NUR 155 EXAM 3 STUDY GUIDE COMPLETE LATEST 2023

NUR 155 EXAM 3 REVIEW: SKIN INTEGRITY AND WOUND CARE Types of cleanliness of wounds:  Clean wound- are uninfected wounds with minimal inflammation and the respiratory, GI, genital, and urinary tracts are not entered. Clean wounds are primarily closed wounds  Clean-contaminated wounds- are surgical wounds in which the respiratory, GI, genital, or urinary tract has been entered. Such wounds show no signs of contamination.  Contaminated wounds- include open, fresh, accidental wounds and surgical wounds involving a major break in the sterile technique or a large spillage from the GI tract. Show evidence of inflammation  Dirty or infected wounds- wounds containing dead tissue and wounds with evidence of clinical infection such as purulent drainage Types of wounds: - Incision- caused by a sharp instrument; open wound; deep or shallow; once the edges have been sealed together as a part of treatment or healing the incision becomes a closed wound - Contusion- caused by a blow from a blunt instrument; closed wound, skin appears ecchymosis because of the damage blood vessels. - Abrasion- caused by surface scrape, either unintentional (scraped knee) or intentional (dermal abrasions to remove pockmarks; open wound involving the skin - Puncture- caused by penetration of the skin and often the underlying tissues by a sharp instrument, either intentional or unintentional; open wound - Laceration- tissues torn apart, often from accidents; open wound, edges are often jagged - Penetrating wound- penetration of the skin and the underlying tissues, usually unintentional (ex- from bullet or fragments); open wound Wound assessments: -very important in documenting. Braden scale consist of 6 subscales; sensory perception, moisture, activity, mobility, nutrition, and friction and shear. 23 points possible, if you score an 18 you are at risk - take photographs of wounds -measure wound depth from deepest part of the wound. -measure wound length from longest portion of the wound. Lab values associated with wounds: - WBC: worried about infection. Normal labs :4500-10,000 - Hemoglobin- carries oxygen in the blood. Normal labs: female: 12-15 male: 15-18 - Albumin- indicates nutritional status. Normal values: 3.5-5.5 g/dL - Serum protein- nutritional value of reserved protein - Wound cultures- swabbed in wound and tested. Looks for bacteria, MRSA, Staph. You want them to be negative Pressure ulcers- consist of an injury to the skin and or underlying tissue usually over a bony prominence - Due to localized ischemia, a deficiency in the blood supply to the tissue. - Skin becomes unblanchable- meaning when you press down on the redness it stays red and doesn’t turn white - This redness is due vasodilation - Incontinence is a bag factor in sacrum pressure ulcer Friction- is a force acting parallel to the skin surface- ex. Sheets rubbing against skin NUR 155 EXAM 3 STUDY GUIDE COMPLETE LATEST 2023 Shearing force- is a combination of friction and pressure. It commonly occurs when a client assumes a sitting position in a bed. The body tends to slide downward toward the foot of a bed. This downward movement is transmitted to the sacral bones and the deep tissues Immobility- refers to a reduction in the amount and control of movement a person has. Different stages of pressure ulcers: - Stage I- redness, non-blanchable, no skin break yet. - Stage II- partial thickness skin loss, only involve epidermis and sometimes dermis. Blister craters, and abrasions appear - Stage III- full thickness skin loss. Damage of epidermis, dermis, and adipose tissue. All the way down to the underlying muscle fascia- no muscle damage yet - Stage IV- full thickness skin loss of all of the layers of the skin, can see tendon loss, muscle loss and can see all the way to the bone. Can also be unstageable if you can’t determine depth Necrosis- dead skin in a wound. Has to be cleaned out via debridement to promote new growth Primary intention healing- occurs when tissue surfaces have been approximated (closed) and there is minimal or no tissue loss. Secondary intention healing- wound that is extensive and involves considerable tissue loss and in which the edges can’t or shouldn’t be approximated - Ex- pressure ulcer - Repair time is longer - Scarring is great - Susceptibility for infection is greater Tertiary intention- wounds that are left open 3-5 days to allow edema or infection to resolve or exudate to drain and then are closed with sutures, staples or adhesive skin closures Phases of wound healing: 1.) Inflammatory phase- begins immediately after the injury and lasts 3-6 days - Hemostasis- cessation of bleeding- results from vasoconstriction of the larger blood vessels in the area - Phagocytosis- macrophages engulf microorganisms and cellular debris 2.) Proliferative phase- the second phase in healing, extends from the day 3-4 to about day 21 post injury; synthesis of collagen occurs which add tensile strength to the wound; granulation tissue 3.) Maturation phase- begins about day 21, and can extend 1 or 2 years after the injury. During maturation, the wound is remodeled and contracted. scar forms. It becomes stronger but never as strong as before injury. Keloid scaring occurs when abnormal amount of collagen is laid down. Granulation tissue- capillary network develops the tissue become red in color, and it bleeds easier. Exudate- fluid and cells that has escaped from the blood vessels during the inflammatory process and is deposited in tissue or on tissue surfaces - Serious exudate- consists chiefly of serum (clear portion of the blood) looks watery and has few cells in it - Purulent exudate- thicker th