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Summary NUR 320 Exam 4 Study Guide
- Course
- FOUNDATION NUR320
- Institution
- Denver School Of Nursing
This is a comprehensive and detailed study guide on Exam 4 for Nur 320. An Essential Study Resource just for YOU!!
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Exam #4 Study GuideChapter 48 (Skin Integrity & Wound Care)
Know the type of tissue you see with wound healing
Hemostasis (1st phase) – clot forms, fibrin matrix established
Inflammatory phase – localized redness, erythema, warmth, throbbing
o Collagen forms as early as second day – main component of scar tissue
o Clean wound established clean wound bed
Proliferative phase – 3 to 24 days
o Fill wound with granulation tissue
o Wound contraction to decrease healing area
o Would resurfacing by epithelialization
Epithelial cells migrate from wound edges to resurface
o Collagen provides matrix for granulation – red, beefy looking
Maturation – sometimes takes place for more than 1 year (depending on depth and
extent of wound)
o Collagen scar reorganized and regains strength
o Scar tissue usually contains fewer pigmented cells and has lighter color than
normal skin
Take note…
o Surgical incision healing by primary intention – should have clean, well
approximated edges
May be some redness at edges of incision that can present for first few
days after surgery
Within 7 – 10 days normally healing wound resurfaces with epithelial
cells, edges close
Know lab data that may be ordered for someone with a pressure ulcer
Know the Braden scale. What is it used for?
Most widely used risk-assessment tool for pressure injuries
Total score: 6 – 23, lower total score indicates higher risk for pressure injury
development
18+ = not at risk for pressure injury development
o Cutoff score for onset of risk in ICU pts is 13
6 subscales:
o Sensory perception
o Moisture
o Activity
o Mobility
o Nutrition
o Friction/shear
Know the different types of wound dressings and for what type of wound they would be used.
Give prescribed analgesic as needed 30 mins prior to dressing changes
Wounds with extensive tissue loss always need a dressing
, Pressure dressings promote hemostasis
o Applied with elastic bandages
o Exerts localized downward pressure over actual or potential bleeding site
Gauze dressings (including gauze sponges)
o Can be applied as…
moist dressing
dry cover dressing over clean surgical wound
dry cover dressing when using enzymes or topical antibiotics
means to deliver solution to wound
o delivers moisture to wound and is absorptive
Transparent film dressing
o Apply over…
Superficial injury with minimal or no exudate
Skin subjected to friction
o Maintains moist environment and offers intact skin protection
Hydrocolloid dressings
Maintains moist environment to facilitate wound healing while protecting
wound base
Hydrogel dressings
o Available in sheet or in tube
o Maintains moist environment to facilitate wound healing
Foam dressings
o Wounds with large amounts of exudate that need packing
o Foam dressings used around drainage tubes to absorb drainage
o Protective and prevents wound dehydration, absorbs moderate-to-large amounts
of drainage
Calcium alginate dressings
o come in sheet and rope form, from seaweed
o Alginate forms soft gel when in contact with wound fluid
o For wounds with excessive amount of drainage and do not cause trauma when
removed from wound
o Do not use in dry wounds
o Require secondary dressing
Silver-impregnated dessings/gels
o Controls bacterial burden in wound
Wound fillers
o Fills shallow wounds, hydrates, and absorbs
What is wound debridement?
Removal of nonviable, necrotic tissue
Necessary to remove source of infection, enable visualization of wound bed, and provide
clean base necessary for healing (helps with healing from inside moving out)
Administer ordered analgesic 30 minutes prior to debridement
Mechanical: wet-to-dry dressing
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