SKIN/WOUNDS/OTHER
THE "C's" of COCAF
TYPE OF WOUND HEALING
PHASES OF WOUND HEALING
COMPLICATIONS OF WOUND HEALING
WHATS MY STAGE
ASSESS MY SKIN
WHAT YA GONNA DO
100
AGE - IMPAIRED MOBILITY - NUTRITION - HYDRATION - DIMINISHED SENSATION - DIMINISHED COGNITION - IMPAIRED CIRCULATION - MEDICATIONS - MOISTURE - FEVER - INFECTION - LIFESTYLE
WHAT ARE THE 12 FACTORS THAT AFFECT SKIN INTEGRITY
100
I AM WATERY, CLEAR TO STRAW COLORED SERUM. I AM SEN IN CLEAN WOUNDS
SEROUS DRAINAGE
100
REGENERATIVE/EPITHELIAL
PRIMARY INTENTION
SECONDARY INTENTION
TERTIARY INTENTION
WHAT ARE THE TYPES OF WOUND HEALING
100
Cells develop & grow to fill in from the base of the wound AS Granulation tissue.
PROLIFERATIVE PHASE
100
WHAT ARE THE 5 COMPLICATIONS OF WOUND HEALING
HEMORRHAGE - INFECTION - DEHISCENCE - EVISCERATION - FISTULA
100
MY SKIN IS INTACT BUT WHEN YOU PRESS ME I NO LONGER BLANCH. MY EPIDERMIS IS AFFECTED.
STAGE I
100
THIS ASSESSMENT SCALE IS USED TO DETERMINE THE PATIENTS RISK FOR DEVELOPING PRESSURE INJURIES
BRADEN SCALE
100
A PATIENT IS AT RISK FOR SKIN INJURY DUE TO THE INABILITY TO REPOSITION THEMSELVES.
TURN & POSITION Q2H WHILE IN BED AND Q1H SHIFT WHILE IN CHAIR. CONTINUE TO ASSESS SKIN.
200
WHAT WOUNDS ARE STAGED?
ONLY WOUNDS CAUSED BY PRESSURE OVER A BONY PROMINENCE
200
A PATIENT FALLS AND HITS THEIR HEAD CAUSING A LACERATION. I WOULD ANTICIPATE WHAT DRAINAGE.
SANGUINEOUS
FRESH BLEEDING
200
I AM A CLEAN WOUND THAT IS WELL APPROXIMATED. I AM HEALING BY..........?
PRIMARY INTENTION
200
EDEMA, ERYTHEMA, PAIN, TEMPERATURE ELEVATION, WBC'S TO THE AREA, AND SCAB FORMATION OCCUR DURING THIS PHASE.
INFLAMMATORY PHASE
200
THE NURSE ASSESSES INCISIONAL WOUND REDNESS, WARTH TO TOUCH IN THE PERIWOUND AND ODOROUS WHITE DRAINAGE. WHAT WOUND HEALING COMPLICATION IS SUSPECTED?
INFECTION
LOCAL = REEDA - REDNESS, EDEMA, ECCHYMOSIS, PURULENT DRAINAGE OR EXUDATE
SYSTEMIC = FEVER AND ELVATED WBC >5000
200
I EXTEND THROUGH 3 SKIN LAYERS BUT DO NOT EXPOSE MUSCLE OR BONE. UNDERMINING MAY BEGIN AT THIS DEPTH OF INJURY.
STAGE III PRESSURE ULCER
200
THE NURSE NOTED CLAVICULAR TENTING OF THE SKIN. WHAT MIGHT THIS INDICATE?
DEHYDRATION
200
TO PREVENT HEEL BREAKDOWN THROUGH COMPRESSION, THE NURSE WILL..........?
ELEVATE THE HEELS OFF THE BED AND APPLY HEEL BOOTS
300
HOW OFTEN DO YOU ASSESS THE SKIN AFTER APPLYING HOT OR COLD THERAPY TO PTS WITH ADVANCED AGE, SENSORY/COGNATIVE IMPAIRMENT
Q15MINS TO PREVENT SKIN INJURY
ESPECIALLY WATCH PTS WITH ADVANCED AGE, SENSORY/COGNITIVE IMPAIRMENT
300
BLOOD - BRIGHT RED TO DARK RED/BROWN = FRESH BLEEDING
THICKER CONSISTENCY THAN SEROUS
SANGUINEOUS
300
THIS TYPE OF WOUND HEALING OCCURS BY FILLING WITH GRANULATION TISSUE INSIDE THE WOUND BED GROWING OUTWARDS
SECONDARY INTENTION
300
WHAT PHASE DOES THIS OCCUR
PROLIFERATIVE PHASE
300
PARTIAL SEPARATION OF WOUND LAYERS WITH NO INTERNAL ORGAN OR VISCERAL PROTRUSION.
DEHISCENCE
300
FULL THICKNESS SKIN LOSS THROUGH MUSCLE, TO BONE & TENDON
STAGE IV
300
THE HCP ORDERED A WOUND CULTURE. WHY?
THE WOUND ASSESSED SHOWED SIGNS & SYMPTOMS OF INFECTION SUCH AS ODOROUS PURULENT DRAINAGE, INCREASED DRAINAGE, INCREASED EDEMA, INCREASED PAIN, INCREASED REDNESS AT SITE...
300
A PATIENT IS AT RISK FOR SKIN INJURY DUE TO EXPOSURE TO MOISTURE D/T INCONTINENCE
CHECK Q1H FOR INCONTINENCE, WASH & DRY AREA, APPLY BARRIER CREAM, APPLY LOTION, CHANGE LINEN.
400
JOINT STIFFNESS, CONTRACTURES, LOW BACK PAIN,
INDICATIONS FOR HEAT THERAPY
400
I AM A COMBO OF BLOOD & SEROUS AND CAN BE SEEN IN NEW WOUNDS
SEROSANGUINEOUS
400
THE PATIENT HAS A STAGE IV PRESSURE INJURY OF THE RIGHT HIP. WHAT TYPE OF WOUND HEALING IS OCCURING?
SECONDARY INTENTION - NOT APPROXIMATED
400
HEMOSTASIS AND INFLAMMATION OCCUR IN THIS PHASE OF WOUND HEALING
INFLAMMATORY PHASE
400
THIS WOUND COMPLICATION IS CAUSED BY INFECTION, DEBRIS, AND PRESSURE.
FISTULA
400
SLOUGH & ESCHAR
WHAT ARE 2 TYPES OF NECROTIC TISSUE ASSOCIATED WITH PRESSURE INJURIES
400
WHAT IS MISSING FROM THIS WOUND ASSESSMENT:
4X6 SURGICAL INCISION, NO REDNESS, NO EDEMA, WELL APPROXIMATED, NO DRAINAGE, NO TEMPERATURE CHANGE, NO TENDERNESS
LOCATION
WHERE IS THE INCISION?
400
IMMOBILITY, IMPAIRED SENSATION, POOR NUTRITION, EDEMA, AGE, IMPAIRED COGNITION, FEVER, IMPAIRED CIRCULATION ARE EXAMPLES OF...?
Intrinsic Factors (Internal) THE Patient health Status
500
WHAT ARE 4 REASONS TO USE COLD THERAPY
FRACTURES, POST INJURY SWELLING, BLEEDING, SPRAINS, STRAINS, FEVER, POST SURGICAL EDEMA
500
I AM A THICK ODOROUS DRAINAGE THAT MAY BE GREY, YELLOW, OR WHITE.
PURULENT
500
I AM AN OPEN WOUND THAT IS FIRST ALLOWED TO HEAL BY SECONDARY INTENTION.
TERTIARY INTENTION
500
THIS PHASE CAN LAST 6 MONTHS
MATURATION
500
TOTAL SEPARATION OF SKIN AND MUSCLE LAYERS OF A WOUND WITH INTERNAL VISCERA PUSHED TO THE SURFACE.
EVISCERATION
500
THIS PARTIAL THICKNESS INJURY AFFECTS THE EPIDERMIS & DERMIS AND HAS A RED, PINK WOUND BED.
STAGE II PRESSURE INJURY
500
A HIGH BLOOD FLOW REACTION THAT OCCURS WHEN PRESSURE IS RELIEVED.
REACTIVE HYPEREMIA
IF THE REDNESS REMAINS AND DOES NOT BLANCH THE TISSUE IS ISCHEMIC (DYING)
500
HOW DOES THE RN PREVENT THE EXTRINSIC FACTOR OF SHEARING
DO NOT KEEP THE PATIENT'S HOB >30 DEGREES, ELEVATE FOOT OF BED, AND USE FOOT BOARDS. THIS PREVENTS SLIDING DOWN IN BED.
600
WHAT ARE THE NANDA DX'S WE CAN USE FOR A PATIENT WITH A STAGE III PRESSURE INJURY
IMPAIRED SKIN INTEGRITY
IMPAIRED TISSUE INTEGRITY
600
WHEN MY WOUND IS INFECTED AND HAS BLOOD I AM THIS KIND OF DRAINAGE
PUROSANGUINOUS
600
WHAT TYPE OF WOUND HEALING OCCURS WHEN THE EPIDERMIS & DERMIS NEED TO REGENERATE?
EPITHELIAL/REGENERATIVE - PARTIAL THICKNESS WOUNDS
600
THIS PHASE OF WOUND HEALING PLACES THE PATIENT AT HIGHER RISK OF INFECTION D/T TIME IT TAKES TO HEAL.
Proliferative Phase—Granulation, also called Regeneration or Healing, occurs from days 5 to 21.
600
THE PATIENT URINALYSIS RESULT REVEALS STOOL PRESENT. WHAT WOUND COMPLICATION WOULD THE RN SUSPECT
FISTULA
600
AN AREA OF INTACT SKIN BUT WITH DARK PURPLE OR DEEP RED DISCOLORATION. WHEN YOU PRESS THE AREA IT FEELS BOGGY (SQUISHY LIKE A WET SPONGE)
DEEP TISSUE INJURY
600
Sensory perception, moisture, activity, mobility, nutrition, friction, and sheer.
WHAT THE BRADEN SCALE MEASURES
600
LIFT SHEETS ARE USED TO PREVENT WHAT EXTRINSIC RISK FACTOR FOR PRESSURE INJURIES
INJURIES FROM FRICTION WHICH IS CAUSED BY DRAGGING THE PATIENT UP IN BED WITHOUT A LIFT SHEET