Fundamentals Exam 3

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a disruption that may occur in the skin’s integrity and lead to loss of the skin’s normal functioning

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Risk factors for wounds

age, altered mental status, impaired mobility, poly pharmacy, substance abuse, obesity, diabetes, impaired nutrition, impaired circulation, edema

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open wound

break in the skin’s surface (incision or puncture)

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closed wound

skin is still intact (bruise)

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superficial wound

involves epidermis

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Partial-thickness wound

involves epidermis, dermis and does not extend to SUBQ tissue

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Full thickness wound

extends through dermis to SUBQ tissue and may extend further into underlying structures (muscle and bone)

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Clean wound

closed, surgical incision made in a sterile environment, there is no infection, low risk for developing an infection

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Clean-contaminated wound

closed, surgicla incision that is made in a sterile environment but involves organ systems that contain bacteria (colon, bowel, appendix) increased risk of infection

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Contaminated wound

results from a break in sterile technique during surgery or from perforation of an organ before or during surgery, high risk for infection

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infected wound

shows signs of clinical infection, microorganisms are present within the wound

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Colonized wound

one or more microorganisms are present on the surface of the wound with a swab culture is obtained but there is no sign of infection below the surface (chronic wounds)

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acute wound

progresses through the phases of healing in a rapid, noncomplicated manner, usually takes 2-3 weeks to heal

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Chronic wound

does not progress through the stages of healing in a timely manner, often remains open for an extended period of time

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Wound healing

the replacement of old tissue with new tissue

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Phases of wound healing

hemostasis, inflammatory phase, proliferative phase, maturation phase

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1st phase, immediate response to injury, a blood clot forms at the sire of injury to stop blood loss, can last up to 2 days

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Inflammatory phase

2nd phase. immune cells enter the area to remove debris, microbes/microorganisms, dead calls. Cleans the wound bed, can last for 3 days

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Proliferative phase

3rd phase. granulation tissue form to resurface the wound bed. Lasts up to several weeks

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Maturation phase

4th phase. remodeling phase collagen, continues to be deposited to form scar tissue which strengthens the wound. Restores up to 80% strength of undamaged tissue, can last up to 1 year

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Granulation tissue

young, connective tissue that has new capillaries that is created to fill in a wound bed when a wound is not closed or sutured. Pink, beefy red color, bleeds easily, bumpy and moist

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Scar tissue

an avascular mass of collagen that strengthens the repaired wound

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Primary intention

surfaces are approximated (closed) shortly after injury, minimal tissue loss, acute wounds, minimal granulation tissue and scarring

ex: closed-surgical incision

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Secondary intention

extensive wound with edges that cannot or should not be approximated, chronic wounds, considerable tissue loss, extensive granulation tissue and scarring, longer repair time, greater risk for infection

Ex: pressure ulcer/injury

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Tertiary intention

wounds that are left open for 3-5 days and then closed with sutures, staples, or adhesives, some granulation tissue and scarring

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Reasons why wounds would be left open

permits exudate drainage, resolve infection or edema, contamination occurs during surgery

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Factors that effect wound healing

oxygenation and tissue perfusion, heart disease, vascular disease, pulmonary disease, smoking, age, diabetes, nutrition, age, infection

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complete or partial separation of the wound edges so the wound is no longer approximated. infection decreases the risk of this. splinting should be used to prevent this

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blocking incision site to prevent it from opening

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a complete separation of the wound edges a protrusion of the organs through the incision site, could happen in an abdominal area incision, infection increases the risk of this, use splinting

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abnormal connection or tunnel between 2 different organ systems, an internal organ and the skin/ outside the body

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active blood loss occuring from the wound

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bacteria or microorganisms are present in a wound and can cause further tissue damage

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Wound assessment subjective data

history of current injury, how it happened and when it happened (mechanism of injury), was is intentional or accidental, date of tetanus vaccination (less than 10 years ago), history of wounds, injuries, or falling. Past medical history including current medications and allergies

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Wound assessment objective data

note appearance of dressing and characteristics of exudate, not color, odor, consistency, and amount of exudate, not wound measurements, note wound characteristics

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clean dressing change

select appropriate dressing and supplies per provider order and facility protocol, wash hands, apply clean gloves and other PPE, remove old dressings and dispose per facility protocol, remove gloves and wash hands again apply new gloves, assess wound, clean wound according to provider, clean from area of least contamination to area of most contamination

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Sterile dressing change

same a clean dressing change, but use sterile technique

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Clean vs sterile technique

use clean gloves for wound care. clean technique is more common

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Expected/normal wound findings

minimal exudate is expected during the first few post op days, incisional line is pink in color, some crusting on incision site, mild edema under sutures/ staples

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Drainage continuum


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Abnormal wound findings

redness/edema around the incisional line, excessive tenderness or pain on palpation (especially if pain level has increased since last visit), exudate that has increased in amount, purulent exudate, active bleeding, foul odor, elevated temperature, wound starting to open up or pull apart the sutures or staples

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Serous exudate

clean, watery exudate

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Sanguineous exudate

bright red exudate

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Serosanguineous exudate

pale, red, watery mixture of serous and sanguineous

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Purulent exudate

thick yellow, green, tan, brown exudate

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Symptoms of hypotensive shock

rapid thready pulse, cold and clammy skin, pallor, hypotension

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Prevent infection

prevent dehiscence/ evisceration, splinting, control pain and edema, promote wound healing

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Wound dressings

gauze, hydrocolloid, transparent, alginate

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Gauze dressing

most common, used to protect open wounds or areas of open skin, used for a variety of wound types, comes in all shapes and sizes, appropriate for wounds with minimum exudate, wounds with heavy exudate will need to be reinforced or changed frequently, can stick to the wound edges and wound bed

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Hydrocolloid dressing

a combination of adhesive and gelling polymers, impermeable to oxygen, water, and water vapor, self-adhesive, flexible, appropriate for wounds with minimal exudate, promotes most wound environments, aids in autolytic debridement

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Transparent dressing

cover the wound with a clear film, allows for wound inspection while protecting the skin, ideal for IV sites, flexible, self adhesive, appropriate for wounds with no to very little exudate, bacteria proof and water proof, cannot absorb wound fluids, can be difficult to remove

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Alginate dressing

made from seaweed, maintains a moist wound environment, absorbs a large amount of exudate, creates a gel that helps to clean and heal wounds more quickly, appropriate for wounds with a lot of exudate, can hinder healing by drying out wounds too quickly

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Pressure injury

damage to the skin and possibly by the underlying tissues caused by pressure that impairs the flow of blood and lymph. this causes ischemia and tissue necrosis. Most commonly ocurrs over bony prominences. Can also occur from medical device use

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Common pressure ulcer sites

occiput (back of head), elbow, hip, sacrum, buttocks area, ankle, heel

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Stage 1 Pressure injury

nonblanchable erythema of intact skin, usually occurs in a localized area over a bony prominence. Identification may be difficult with clients with dark skin

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Stage 2 Pressure injury

Partial thickness skin loss involving the dermis. Presents as shallow open ulcer without slough, may also present an intact or open pus or blood filled blister or a shiny, dry ulcer without slough. Does not extend through the dermis

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Stage 3 Pressure Injury

full thickness skin loss involving damage or necrosis of SUBQ tissue, bone, tendon, and muscle are not exposed. The ulcer presents clinically as a deep crater with or without undermining and tunneling of adjacent tissue. Slough may be present. Depth of this stage of ulcer may vary by anatomical location, in areas without adipose tissue.

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Stage 4 Pressure injury

full thickness skin loss with extensive tissue damage and necrosis of muscle, tendon, and bone are exposed and palpable. Slough or eschar may be present. undermining and tunneling are usually present. Dead tissue and drainage are likely to occur

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Unstageable pressure injury

full thickness tissue loss with depth completely obscured by slough or eschar in the wound bed. Depth of the wound cannot be determined until slough or eschar is removed. Once removed, the ulcer will be staged as a 3 or 4

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Suspected deep tissue injury

intact skin with purple discoloration of blood, filled blister, indicates damage of underlying soft tissue from pressure or shear, may rapidly evolve into a thin blister over a dark wound bed or develop thin eschar. May be difficult to detect in a client with dark skin. Discoloration or blister may be preceded by painful tissue that is a different temperature and consistency than surrounding skin

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a collection of dead tissue that is separated from the surrounding living tissue

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a scab or dry crust that consists of dry plasma proteins and dead cells that form over damaged skin, necrotic tissue

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a pocket beneath the skin and wound edges that result from the erosion of the wound tissue

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the formation of channels or tracks that extend from the wound deeper into the SUBQ tissue or even into the muscle

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Pressure injury risk assessment

Braden scale, assess sensory perception, moisture, activity, mobility, nutrition, friction and shear

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Assessment of injury

inspection, palpation, measure, wound culture, CBC to assess for elevated WBC, biopsy

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Prevention of pressure injury

thoroughly assess skin every shift and as needed, complete braden scale, provide adequate nutrition and hydration, high protein diet with adequate intake of calories and vitamins, maintain skin hygiene, bathe routinely and as needed with mild soap, apply lotion to dry skin, do not massage bony prominences, do not use talcum powder, manage exposure to moisture, avoid use of incontinence briefs if possible, avoid skin trauma, promote mobility

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Wound treatment

surgery- debridement for stage 3-4 pressure injuries to remove necrotic tissue, dressings and topical agents stage 1- transparent dressing stage 2- benefits from moist wound environment (foams, gels, hydrocolloids, transparent) stage 3-4 surgical mechanical, enzymatic, autolytic or biological debridement is often needed, pharmacologic therapy, nonpharmacologic therapy

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Mechanical debridement

wet to moist dressing changes, whirlpool

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Enzymatic debridement

topical wound agents (santyl, pahdal, accuzyme)

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Autolytic debridement

occlusive dressings (hydrocolloids, transparent)

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Biologic debridement

sterile maggots

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Wound pharmacologic therapy

topical or systemic antimicrobials and antibiotics

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Wound Nonpharmacological therapy

negative pressure wound therapy (wound VAC)

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skin cancer

an abnormal growth of skin cells

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pigmented cancers that arise from the melanin-producing epidermal cells (melanocytes), most aggressive and lethal form of cancer

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arise from epithelial tissue; basal cell or squamous cell carcinoma are types of this cancer

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Precursor leison

lesion that is at risk for becoming malignant

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Characteristics of a melanoma nevi

asymmetrical with an irregular border, color variation, diameter greater than 6mm, grows parallel to the skin’s surface during the initial radial phase, during the vertical phase, the tumor rapidly spreads deeper into the SUBQ tissue increasing the risk for metastasis and death

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Basal cell carcinoma

typically originates from the basal layer of the epidermis, most common type of skin cancer, least aggressive type of skin cancer that rarely metastasizes, tends to reccur, presents as a papule that grows at a steady state, can bleed and become painful

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Squamous cell carcinoma

malignant tumor of the squamous epithelium of the skin or mucous membranes, can invade locally and become metastastic, more agressive than the other type of skin cancer, much greater potential for metastasis if untreated, begins as a small firm, red nodule that may be crusted, may ulcerate, bleed, and become painful, tumor extends into the surrounding tissue and becomes a nodule

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Skin cancer risk factors

UV radiation, pollutants, ionizing radiation, viruses, chemicals, physical skin trauma, skin pigmentation (the more melanin present, the less likely for skin cancer to occur), premalignant factors,, chemicals

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Skin cancer assessment

ABCDE, palpate and measure lesion, assess exudate, note other concerning findings, palpate lymph nodes, liver, spleen, potential biopsy of skin, test for metastasis (liver function tests, CT or MRI of abdomen, brain, chest, or other, painful areas, serum blood chemistry, chest xray, CBC, bone scan)

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Skin cancer treatment

surgery-exclusion, cryosurgery, curettage and electrodesiccation

Pharmacologic therapy- immunotherapy, chemotherapy, radiation therapy

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Contact dermatitis

an inflammatory eczematous skin disease

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exema an inflammatory condition of the skin

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Allergic contact dermatitis

delayed hypersensitivity reaction to an allergen or contact antigen from repeated exposure (poison oak, chemicals, poison ivy, medications, nikel)

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Topical medications for allergic contact dermatitis

bacetracin and neomyocin

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Irritant contact dermatitis

nonspecific inflammatory response of the skin to direct chemical or physical agents (physical irritants- friction, occlusion, abrasion Chemical irritants- soaps, detergents, perfumes, dyes)

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Assessment of dermatitis

assess symptoms or possible exposure, inspect and palpate

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Clinical manifestations of dermatitis

erythema, pruritus, vesicles, bullae, edema

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Testing and treatment for dermatitis

end exposure to causative agent, allergen skin testing, calamine lotion to control itching, antihistamines to control itching, corticosteroids to reduce inflammation, antibiotics if the lesions become infected

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superficial bacterial skin infection common in children, caused by staph, strep, or both, presents as itchy rash with clusters of fluid filled vesicles that rupture easily, ruptured leisons develop a honey colored crust, most commonly seen in arms legs and face, treated with topical or oral antibiotic, highly contaigous

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yeast infection within the candida species that occurs in mouth or skin folds, skin infections present with erythematous patches that vary in size. Papules and pustules may be present. Often occur in moist areas. Oral infections are referred to as thrush. Presents as a white plaque on the tongue and oral mucosa, treated with antibiotics and antifungals

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Tinea corporis

fungal infection of the skin, referred to as ringworm, highly contagious, can be spread from people or from animals, presents as small pink or red lesions that spread into rings as they progress, treated with antifungals

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Tinea capitis

fungal infection of the scalp

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Tinea pedis

fungal infection of the feet

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Varicella zoster

acute systemic infection with the varicella zoster virus, extremely contaigous, spreads through direct contact, airborne droplets, or aerosolar particles, starts as macular rash in the face and trunk that spreads and progresses to papules and then vesicles that crust over. Fever, itching, headache, and malaise. Treatment includes putting a client in a negative airflow room with airborne precautions, oral and IV medications, the varicella vaccine is administered for prophylaxis, pregnant staff should not provide care to these patients

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Herpes zoster

aka shingles, caused by the same virus that causes chicken pox, frequently occurs in older adults or immunocompromised patients, presents as a painful itchy tingly rash with clusters of small vesicles on unilateral area of skin (dermatome), can be exacerbated by stress, vaccines for prevention, treated with antivirals

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Bed bugs

small oral insects that are attracted to humans, they bite exposed skin, typically at night, they hide in cracks, crevices, furniture, and walls, bed bugs multiply rapidly and are difficult and expensive to exterminate, lesions can present as maccules, papules, wheals, or blisters, lesions resolve in 1 week, treated with steroid cream

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