ATI skin integrity

Flashcard 85:

Q: What is the definition of a wound?
A: A wound is a disruption in the normal composition and performance of the skin and its underlying structures.

Flashcard 86:

Q: How are wounds classified?
A: Wounds are classified as acute or chronic based on their origin and healing progression.

Flashcard 87:

Q: What is the difference between acute and chronic wounds?
A: Acute wounds develop rapidly and typically heal in a predictable time frame, while chronic wounds fail to heal in a normal time frame and may last for weeks or months.

Flashcard 88:

Q: What are intentional acute wounds?
A: Intentional acute wounds are those created during a surgical procedure.

Flashcard 89:

Q: What are unintentional acute wounds?
A: Unintentional acute wounds develop as a result of traumatic injuries, such as burns, punctures, or gunshot wounds.

Flashcard 90:

Q: What are lacerations?
A: Lacerations are tears in the skin caused by blunt or sharp objects and typically have an irregular or jagged shape.

Flashcard 91:

Q: How are lacerations classified?
A: Lacerations are classified as simple or complicated depending on the severity and extent of damage.

Flashcard 92:

Q: What causes skin tears?
A: Skin tears are caused by mechanical forces such as removing tape from a client’s skin and are common in older adults.

Flashcard 93:

Q: How is the severity of a skin tear determined?
A: The severity of a skin tear is defined by the depth of skin loss.

Flashcard 94:

Q: What are surgical wounds?
A: Surgical wounds are acute wounds intentionally created during surgery and are classified as clean, clean-contaminated, contaminated, or dirty, depending on the level of bacterial contamination.

Flashcard 95:

Q: What is the difference between clean and contaminated surgical wounds?
A: Clean and clean-contaminated surgical wounds have minimal bacterial loads, while contaminated and dirty wounds have higher bacterial loads that may require long-term wound management.

Flashcard 96:

Q: What are the stages of surgical wound healing?
A: Surgical wounds typically appear red (days 1–4), bright pink (days 5–14), and pale pink (after day 15). Edema and exudate decrease over time.

Flashcard 97:

Q: What is exudate in relation to wounds?
A: Exudate is fluid consisting of plasma secreted by the body during the inflammatory phase of healing. It should progressively decrease and resolve by postoperative day 5.

Flashcard 98:

Q: What is moisture-associated skin damage (MASD)?
A: MASD is a form of dermatitis caused by skin exposure to irritants like feces, urine, and wound exudates, and it can lead to pain, burning, and itching.

Flashcard 99:

Q: How does moisture-associated skin damage (MASD) affect wound healing?
A: MASD predisposes clients to pressure injury formation and can complicate wound healing.

Flashcard 100:

Q: What conditions contribute to chronic wounds?
A: Chronic wounds can result from chronic venous insufficiency, peripheral artery disease, and diabetes mellitus, as well as aging, smoking, malnutrition, immunosuppression, and infection.

Flashcard 101:

Q: What are the major categories of chronic lower extremity wounds?
A: The three major categories of chronic lower extremity wounds are venous disease wounds, arterial disease wounds, and neuropathic disease wounds.

Flashcard 102:

Q: What should be assessed during dressing changes?
A: During dressing changes, wounds should be assessed for manifestations of healing, infection, changes in color, amount, and odor of exudate.

Flashcard 103:

Q: What types of exudate may be present in wounds?
A: Wound exudate may be serous, serosanguineous, sanguineous, or purulent.

Flashcard 104:

Q: What does purulent exudate indicate?
A: Purulent exudate indicates infection and should be reported to the provider.

Flashcard 105:

Q: Why is wound documentation important?
A: Wound documentation allows for future comparisons in appearance, size, and healing progress.

Flashcard 106:

Q: How should wounds be measured during assessment?
A: Wounds should be measured according to facility policy, and the most common methods are:

1. Tracing the wound circumference and calculating the wound surface area using a see-through film.

2. Measuring the length and width of the wound using a ruler.

Flashcard 107:

Q: Why should the same wound measurement method be used throughout treatment?
A: Using the same measurement method throughout treatment ensures accurate tracking of the progression of wound healing.

Flashcard 108:

Q: How is wound depth measured?
A: Wound depth is measured by gently inserting a sterile, premoistened cotton tip applicator under the wound edges until resistance is felt, marking the depth on the applicator, and then measuring with a ruler.

Flashcard 109:

Q: What is tunneling in a wound?
A: Tunneling refers to the development of a narrow channel or passageway extending in any direction from the base of the wound.

Flashcard 110:

Q: What causes pressure injuries?
A: Pressure injuries develop due to prolonged pressure on an area of skin or a combination of pressure and shearing, which is caused by forces exerted parallel to the skin's surface.

Flashcard 111:

Q: What is shearing?
A: Shearing occurs when deeper tissues, such as fat and muscles, are pulled downward by gravity while the top layers of skin remain in contact with the surface, stretching and traumatizing blood and lymphatic vessels.

Flashcard 112:

Q: Where do pressure injuries commonly occur?
A: Pressure injuries most often occur over bony prominences but can also develop where pressure is produced by medical devices like urinary catheters, oxygen tubing, endotracheal tubing, and surgical or wound drains.

Flashcard 113:

Q: What are the main factors contributing to pressure injury development?
A: The main factors contributing to pressure injury development are pressure, shear, and friction.

Flashcard 114:

Q: What are some risk factors for developing pressure injuries?
A: Risk factors include immobility, malnutrition, reduced perfusion, altered sensation, decreased level of consciousness, and exposure to moisture, friction, tears, cuts, and bruises.

Flashcard 115:

Q: How does friction contribute to pressure injury development?
A: While friction doesn't directly cause pressure injuries, it increases skin and tissue trauma, which raises the risk of developing a pressure injury.

Flashcard 116:

Q: How can tightly braided hair increase the risk of pressure injuries?
A: Tightly braided hair increases the risk of occipital pressure injuries due to constant pressure on the scalp, especially in immobile clients who cannot relieve the pressure. This can lead to scarring, alopecia, and permanent hair loss.

Flashcard 117:

Q: What should a nurse do for a client with tightly braided hair?
A: For clients with tightly braided hair, the nurse should suggest removing the braids upon admission to reduce the risk of occipital pressure injury.

Flashcard 118:

Q: Why are pressure injuries a concern in healthcare settings?
A: Pressure injuries can be painful, have prolonged healing times, are potential sources of infection, and may significantly affect both the client’s health and the healthcare facility’s finances. Pressure injuries can also lead to death, with approximately 60,000 deaths annually in the U.S. due to complications.

Flashcard 119:

Q: Where are the areas most susceptible to pressure injury formation?
A: The areas most susceptible to pressure injury formation are bony prominences, including the heels, toes, sacrum, hips, elbows, shoulders, and back of the head.

Flashcard 120:

Q: Why are bony prominences more susceptible to pressure injuries?
A: Bony prominences are more susceptible to pressure injuries because these weight-bearing points apply pressure on the deeper layers of tissue, especially where bones and muscles meet, leading to greater damage to deep tissue.

Flashcard 121:

Q: What makes tissue damage from pressure injuries difficult to assess?
A: The exact extent of tissue damage from pressure injuries might not be visible from the surface, as deep tissuedamage often occurs beneath the skin where bones and muscles meet.

Flashcard 122:

Q: What is the first step in decreasing the risk of pressure injury development?
A: The first step in decreasing the risk of pressure injury development is conducting a thorough risk assessment to identify individual client preferences and determine specific risk factors that may increase the client’s risk for skin breakdown.

Flashcard 123:

Q: Which factors are most often assessed by nurses to determine the risk for pressure injury development?
A: The factors most often assessed by nurses to determine the risk for pressure injury development include immobility, malnutrition, reduced perfusion, and sensory loss.

Flashcard 124:

Q: Why is immobility considered a major risk factor for pressure injuries?
A: Immobility is a major risk factor for pressure injuries because it results in consistent pressure on one area without relief, increasing the likelihood of skin breakdown. This can occur in both temporary situations (e.g., acute illness) and permanent conditions (e.g., spinal cord injury).

Flashcard 125:

Q: How does malnutrition increase the risk for pressure injuries?
A: Malnutrition and low albumin levels place clients at a greater risk for developing pressure injuries because poor nutritional intake and the inability to maintain weight weaken tissue integrity, making it more prone to breakdown.

Flashcard 126:

Q: What is hypoperfusion, and how does it contribute to pressure injury development?
A: Hypoperfusion is low oxygen levels in the tissues caused by poor circulation. It can occur during acute blood loss or low blood pressure, and chronic hypoperfusion can lead to tissue breakdown in less than 2 hours when combined with prolonged pressure.

Flashcard 127:

Q: How does sensory loss contribute to the risk of pressure injury formation?
A: Sensory loss, due to conditions like dementia, delirium, or spinal cord injuries, alters the perception of pain and pressure sensation, increasing the risk for pressure injury formation because clients may not feel or respond to pressure buildup.

Flashcard 128:

Q: What is the Braden Scale, and how is it used in pressure injury risk assessment?
A: The Braden Scale is a risk assessment tool used to assess the likelihood of a client developing pressure injuries. It rates risk in six categories: sensory perception, moisture, activity, mobility, nutrition, and friction and shear. The lower the score, the greater the risk of developing pressure injuries.

Q: What are the key factors a nurse should observe when staging a pressure injury?
A: When staging a pressure injury, the nurse should observe for non-blanchable erythema, the amount and depth of skin and tissue loss, the condition of tissue in the wound bed, the presence of dead tissue, and tunneling and undermining.

Flashcard 130:

Q: Why is accurate staging of pressure injuries important?
A: Accurate staging of pressure injuries is crucial because it guides the treatment plan, helps evaluate healing progress, and allows for benchmarking the facility’s performance against others in terms of pressure injury prevention and outcomes.

Flashcard 131:

Q: What is undermining in the context of a pressure injury?
A: Undermining refers to an open area extending under the skin along the edge of the wound, where tissue damage is occurring beneath the surface, which is difficult to detect without careful assessment.

Flashcard 132:

Q: What is the difference between stage 1 and stage 2 pressure injuries?
A:

• Stage 1: The skin is intact, with non-blanchable erythema and possible changes in sensation, temperature, and consistency.

• Stage 2: Partial-thickness skin loss occurs with visible pink or red viable tissue and may present as a ruptured serum-filled blister.

Flashcard 133:

Q: What is visible in a stage 3 pressure injury?
A: In stage 3 pressure injuries, there is full-thickness skin loss, with visible adipose tissue. Granulation tissue may be present, and the wound may have rolled edges, with possible undermining and tunneling.

Flashcard 134:

Q: What distinguishes a stage 4 pressure injury from stage 3?
A: Stage 4 pressure injuries involve full-thickness tissue loss, with visible fascia, muscles, tendons, ligaments, cartilage, and/or bone. Undermining and tunneling may also be present, and dead tissue is commonly observed.

Flashcard 135:

Q: What is an unstageable pressure injury?
A: An unstageable pressure injury is one where the full-thickness skin and tissue loss is obscured by either slough(yellow, stringy nonviable tissue) or eschar (black/brown hard nonviable tissue). Once the eschar is removed, the injury is classified as either stage 3 or stage 4.

Flashcard 136:

Q: What is granulation tissue, and in which stage of pressure injury is it commonly seen?
A: Granulation tissue is new tissue that forms on the surface of a wound as it heals. It is often seen in stage 3 pressure injuries.

Flashcard 137:

Q: What characterizes a Deep Tissue Pressure Injury (DTPI)?
A: A Deep Tissue Pressure Injury (DTPI) is characterized by non-blanchable, deep red, maroon, or purple discoloration of the skin, which can be intact or broken depending on when it is discovered. It is caused by intense and/or persistent pressure and shearing forces.

Flashcard 138:

Q: How does a device-related pressure injury form?
A: Device-related pressure injuries occur due to prolonged pressure from medical devices, equipment, or everyday objects that remain in direct contact with the skin for an extended period. The injury usually takes the shape of the device in contact with the skin, such as oxygen masks or urinary catheters.

Flashcard 139:

Q: What is a medical device-related pressure injury (MDRPI)?
A: A medical device-related pressure injury (MDRPI) refers to a pressure injury caused by the prolonged use of medical devices, including oxygen masks, urinary catheters, cervical collars, and compression stockings.

Flashcard 140:

Q: What is a mucosal membrane pressure injury?
A: A mucosal membrane pressure injury occurs in the lining of body cavities such as the respiratory tract, gastrointestinal tract, or genitourinary tract. It results from the pressure of devices like endotracheal tubes, oxygen tubing, and feeding tubes. These injuries cannot be staged due to the lack of skin layers in mucosal tissue.

Flashcard 141:

Q: What are Hospital Acquired Pressure Injuries (HAPIs)?
A: Hospital Acquired Pressure Injuries (HAPIs) are pressure injuries that occur during hospitalization. They are considered a hospital-acquired condition and can increase healthcare costs and hospital stays. HAPIs that are Stage 3 or Stage 4 are not reimbursed by Medicare or Medicaid.

Flashcard 142:

Q: Why are pressure injuries in clients with darkly pigmented skin difficult to detect?
A: In clients with darkly pigmented skin, indicators such as non-blanchable erythema are harder to detect. Instead, changes in skin temperature, moisture levels, edema, hardened skin, and localized pain are often the first signs. The nurse should palpate the skin for changes in sensation and look for taut, shiny, or indurated skin.

Flashcard 143:

Q: How should a nurse assess for Stage 1 or deep tissue pressure injuries in clients with dark skin?
A: In clients with dark skin, the nurse should assess the adjacent skin area that may appear darker than the surrounding skin. Non-blanchable erythema may not be visible, so the nurse should palpate the area to detect changes in sensation, temperature, and texture of the skin.

Q: When should pressure injuries be assessed and documented?
A: Pressure injuries should be assessed and documented on admission, during routine assessments, and with each dressing change to monitor their progression and ensure proper treatment.

Flashcard 146:

Q: What should be included when documenting a pressure injury?
A: When documenting a pressure injury, the nurse should include the following details:

• Location and stage of the wound

• Size (length, width, and depth)

• Description of tissue in the wound bed

• Color of the wound bed

• Condition of surrounding tissue

• Appearance of wound edges

• Presence of undermining and tunneling

• Any foul odor

• Characteristics of wound drainage

• Reports of pain at the wound site

Flashcard 147:

Q: Why might a nurse recommend further diagnostic testing for a pressure injury?
A: If a pressure injury is not healing as expected or if complications arise (e.g., infection, change in exudate, deterioration), the nurse might recommend further diagnostic testing, such as a tissue biopsy, to help guide the treatment plan.

Q: What is surgical debridement?
A: Surgical debridement is the process of removing dead tissue and debris from a wound using a scalpel or scissors. It helps decrease bacterial load, stimulates wound closure, and is often performed multiple times for chronic wounds. Tissue from the debridement may be sent for culture to guide antibiotic treatment.

Flashcard 149:

Q: What is the purpose of wound irrigation?
A: Wound irrigation is used to remove surface debris and decrease bacterial levels in the wound. It is commonly performed with a 0.9% sodium chloride solution, helping to maintain a clean environment for healing.

Flashcard 150:

Q: What is biological debridement?
A: Biological debridement involves using enzymatic agents (e.g., collagenase, papain, bromelain) or larvae therapy(e.g., green bottle fly larvae) to clear dead tissue from a wound. The larvae secrete enzymes that liquefy necrotic tissue, which they then ingest, leaving healthy tissue intact.

Flashcard 151:

Q: How do open dressings differ from semi-occlusive dressings?
A:

• Open dressings, like gauze, are used to pack wounds for debridement. They can remove both necrotic tissue and new tissue, which is a disadvantage.

• Semi-occlusive dressings cover wounds with a variety of properties to manage moisture, bacteria, and tissue healing. These dressings are more advanced in controlling moisture and reducing infection.

Flashcard 152:

Q: What are hydrocolloid dressings used for, and what are their advantages?
A: Hydrocolloid dressings are used for small abrasions, superficial burns, pressure injuries, and postoperative wounds. They occlude the wound, maintain moisture, have bacteriostatic properties, and promote granulation tissue growth. They are comfortable but may cause contact dermatitis and a foul-smelling yellow film as bacteria are trapped under the dressing.

Flashcard 153:

Q: What are alginate dressings and their primary use?
A: Alginate dressings are used for moderate to highly exudative wounds. They provide hemostasis, have high absorptive abilities, and can remain in place for several days, reducing the frequency of dressing changes. A secondary dressing is needed to cover the alginate.

Flashcard 154:

Q: What are the benefits of hydrofiber dressings?
A: Hydrofiber dressings are used for moderate to highly exudative wounds. They offer high absorbency and can stay in the wound for several days. Compared to alginates, they draw less fluid from the wound edges, reducing the risk of maceration around the wound.

Flashcard 155:

Q: What are the benefits and limitations of foam dressings?
A: Foam dressings are used for wounds with mild to moderate exudate. They provide absorption but require more frequent changes. They can help prevent hospital-acquired pressure injuries (HAPIs) when applied within 24 hours of admission but may produce malodorous discharge.

Flashcard 156:

Q: How do hydrocolloid and polymeric membrane dressings differ?
A:

• Hydrocolloid dressings are used for superficial wounds and promote a moist healing environment.

• Polymeric membrane dressings are used for mildly exudative wounds and help stimulate the growth of new epithelium without sticking to the wound bed, resulting in less trauma during dressing changes.

Flashcard 157:

Q: What is the purpose of hydrogel dressings?
A: Hydrogel dressings, available in gel or sheet form, are used for dry wounds, particularly for debridement of necrotic tissue and eschar. They help maintain moisture, provide a soothing effect, and cause minimal trauma to the wound bed.

Flashcard 158:

Q: What are some common antimicrobial agents used in wound care?
A: Common antimicrobial agents include iodine, silver, and honey.

• Iodine is an antiseptic that cleanses the wound.

• Silver is effective on moist, exudative, or infected wounds.

• Honey helps manage infection, decrease odor, and has anti-inflammatory and antimicrobial properties.

Flashcard 159:

Q: What are sutures and staples used for in wound closure?
A: Sutures and staples are used to secure and close wounds, such as surgical or traumatic wounds. Sutures can be absorbable or nonabsorbable, while staples are often faster to place and heal wounds more quickly, typically requiring removal in 7 to 14 days.

Flashcard 160:

Q: What are the advantages and disadvantages of staples for wound closure?
A: Advantages of staples include faster placement and faster healing.
Disadvantages can include difficulty of removal, scarring, and the risk of bleeding or infection during staple removal.

Flashcard 161:

Q: How do skin adhesives work for wound closure?
A: Skin adhesives are used as an alternative to sutures and staples for small, straight-edged wounds. They form a waterproof protective covering and are applied in layers, typically peeling off in 5 to 10 days.

Flashcard 162:

Q: What is Negative Pressure Wound Therapy (NPWT)?
A: NPWT assists wound healing by reducing edema and promoting granulation tissue formation. It involves a foam dressing covered by a semi-porous occlusive dressing, with suction applied constantly or intermittently.

Flashcard 163:

Q: What are wound drains used for?
A: Wound drains are used to reduce fluid accumulation, remove air, and collect wound drainage for testing. They are often used in surgeries like those involving the chest, abdomen, or thyroid.

Flashcard 164:

Q: What are the two types of wound drains?
A:

• Passive drains (e.g., Penrose drains) rely on gravity to remove fluid.

• Active drains (e.g., portable wound bulb suction devices) use negative pressure to suction fluid from the wound.

Flashcard 165:

Q: What are the differences between open and closed wound drains?
A:

• Open drains (e.g., Penrose) release fluid into the air.

• Closed drains (e.g., portable wound bulb suction) send fluid to a closed containment system, reducing contamination risks.

Flashcard 166:

Q: When are drains typically removed?
A: Drains are usually removed when the total wound drainage is between 30 and 100 mL in a 24-hour period, or based on provider preference.

Flashcard 167:

Q: What are the complications associated with wound drains?
A: Complications can include clot formation at the insertion site, tissue obstruction of the tubing, accidental removalof the drain, and the formation of hematomas (blood accumulation) or seromas (fluid collection).

Flashcard 168:

Q: What is a Penrose drain and how is it used?
A: A Penrose drain is a passive, flat drain that relies on gravity to remove fluids from a wound. It is open and does not have a collection chamber, so drainage is collected on gauze placed around the drain.

Flashcard 169:

Q: How does a portable wound bulb suction device work?
A: A portable wound bulb suction device is an active, closed system that uses negative pressure to remove fluid. The bulb is compressed to create suction, and the fluid is collected in the bulb, which should be emptied every 8 hours or when more than half-full.

Flashcard 170:

Q: How is fluid measured in a large bottle drainage system?
A: In a large bottle drainage system, the bottle is placed at eye level, and a line is drawn next to the fluid level. The amount of drainage since the last emptying is calculated and documented.

Flashcard 171:

Q: How does a circular portable wound suction device work?
A: A circular portable wound suction device provides continuous low vacuum suction from the wound. The fluid is emptied into a measuring cup, and the drain is compressed before the plug is replaced to restore suction.

Flashcard 172:

Q: What is a Penrose drain and how is it used?
A: A Penrose drain is an open, corrugated rubber drain used to remove fluid from a wound. It works by gravity to drain accumulated fluids and is commonly used in surgical wounds. It's typically covered by a sterile dressing for fluid collection.

Flashcard 173:

Q: What is a Jackson-Pratt (JP) drain?
A: A Jackson-Pratt (JP) drain is a bulb drain with a flexible plastic bulb that creates suction to drain fluid from a wound. The bulb is connected to a plastic drainage tube that has multiple holes to increase drainage capacity.

Flashcard 174:

Q: What is a Bottle drain used for?
A: A Bottle drain is typically used for large amounts of drainage. It consists of a silicone drain attached to a bottle for collection. The bottle is used to store and remove fluids, typically after significant surgeries.

Flashcard 175:

Q: How does a Hemovac drain work?
A: A Hemovac drain has a spring mechanism that expands to create suction, drawing out fluid from the wound. The tube is connected to a container that stores the drainage. Hemovac drains are useful for large amounts of fluid.

Flashcard 1: Drainage Monitoring

• Question: What type of drainage is expected immediately after a drain placement?

• Answer: The drainage initially appears sanguineous (bloody) and gradually changes to serosanguineous (pinkish) as the wound heals.

Flashcard 2: Documenting Drainage

• Question: What should the nurse document regarding drainage from a surgical drain?

• Answer: The nurse should document the type, amount, consistency, and odor of the drainage.

Flashcard 3: Complications to Watch For

• Question: When should the provider be notified about drainage?

• Answer: Notify the provider if there is a significant increase or decrease in drainage, presence of blood clots, signs of infection, or if the drain is accidentally removed.

Flashcard 4: Skin Monitoring Around the Drain

• Question: What should the nurse monitor around the drain site?

• Answer: The nurse should monitor for maceration (skin breakdown) around the drain site.

Flashcard 5: Drain Site Cleaning

• Question: How should the drain site be cleaned if the client cannot shower?

• Answer: Clean the drain site once a day by inspecting for infection signs and replacing the dressing.

Flashcard 6: Signs of Infection

• Question: What are the signs of infection at the drain site?

• Answer: Signs include pain, swelling, redness, pus, and an increase in body temperature.

Flashcard 7: Preventing Kinking and Maintaining Suction

• Question: What should be done to prevent issues with the drain tubing?

• Answer: Prevent kinking of the tubing and ensure suction is maintained.

Flashcard 8: Drain Removal Criteria

• Question: When is a drain usually removed?

• Answer: A drain is typically removed when the drainage is less than 30-100 mL per day.

Flashcard 9: After Drain Removal Care

• Question: What care should be given after drain removal?

• Answer: Apply gauze to the site, monitor for infection, and after 24 hours, leave the site open to air for healing.

Match the type of drain to its description. (Drag each option to the desired category.)

Bottle drain

A silicone drain with a bottle that is used when the amount of drainage is expected to be large.

Penrose drain

An open drain made of corrugated rubber that is kept outside of the wound by attaching it with a safety pin.

Circular portable wound suction device

A drain in which the drainage tube is attached to a container with a spring inside. The spring expands as the container draws fluid out of the wound.

Portable wound bulb suction device

An active, closed system drain that uses negative suction to drain fluid from the wound; it contains a flexible plastic bulb that is connected to a plastic drainage tube.

Flashcard 1: Holistic Skin Care

• Question: What does holistic skin care address?

• Answer: Holistic skin care addresses tissue injury prevention and individual client needs, including hygiene, nutrition, hydration, and circulation.

Flashcard 2: Prevention of Pressure Injuries

• Question: What are the two main components of preventing pressure injuries?

• Answer: The two main components are identifying clients at risk and implementing interventions to reduce risk.

Flashcard 3: Risk Factors for Pressure Injuries

• Question: What are some risk factors for developing pressure injuries?

• Answer: Risk factors include malnutrition, immobility, altered circulation, decreased sensory perception, physical or behavioral health disorders, incontinence, and being an older adult.

Flashcard 4: The Braden Scale

• Question: What tool should be used to identify clients at risk for pressure injuries?

• Answer: The Braden Scale or another facility-preferred risk assessment tool should be used.

Flashcard 5: Skin Assessment

• Question: What should be included in a skin assessment for clients at risk of skin integrity issues?

• Answer: The assessment should include a full medical history, risk level determination using the assessment tool, skin examination, and identification of previous pressure injury sites, focusing on bony prominences.

Flashcard 6: Repositioning and Early Mobilization

• Question: How does repositioning help prevent pressure injuries?

• Answer: Repositioning relieves or redistributes pressure points, reducing the risk of tissue breakdown.

Flashcard 7: Repositioning Guidelines

• Question: How should clients be repositioned to reduce pressure injury risk?

• Answer: Clients should be repositioned frequently, with body tilts between 20° and 30° when placed on their side, and support with pillows.

Flashcard 8: Early Mobilization

• Question: What is early mobilization, and why is it important?

• Answer: Early mobilization involves encouraging clients to move and shift positions to increase activity and mobility, which helps prevent pressure injuries and promotes healing.

Flashcard 9: Correct Bed Positioning

• Question: How should the bed be positioned to minimize pressure and shear forces?

• Answer: The head of the bed should be kept lower than 30°, and pillows should be used to prevent sliding down in bed.

Flashcard 10: Supportive Surfaces

• Question: What type of surfaces should be used for clients at risk of pressure injuries?

• Answer: Special mattresses and pressure-relieving beds should be used to redistribute pressure and minimize the risk.

Flashcard 11: Hygiene and Skin Care

• Question: How does regular hygiene impact skin integrity?

• Answer: Regular hygiene helps remove unwanted substances, reduces the risk of skin damage, and should include gentle cleansing and moisturizing to promote skin health.

Flashcard 12: Hydration and Skin Health

• Question: How does adequate hydration support skin health?

• Answer: Hydration helps eliminate waste products, move nutrients, and maintain skin elasticity, reducing the risk of skin breakdown.

Flashcard 13: Monitoring Dehydration

• Question: What are signs of dehydration to monitor in clients?

• Answer: Signs include skin turgor, weight loss, urine output, elevated serum sodium, and serum osmolality.

Flashcard 14: Nutrition and Skin Integrity

• Question: How does nutrition affect skin integrity and healing?

• Answer: Adequate nutrition, especially protein, omega-3 and omega-6 fatty acids, and vitamins A and C, is crucial for preventing pressure injuries and promoting wound healing.

Flashcard 15: Nutritional Needs for Clients at Risk

• Question: What nutritional interventions should be considered for clients at risk of pressure injuries?

• Answer: High-calorie, high-protein, fortified foods or supplements should be offered to clients at risk, along with consultation from a dietitian if needed.

Flashcard 16: Malnutrition and Skin Integrity

• Question: How does malnutrition impact skin integrity?

• Answer: Malnutrition can lead to unintentional weight loss, delayed wound healing, and an increased risk of pressure injuries due to insufficient intake of essential nutrients.

Flashcard 1: Circulation and Tissue Perfusion

• Question: What happens when blood circulation is compromised?

• Answer: Compromised circulation leads to ischemia (lack of oxygen), resulting in reduced nutrient supply and failure to remove metabolic cellular wastes.

Flashcard 2: Circulation in Older Adults and CNS Injuries

• Question: Why are older adults and clients with CNS injuries at risk for impaired circulation?

• Answer: These clients have fewer capillary vessels in the tissue, which decreases overall tissue perfusion.

Flashcard 3: Impact of Critical Illness on Circulation

• Question: How does critical illness affect circulation?

• Answer: Critically ill clients have an increased risk for impaired circulation due to physiologically unstable hemodynamic status, which can reduce tissue circulation.

Flashcard 4: Vasopressors and Circulatory Problems

• Question: How do vasopressors affect circulation?

• Answer: Vasopressors can further compromise circulation, increasing the risk for circulatory problems.

Flashcard 5: Preventive Measures for Impaired Circulation

• Question: What preventive measures are key for clients with compromised circulation?

• Answer: Repositioning and early mobilization are key to preventing circulatory problems, though some clients may be too unstable for these measures.

Flashcard 6: Factors Influencing Wound Healing

• Question: What are some factors that influence wound healing?

• Answer: Factors include diabetes, infection, foreign bodies in the wound, medications, malnutrition, tissue necrosis, hypoxia, and multiple wounds.

Flashcard 7: Diabetes and Wound Healing

• Question: How does diabetes affect wound healing?

• Answer: Diabetes decreases peripheral perfusion and impairs sensation, placing clients at greater risk for delayed wound healing.

Flashcard 8: Infection and Wound Healing

• Question: How does infection influence wound healing?

• Answer: Infection breaks down collagen, making tissues more vulnerable to damage and delaying wound healing.

Flashcard 9: Foreign Bodies in Wounds

• Question: What is the effect of foreign bodies in a wound?

• Answer: Foreign bodies increase the risk for infection, which delays wound healing.

Flashcard 10: Impact of Steroids on Wound Healing

• Question: How do steroids affect wound healing?

• Answer: Steroids prevent the formation of collagen and fibroblasts, which are essential for wound healing.

Flashcard 11: Malnutrition and Wound Healing

• Question: How does malnutrition impact wound healing?

• Answer: Malnutrition impairs wound healing by not providing sufficient protein, calories, vitamins (like A and C), and minerals (like zinc) needed for healing.

Flashcard 12: Tissue Necrosis and Wound Healing

• Question: How does tissue necrosis affect wound healing?

• Answer: Tissue necrosis decreases blood supply to the wound, which hinders the healing process.

Flashcard 13: Hypoxia and Wound Healing

• Question: How does hypoxia affect wound healing?

• Answer: Hypoxia, caused by vasoconstriction or low oxygen levels, can delay wound healing due to reduced oxygen supply to the wound site.

Flashcard 14: Multiple Wounds and Healing

• Question: How do multiple wounds affect the healing process?

• Answer: When multiple wounds are present, each wound competes for nutrients, delaying healing at all sites.

Flashcard 1: Wound Healing Process

• Question: What factors influence wound healing?

• Answer: Factors include wound type, cleanliness, and the overall health status of the client.

Flashcard 2: Types of Wound Healing

• Question: What are the three types of wound healing?

• Answer: Primary healing (first intention), secondary healing (second intention), and delayed primary closure (tertiary intention).

Flashcard 3: Primary Healing (First Intention)

• Question: What is primary healing (first intention)?

• Answer: Primary healing occurs in clean lacerations or surgical incisions that are closed with skin adhesives or sutures. It is the fastest healing method.

Flashcard 4: Secondary Healing (Second Intention)

• Question: What is secondary healing (second intention)?

• Answer: Secondary healing happens when the wound is left open to heal. Granulation tissue forms from the bottom up. It is a longer process with a higher risk of infection.

Flashcard 5: Delayed Primary Closure (Tertiary Intention)

• Question: What is delayed primary closure (tertiary intention)?

• Answer: Tertiary intention combines primary and secondary healing. The wound is left open for 5 to 10 days to decrease infection risk before being sutured closed.

Flashcard 6: Phases of Wound Healing

• Question: What are the three phases of wound healing?

• Answer: The three phases are the hemostatic/inflammatory phase, the proliferative phase, and the remodeling phase.

Flashcard 7: Hemostatic/Inflammatory Phase

• Question: What happens during the hemostatic/inflammatory phase of wound healing?

• Answer: This phase starts immediately after injury and lasts 3 to 6 days. Blood vessels constrict to stop bleeding, and white blood cells clean the wound. Histamine release leads to vasodilation and increased blood flow to the injury.

Flashcard 8: Role of White Blood Cells in Hemostasis

• Question: What is the role of white blood cells during the hemostatic/inflammatory phase?

• Answer: White blood cells, especially neutrophils, act as phagocytes and enhance cytokine release, which promotes new blood vessel formation, fibroblast and keratinocyte production, and tissue maturation.

Flashcard 9: Proliferative Phase of Wound Healing

• Question: What occurs during the proliferative phase of wound healing?

• Answer: Starting 3 days after injury and lasting up to 24 days, the blood supply to the wound improves. Granulation tissue forms, and collagen strengthens the wound. Re-epithelialization begins, covering the wound with keratinocytes.

Flashcard 10: Remodeling (Maturation) Phase

• Question: What happens during the remodeling (maturation) phase of wound healing?

• Answer: The remodeling phase begins around day 21 and lasts up to a year or more. Collagen is replaced with stronger collagen, aiding in wound maturation. Myofibroblasts help close the wound by pulling the edges together.

Flashcard 1: Risk Factors for Delayed Wound Healing

• Question: What are some risk factors that can delay wound healing?

• Answer: Infection, decreased blood supply and oxygen perfusion, long-term steroid use, aging, chronic conditions like diabetes mellitus, and malnutrition.

Flashcard 2: Local Infections in Wounds

• Question: What are the clinical manifestations of a localized infection in a wound?

• Answer: Cellulitis, redness, warmth around the wound, exudate, and foul odor.

Flashcard 3: Systemic Infection Indicators

• Question: What are the signs that a wound infection has become systemic and the client is at risk for sepsis?

• Answer: Fever, chills, nausea, vomiting, hypotension, high blood sugar, increased white blood cell count, and changes in mental status.

Flashcard 4: Surgical Site Infections (SSIs)

• Question: What are superficial and deep surgical site infections (SSIs)?

• Answer: Superficial SSIs occur within 30 days of surgery, while deep SSIs occur 30 to 90 days after surgery.

Flashcard 5: Causative Agent of SSIs

• Question: What is the most common causative agent of surgical site infections (SSIs)?

• Answer: The most common causative agent is Staphylococcus aureus.

Flashcard 6: Preventing Surgical Site Infections (SSIs)

• Question: How can the risk of surgical site infections be reduced?

• Answer: Using perioperative antiseptic solutions or cloth wipes containing chlorhexidine gluconate/digluconate (CHG) helps reduce skin colonization by microorganisms and lowers the risk of SSIs.

Flashcard 7: Wound Culture Collection

• Question: How should a wound culture be collected to test for infection?

• Answer: Clean the wound with 0.9% sodium chloride, then use a sterile cotton applicator to obtain a drainage sample, avoiding contact with surrounding tissues. Place the swab in a vial to keep it moist for lab analysis.

Flashcard 8: Wound Culture Collection Techniques

• Question: What other methods can be used to collect a wound culture besides using a sterile cotton applicator?

• Answer: Needle aspiration or tissue biopsy can also be used for wound culture collection.

Flashcard 1: Dehiscence Definition

• Question: What is dehiscence?

• Answer: Dehiscence is the complete or partial separation of the suture line and underlying tissues, occurring due to poor surgical technique, infection, or foreign particles in the wound.

Flashcard 2: Timing of Dehiscence

• Question: When does wound dehiscence typically occur after surgery?

• Answer: Wound dehiscence generally occurs 7 to 10 days after surgery.

Flashcard 3: Symptoms Preceding Dehiscence

• Question: What symptom often precedes wound dehiscence?

• Answer: A serosanguineous discharge from the wound often precedes dehiscence.

Flashcard 4: Management of Dehiscence

• Question: What should be done if dehiscence occurs?

• Answer: Notify the healthcare provider, cover the wound with a sterile saline-moistened dressing, and prepare the client for a possible return to the operating room. An abdominal binder or negative pressure wound therapy may be applied.

Flashcard 5: Evisceration Definition

• Question: What is evisceration?

• Answer: Evisceration occurs when all layers of tissue under the wound separate, leading to the protrusion of internal organs through the suture line.

Flashcard 6: Emergency Response to Evisceration

• Question: What is the immediate treatment for evisceration?

• Answer: Place a sterile saline-soaked dressing over the exposed organs, and prepare the client for surgery to reduce the organs back into the abdomen and close the wound.

Flashcard 7: Hemorrhage Definition

• Question: What is hemorrhage in wound care?

• Answer: Hemorrhage is bleeding, either internal or external, following an injury or surgical incision.

Flashcard 8: Hemorrhage and Clotting Cascade

• Question: What happens during the clotting cascade in response to hemorrhage?

• Answer: Platelets accumulate at the site, triggering the release of growth factors that initiate the healing process and form a new matrix from fibrins, stabilizing the wound.

Flashcard 9: Hematoma and Seroma Risk Factors

• Question: What are the risk factors for developing hematomas and seromas?

• Answer: Anticoagulant medications and obesity increase the risk for hematomas and seromas.

Flashcard 10: Symptoms of Hematomas and Seromas

• Question: What are the usual indicators of hematoma and seroma formation?

• Answer: Swelling, pain, and/or drainage at the incision site.

Flashcard 11: Infection in Hematomas/Seromas

• Question: What happens if a hematoma or seroma becomes infected?

• Answer: Symptoms of infection include increased pain, fever, elevated white blood cell count, redness, and edema or discharge at the site.

Flashcard 12: Management of Small Hematomas/Seromas

• Question: How are small hematomas and seromas managed?

• Answer: Small hematomas and seromas are monitored for healing.

Flashcard 13: Management of Large Hematomas/Seromas

• Question: How are large hematomas and seromas managed?

• Answer: Large hematomas and seromas may require partial opening of the incision for inspection, drainage of the seroma, and packing of the wound with gauze.