Stages of Wounds
Name the Stage of a pressure injury when the skin is intact and non-blanchable but, is painful and can be soft, firm, warm, or cool?
Stage 1 Pressure Injury
Name the layers of the skin in order:
1.Epidermis, 2.Dermis, 3.Subcutaneous
What is a laceration? Give example
open wound
Cause: tissues torn apart, often accidental
EX:Skin tear
What is an example of a primary skin lesion?
What ethnicity has the majority of lactose intolerance?
Asian
Which stages of pressure injuries are FULL thickness?
Stage 3,4 & unstageable
What is necrosis?
Tissue Death
What is a penetrating wound, cause + example?
What is an incision, cause + example?
open wound, deeper into the skin
Cause: penetration of the skin and underlying tissue
EX: a bullet
Open wound
Cause: sharp instrument
EX: Knife,Scalpel
Name the 3 classifications of wounds (colors) & what they mean:
RED- protect
YELLOW- Clean/Irrigate
BLACK- Debride
Name some cultural barriers to healthcare?
-stereotyping
-social justice
-healthcare disparity
-vulnerable populations
Name the stage: partial thick. loss, involving the dermis/epidermis, shallow, open ulcer, pink, painful serum-filled blister
Stage 2
What is the definition of Wheal? and What is an example of this?
irregular, superficial area of localized skin edema EX: (hives, mosquito bite)
What is a contusion, cause + example?
What is a puncture wound? What is the cause? Example?
closed wound, ecchymosis
Cause:Blow from instrument
EX: Bruise, hematoma
open wound
Cause: Penetration of the skin and underlying tissue by a sharp instrument
EX:IV or injection
What 2 assessment tool scales are used in predicting pressure injuries?
Braden Scale & Norton Scale
A nurse is interviewing a newly admitted patient. Which question would be considered culturally sensitive?
a. “Do you think you will be able to eat the food we have here?”
b. “Do you understand that we can’t prepare special meals?”
c. “What types of food do you eat for meals?”
d. “Why can’t you just eat our food?”
C.) “What types of food do you eat for meals?”
Name this stage: the injury has full thickness loss
bone, tendon, or muscle ARE exposed
may see slough, eschar,undermining or tunneling..
Stage 4
Name what should be inspected in a skin assessment:
skinfolds
moist areas, bony prominences
skin color
lesions?
scars
odors
hair distributor
What type of wound is caused by a surface scrape to the dermal? An example is a scraped knee.
Is this an open or closed wound?
Incision
Open wound
Cause: sharp instrument
EX: Knife,Scalpel
Name the populations at risk for pressure injuries, wound healing, & compromised tissue integrity?
PI: Older adults
WH: smoking, malnourished, obese, immobile, respiratory deficits (anti-inflammatory drugs- steroids).
CTI:Everyone - Newborns, children, adolescents, older adults
a. Arrange furniture so that clients have a view from their bed
b. Respect each client as a unique individual
c. Provide for basic physiologic needs
d. Ensure continuity of care
B.) Respect each client as a unique individual
Name BOTH stages: full thickness loss
damage to subcu.
bone, tendon, muscle NOT exposed
slough + eschar may be present.... and the worst stage of a wound is called?
Stage 3 & Unstageable
What questions should be asked during a skin assessment?
history of skin problems?
current skin problems? allergies? medications? sunlight exposure? skin care regimens? changes in the skin? excessive dryness/moisture? hair loss? change in mole (color/size)? environmental/occupational hazards?
What are the phases of wound healing? What happens during each phase? and How long does each phase last?
1. Inflammatory-2 processes
Hemostasis-blood clots
Phagocytosis-macrophages clean debris (immediately + lasts 3-6 days after injury)
2. Proliferative-capillaries grow, collagen synthesize, blood supply increase, + granulation tissue form (3-21 days)
3. Maturation-scars form, site is remodeled, and tissue is never as strong as original(day 21)
Name the 4 types of would exudate, and what they are.
What is Social Justice?
The equal treatment of culturally diverse groups!