in ______ (color, tissue), and changes in exudates (color, quantity, odor).

granulation

To ensure there is no further deterioration to higher-stage ulceration or infection follow the facility’s ______ for ulcer treatment.

protocol

To ensure there is no further deterioration to higher-stage ulceration or infection you might need to confer with _______ specialist.

wound care

Monitoring for indications of _____ (changes in level of consciousness, persistent recurrent fever, tachycardia, tachypnea, hypotension, oliguria, or an increase in WBC count) is important to avoid systemic infection with pressure ulcers.

sepis

Prevent infection by using _____ when performing ulcer treatment and dressing changes to avoid systemic infection with pressure ulcers.

asepsis

Provide optimal _______ to promote the immune response systemic infection with pressure ulcers.

nutrition

Ensure adequate rest to promote _______ to avoid systemic infection with pressure ulcers.

healing

Administer antibiotic therapy after collecting ______ for culture and sensitivity testing.

specimens

In suspected deep tissue injury and stage 1 use ____ devices such as an air fluidized bed.

pressure relieving devices