Types of Wounds
What are venous leg ulcers
Bonus 10 points: What are the symptoms
Caused by cardiovascular disease
Poor blood flow in the veins
Leg veins send blood back up to the heart, if the veins are weak, blood pools in the legs
Usually near the ankles, often painful when standing
Symptoms:
Swelling
Increased pressure
Skin breakdown
Eventually, an ulcer which is a slow-healing wound
Stage 1
Non blanchable erythema of intact skin
What is the Braden Scale
Tool to predict the risk of developing pressure injuries
Inflammatory Phase
Bonus 10 points: What are the symptoms
Begins at the time of injury or cell death and lasts 3-5 days
Immediate responses are vasoconstriction and clot formation
After 10 min, vasodilation occurs with increased capillary permeability and leakage of plasma into the surrounding tissue
WBC come into the wound
Signs and symptoms: local edema, pain, erythema, warmth
What is Pruritis?
Itching
What is a diabetic foot ulcer?
Bonus 10 points: What are the two main issues
Caused by diabetes mellitus
At the bottom of the foot
Bonus: Two main issues
1. nerve damage (neuropathy)
2. poor circulation (peripheral artery disease)
Stage 2
Partial thickness skin loos with exposed dermis
Early signs of pressure injury:
What is blanchable and nonblanchable erythema
Blanchable erythema: redness over a bony area that turns white when pressed
Nonblanchable erythema: red area that does not turn white when pressed
Proliferative Phase
Begins about the fourth day after injury and lasts 2-4 weeks
Granulation tissue grows
Epithelial cells grow over the granulation tissue bed
What is Urticaria
Bonus 10 points: what are the common causes of it
Hives
Rash of white or red edematous papules of various sizes
Common causes: drugs, temperature extremes, foods, infection, diseases, cancer, insect bites
What are pressure ulcers?
Caused by vascular stasis in the area
Blood flow stops/slows down, especially in the veins
aka: bed sores
Stage 3
What is cellulitis
Inflammation that spreads beyond the injury site involving skin and subcutaneous tissue
Need antibiotics
Maturation Phase
Begins as early as 3 weeks after injury and may continue for a year or longer
Scar tissue gradually becomes thinner and paler in color
The mature scar is firm when palpated
What is shingles?
Infection caused by varicella zoster virus (chickenpox)
Characterization: red skin rash, pain, burning
Usually appears as a blister on one side of the body-typically on torso, neck, face
Risk factor: weak immune system
Shingles is not contagious but varicella can spread to someone with shingles who hasn't had chickenpox or the vaccine
Treatments are to ease symptoms and shorten length of infection
What are radiation burns?
Where the ionizing radiation penetrated deep into the tissues causing primary damage to the vascular structures which leads to skin lesions as secondary damage
Happens usually from cancer treatment (radiation therapy)
Stage 4
Full thickness skin and tissue loss
How much fluid intake is important to prevent pressure injuries
Bonus 10 points: How often should skin be inspected and how often should perineal care be done
2000-3000ml/day
Bonus: every 2 hours
A nurse is assessing clients with pressure injuries. Which wound description is correctly matched to its description?
A. Suspected deep tissue injury: nonblanchable deep purple or maroon
B. Stage 2: may have visible adipose tissue and slough
C. Stage 3: may have pink or red wound bed
D. Stage 4: wound bed is obscured with eschar or slough
What are the degrees of burns
What is the definition of a burn
Bonus 10 points: What is the rule of nines in burns
Burn definition: occurs when heat, chemicals, sunlight, electricity, or radiation damage skin tissue. Mostly happens by accident.
First degree
Second degree
Third degree
Fourth degree
Rule of nines in burns: measure by estimating the body surface area.
Arm (including hand): 9% each
Anterior trunk (chest, abdomen, pelvis): 18%
Genitalia: 1%
Head/neck: 9%
Legs (including feet): 18%
Posterior trunk (upper, middle, lower back and back of pelvis and buttocks): 18%
A nurse is caring for a client who has a nonhealing pressure injury on the right ankle. Which action would the nurse take first?
A. Draw blood for albumin, prealbumin, and total protein
B. Prepare for and assist with obtaining a wound culture
C. Instruct the client to elevate the foot
D. Assess the right leg for pulses, skin color, and temperature
ANS: D
Deep Tissue Pressure Injury
Obscured full-thickness skin and tissue loss
Persistent non blanchable deep red, maroon, purple discoloration
What is eschar
What is granulation tissue
Eschar: dead and necrotic tissue, looks black, brown, gray
May be dry and leathery and wet and full of yellow/tan exudate
Granulation tissue: healthy healing tissue
Appears pale and pink (early) -->beefy red (mature)
A new nurse reads a client has a wound "healing by the second intention" and asks what that means. Which description by the charge nurse is most accurate?
A. The wound edges have been approximated and stitched together
B. The wound was stapled together after an infection was cleared up
C. The wound is an open cavity that will fill in with granulation tissue
D. The wound was contaminated by debris and can't be closed at all
ANS: C
First degree burns
Second degree burns
Third degree burns
Fourth degree burns
2. Second-degree burns: affects the skin's top and lower layers (dermis). You may experience pain, redness, swelling and blistering
3. Third-degree burns: Affects all three skin layers: epidermis, dermis, and fat. The burn also destroys hair follicles and sweat glands. Because third-degree burns damage nerve endings, you probably won't feel pain in the area of the burn itself, but rather adjacent to it. Burned skin may be black, white, or red with a leathery appearance.
4. Fourth-degree burns: damage extends into the muscle, tendon, and bone. Needs specialized care.