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CHRONIC WOUNDS PRESSURE ULCERS
DIABETIC FOOT ULCERS AND VENOUS STASIS
ULCERS EXAMPREP FULLY SOLVED EDITION
WITH DETAILED VERIFIED ANSWERS
◉Protection of the Skin. Answer: The skin is a barrier from infection ◉Thermoregulation of the Skin. Answer: The skin helps regulate body temperature ◉Sensation of the Skin. Answer: Contains sensory organs for touch, pain, heat, and cold ◉Metabolism of the Skin. Answer: Metabolizes vitamin D ◉Communication of the Skin. Answer: Emotions are expressed in the sign language of the face and body posture ◉Excretion/Secretion of the Skin. Answer: Sweat promotes heat loss by evaporation. Sebum lubricates skin and hair.
◉Structures of the Skin. Answer: Epidermis, dermis, subcutaneous tissue ◉Characteristics of Normal Skin. Answer: - Color: depends on production of melanin
- Temperature: usually warm
- Moisture: dry to touch
- Texture/Thickness: unexposed smooth
- Odor: none ◉Newborn/Infant Skin. Answer: Epidermis and dermis are bound together loosely, and the skin is very thin. Friction against skin causes bruising ◉Toddler & Preschooler Skin. Answer: More tightly bound together. Child has greater resistance to infection and skin irritation ◉School-age & Adolescent Skin. Answer: Growth and maturation of the integument increase. In girls, estrogen secretion causes the skin to become soft, smooth and thicker with increased vascularity. Male hormones produce increased thickness of skin with some darkening in color
wound with granulation tissue, wound contraction, and wound resurfacing by means of epithelization ◉Maturation Phase (epithelization). Answer: Final phase, begins about 2nd/3rd week after injury and lasts more than a year. Collagen scar continues to reorganize and gain strength for several months. Collagen fibers undergo remodeling/reorganization before assuming their normal appearance ◉Primary Intention. Answer: Skin edges are approximated or closed and risk of infection is low. Healing occurs quickly, with minimal scar formation. A clean surgical incision is an example of a wound with little tissue loss ◉Secondary Intention. Answer: Takes longer for wound to heal, therefore chance of infection is greater. Wound edges are not approximated. If scarring is severe loss of tissue function is permanent (burn, stage 2 injury, or severe laceration) ◉Tertiary Intention. Answer: Delay between injury and wound closure. Incisions are left open purposely. There is less scarring ◉Complications of Wound Healing (Hemorrhage). Answer: Normal during & immediately after initial trauma. Internal can be detected by looking for distention or swelling of affected body part, change in type/amount of drainage from surgical drain, or signs of hypovolemic
shock (hematoma). Risk of hemorrhage is great during first 24-48 hrs after surgery or injury ◉Complications of Wound Healing (Infection). Answer: Local clinical signs of wound infection erythema; increased amount of wound drainage; change in appearance of a wound drainage (thick, color change, presence of odor) & peri wound warmth, pain or edema ◉Complications of Wound Healing (Dehiscence). Answer: Partial or total separation of wound layers. Can occur 5-12 days after suturing. A patient who has poor wound healing, poor nutritional status, infection, or underlying diseases such as diabetes mellitus or peripheral vascular disease is at risk ◉Complications of Wound Healing (Evisceration). Answer: Protrusion of visceral organs through a wound opening occurs with total separation of wound layers. Emergency that requires surgical repair ◉Complications of Wound Healing (Fistula). Answer: Abnormal passage from an internal organ to the body surface or between two internal organs ◉Chronic Wounds. Answer: Pressure ulcers, venous stasis ulcers, diabetic foot ulcers, arterial ulcers
◉Friction. Answer: The force of two surfaces moving across one another such as the mechanical force exerted when skin is dragged across a coarse surface such as bed linens. Affects epidermis or top layer of the skin ◉Moisture. Answer: Reduces resistance of the skin to other physical factors such as pressure, friction, or shear. Prolonged moisture softens skin, making it more susceptible to damage ◉Diminished Sensation. Answer: Peripheral neuropathy due to diabetes ◉Stage 1 Pressure Injury. Answer: Non-blanchable red intact skin ◉Stage 2 Pressure Injury. Answer: Partial thickness skin loss with exposed dermis ◉Stage 3 Pressure Injury. Answer: Full thickness skin loss. Adipose tissue is visible and granulation tissue and epibole are often present. Slough and eschar may be visible ◉Stage 4 Pressure Injury. Answer: Full thickness skin loss and tissue with exposed palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer
◉Unstageable Pressure Injury. Answer: Obscured full thickness skin and tissue loss by slough or eschar ◉Deep Tissue Pressure Injury. Answer: Intact or non intact skin with localized area of persistent nonblanchable deep red, maroon, purple discoloration, or epidermal separation revealing a dark wound bed/blood filled blister ◉Skin Integrity Assessment. Answer: Subjective Data: interview, risk identification Objective Data: inspection of skin, wound assessment, Braden scale ◉Braden Scale. Answer: Reliable tool for pressure injury risk assessment. Score ranges from 6-23 and the lower score indicates a higher risk for pressure injury ◉Braden Scale Subscales. Answer: - Sensory Perception: ability to respond to discomfort
- Moisture: degree to which skin is exposed to moisture
- Activity: how much the patient moves around
- Mobility: whether the patient is able to move body position independently
- Nutrition: usual food intake
- Friction and Shear: degree of sliding on beds/chairs
◉Hydrogel. Answer: Hydrates wounds and absorbs small amounts of exudate. For use in partial thickness/full thickness, deep with some exudate and necrotic wounds, burns/radiation damaged skin ◉Wound Vac. Answer: A medical device that applies negative pressure to a wound to promote healing and prevent infections. Needs to be tightly sealed a ◉Collagen Dressings. Answer: Encourages new cell growth, removes dead tissue, and promoted new blood vessel growth ◉Antimicrobial Dressings. Answer: - Cadexomer Iodine
- Silver Helps heal ◉Types of Wound Drains. Answer: - Hemovac
- Jackson Pratt (JP)
- Penrose ◉Perioperative Nursing. Answer: Includes a RNs planned patient- centered approach in providing care to patient's preoperatively, intraoperatively, and postoperatively ◉Never Events. Answer: Serious errors that are usually preventable
◉Surgical Risk Factors. Answer: Smoking, age, nutrition, obesity, obstructive sleep apnea, immunosuppression, fluid & electrolyte imbalance, nausea/vomiting, urinary retention, venous thromboembolism, allergies, mental status, type of wound, diabetes ◉Preoperative Care. Answer: Begins when the order for surgery is written. Plan for post-op needs, provide teaching, and identify health concerns ◉Obtaining Surgical Consent .... Answer: Type of surgery, name of person performing surgery, statement that risk and benefits have been explained, statement showing patient had opportunity to refuse treatment ◉Intraoperative. Answer: Requires careful preparation, knowledge of events that occur during surgery and use of safety practices ◉Scrub Nurse Duties (LPN). Answer: - set up and maintain sterile field
- prepare instruments
- anticipate surgeons needs
- assist with draping ◉Circulating Nurse Duties (RN). Answer: - monitors sterile field
- advocate for patient
