Flashcards: Skin Integrity and Wound Care

irritation of epidermis caused by moisture

a red skin irritation that develops when the skin is exposed to irritants such as feces, urine, stoma effluent, and wound secretions

early stages and late stages of life

collagen stores decrease

loss of elasticity (inc risk of skin tears and tissue trauma)

impairments in mobility, such as congenital conditions like spina bifida and cerebral palsy, and chronic diseases, including liver failure, kidney disease, and cancer.

Localized damage to the skin and/or the soft underlying tissue, which can be caused by prolonged contact with a firm surface that interferes with circulation to the area.

A bacterial infection of the superficial layers of skin.

Decreased

*elasticity

*subcutaneous tissue

*blood supply

*hydration

examine bony prominances for manifestations of erythema

An area of a reddened skin that temporarily turns white or pale when light pressure is applied. the skin then reddens when pressure is relieved.

Redness of the skin that does not go away when pressure is applied and indicates structural damage has occurred in the small vessels supplying blood to the underlying skin and tissues.

Inc temp = inc blood flow, inflamation

dec temo= ded blood flow

under skin folds

is a disruption in the normal composition and performance of the skin and it s underlying structures.

include intentional and unintentional wounds. short term

a type of acute wound created during a surgical procedure. classified as either clean, clean-contaminated, or dirty

a type of acute wound created as a result of trauma (*injury, burns, punctures, gunshots)

a type of traumatic wound which is a tear in the skin thry blunt or sharp objects, can be irregular or jagged shape. Either simple (min bleeding/pain) or complex(bone or tendon showing).

true

tru

red

bright pink

pale pink

Fluid secreted by the body during the inflammatory stage of healing and is made of plasma.

5

true

Form of dermatitis that develops when the skin is exposed to irritants such as feces, urine, stoma effluent, and wound exudates.

Excessive sweating, increased local skin temperature, abnormal skin pH, and deep skin folds all predispose clients to MASD.

other manifestations include: pain, burning, and itching

pressure injury formation

develope over time as a result of disruption in the wound healing process associated with acute wounds or due to conditions that cause alterations in blood flow.

chronic venous insufficiency, peripheral artery disease, and diabetes mellitus. In addition, older adults and clients who smoke, are undernourished, are immunosuppressed, are immobilized, or have an infection in the wound

Thin, watery wound drainage.

Thin, watery wound drainage mixed with blood.

Bloody wound drainage.

Green/yellow wound drainage.

development of a narrow channel or passageway extending in any direction from the base of the wound

Pressure injuries develop due to prolonged pressure over an area of the skin or due to a combination of pressure and shearing—that is, forces exerted parallel to the surface of the skin

medical devices, such as urinary catheters, oxygen tubing, endotracheal tubing, and surgical or wound drains

immobility, malnutrition, reduced perfusion (hypperfusion), altered sensation, and dec level of consciousness, exposure to moisture, tearing, cuts, bruises, and friction.

False, its a factor that does cause trauma to skin and tissue and inc risk of developing pressure injury.

non-blanchable erythema, the amount and depth of skin and tissue loss, the condition of tissue in the wound bed and surrounding areas, the presence of dead tissue, and tunneling and undermining

Nonblanchable erythema

skin intact with localized area of non blanchable erythema

Sensation, temperature, and changes in consistency of the skin and tissues may precede color changes

hard to detect on darker individuals (mexicans)

partial thickness skin loss

pink or red viable tissue in wound bed

tissue is moist and deeper tissue not yet visible

this stage may also presnet itself as a ruptured serum filled blister

full thickness skin loss with visible adipose tissue. Granulation tissue is often present and wound edges may be rolled

dead tissue may have formed

undermining/ tunneling may be present

Fascia, muscles, tendons, bone, ligament, and cartilage are not visible in this stage

full thickness skin and tissue loss. fascia, muscles, tendons, ligaments, cartilage, and or bone visible

edges rolled

undermining/tunneling may be present

dead tissue may be present

new skin tissue that forms on the surface of the wound

full damage in wound bed cannot be determined due to obscured full thickness skin and tissue loss injury

covered with either slough, a yellow stringy nonviable tissue found in base of wound, or escahr, a hard nonviable black/brown tissue.

Yellow, stringy nonviable tissue found in the baase of the wound.

found in unstageable pressure injury

Hard nonviable black/brown tissue found in the wound bed.

Persistent nonblanchable tissue injury of the skin appearing deep red, maroon, or purple color.

surgically removing dead tissue and other debris that can cause infection

debris, dead tissue, biofilm removed with scalpel or scissors

True

clean surface of wound to dec bacterial levels

can be preformed at bedside or surgical suite

0.9% sodium chloride used normally

is an agent that targets only necrotic tissue and promotes wound healing by helping keratinocyte and endothelial cell migration across wound

also used for patients who need wound debridement but are not surgical candidates

true, (green bottle fly and australian sheep blowfly) they secrete an enzyme that liquifies necrotic tissue

Sterile dressings are applied after surgery and are usually kept on the incision site for 24 to 48 hours.

if dressing saturated or loose, dressing changed using sterile technique

after 48 hours of dressing usage, clean technique is used as wound is considered colonized by clients enviroment.

True

Gauze bandage

first moistened w/ 0.9% sodium chloride, then packed to help with debridement process. also known as wet-to-dry dressing

when gauze dries, it sticks to the ineer wound and also pulls on new tissue (granulations)

inc risk of infection

gauze fragments stay in wound

Rarely used

3 layers

bottom layer: knit gauze infused with therapeutic ointment

middle layer: padding and absorbent gauze

top layer: adhesive

cons: doesn't control drainage welll, has poor wound healing properties / breakdown of tissue near wound

cover wound and control moisture and bacteria

air can move in and out but not moisture

used commonly i vascular access

covering superficial wounds that have minimal exudate

allow moisture to evaporate while still maintainig a moist wound bed

o2 enter and exit with dec risk of microorganims entering

allows for wound visualization without removal

have leakage and cause skin maceration and injury to epidermal layer

gell like dressing that occlude wound, maintain a moist wound bed, have bacteriostatic properties, and stimulate growth of new granulation

pros:comfortable and produce less maceration, maintain a moist wound bed, have bacteriostatic properties, and stimulate growth of new granulation

cons: potential dermatitis, foul smelling yellow gelatinous film develops as bacteria trapped on underside of dressing

used for mod to high exudative wounds

provide homeostasis and can be used cont for various days without change

forms: ribbons, pads, and beads

used in wound coverage and packing

cons: a secondary dressing needed to cover alignate which inc cost

used for mod to high exudative wounds

high absorbance and can stay in wound for several days

draws less fluids from wound edges = less maceration than alginate

used with mild to mod exudate

require more frequent dressing changes

May produce a malodorous discharge

used in mildly exudative wounds.

stimulate the growth of new epithelium and do not stick to the wound bed, resulting in less trauma to the new granulation tissue

Used in dry wounds for debridement of necrotized tissue and eschar

can provide moisture to or pull away moisture from the wound depending on wound needs

soothing effect with little trauma to wound bed

con: frequent dressing change

face and neck wounds

faster to place

heal faster

7-14 days can be removed with staple remover

synthetic materials such as nylon or polyester, or from natural fibers such as silk, linen, and dried animal intestines.

Partially, there are both absorbable and non absorbable sutures

days to weeks, and may last up to 2 months

nonabsorbable sutures

true

reducing edema surrounding wound and increased garnulation tissue formation

passive drain

rely on gravity to remove accumulated fluid from a body cavity or wound

open drain, fluid collected directly on gauze

sterile dressing maintained 24-48 hours, if saturated sterile tech used for replacement

open: remove fluids to the air

closed: send fluids to a closed containment system ( req small incision and are less likely to become contaminated with bacteria)

True, early removal of drains has been associated with hematoma and seroma formation

Accumulation of serous fluid.

clot formation at the insertion site, small tissue fragments that obstruct the tubing and prevent the outflow of drainage, and accidental removal of the drainage tube

(aka bulb suction drain aka Jackson Pratt Drain)

closed system drain w/ negative suction to drain fluid from the wound

suction created by squeezing

bulb should be emptied every 8 hours or when more than half full

the fluid and document the date, time, color, and volume of the fluid collected

used when higher pressure needed for large amount of fluid

closed, negative pressure

changed when half full and nozzle expanded

aka hemovac

continous suction drainage from wound by using low vaccum pressure

circular drainage device with a spring that is squeezed flat on insertion. One or more stitches are placed to hold the drain in place

looks like a lil sandwich

notify the provider

the skin around the drain site for maceration as well as the client’s lab work for manifestations of fluid and electrolyte imbalances

these are expected findings for the first few days a drain is inserted

remove drain and gauze applied to drain site

puncture site should be monitored for manifestation of infection

A-low exudate levels

B-low to moderate exudate

C-moderate to high exudate levels

malnourished, are immobile or have altered circulation or decreased sensory perception, have general physical and mental disorders, or are experiencing incontinence

older people more at risk

true

20-30

support client with pillows

if in pain, attempt administering an analgesia before repositioning

30

sacral

a special pressure relieving bed

ph balanced foam cleansers used when cleaning.

deep/fast massage/ rubbing avoided to dec friction and inc skin damage

helps with adequet movement of nutrients thru body

malnutrition can dec wound healing and pressure injury formation

dec intake of nutrients:

protein, omega-3 and omega-6 fatty acids, and vitamins A and C.

nurse should offer High-calorie, high-protein, fortified foods and/or supplements should be offered to clients to dec risk

lack of o2 circulating

red nutrient supply to cell and failure to remove metabolic cellular wastes

CNS issues and. fewer capillaries dec tissue perfusion

Dec peripheral perfusion and impairs sensation, placing clients at greater risk for delayed wound healing

breaks down collagen, making tissue more vulnerable to damage

inc risk for infection, which delays wound healing

prevent formation of collagen and fibroblasts needed for wound healing

impairs wound healing process by not providing sufficient amount of protein, calories, vitamins (A&C), and mineral (zinc) required for healing

death of tissue cells resulting from wound ischemia decreases blood supply to wound

low o2 levels caused by vasoconstriction due to acute blood loss, pain and or low body temp at site of injury

each wound competes for nutrients needed for wound healing to occur, resulting in delayed wound healing in all sites

hydration, nutrition, hygiene, and circulation.

occurs in clean lacerations and surgical incisions closed with skin adhesives or sutures

fast to heal

wound is left open to heal and granulation tissue from bottom up in wound bed

prolonged healing process

wound bed needs to be kept moist for proper healing to occur

riks of infection in these wounds is much higher bc wound bed in direct contact with enviroment

combo of 1st and 2nd intention

wound left open for 5-10 days before closed with sutures

Hemostatic/Inflamatory phase

proliferative phase

remodeling pahse

lasts 3-6 days

blood vessels constrict

damaged tissue release protines that trigger activation of clotting factors

both work together to stop bleeding

when bleeding controlled, histamine released for vasodialation and inc cap permeability, allowing inc blood flow and inc WBC and phagocytes to enter

new BV formation

inc fibroblast and keratinocyte production

aid in tissue maturation

3 days after injury and can last up to 24 days

blood supply to wound improves

granulation tissue composed predominantly of fibrobalsts and collagen

collagen strengthens wound allowing maturation and closure to start

keratinocytes aoround periphery of wound move towards center to cover and fill

after 21 days and can last more than a year

collagen formed in granulation tissue replaced by stronger collagen, aiding in wound maturation

wound cont to close as myofibroblasts secrete proteins that produce a contractile force pulling wound edges together

label cuture tube

remove old dressing

rinse wound w/ 0.9% sodium chloride

remove swab from culture tube

place sterile swab into wound bed

rotate the swab stick in an area of drainage

activate the culture medium

note if client has received any recent antibacterial or antifungal therapy

The complete or partial separation of the suture line and underlying tissues that occurs when a wound fails to heal properly.

Protrusion of internal organs through a surgical wound which has dehisced or opened.

Relieve pressure

Frequent turning/repositioning

Pressure-relieving devices

Promote hydration and nutrition

Keep clean and dry

do stage 1 interventions

Relieve pressure

Frequent turning/repositioning

Pressure-relieving devices

Promote hydration and nutrition

Keep clean and dry

aditionally

Moist healing environment (saline or occlusive dressing)

Nutritional supplements

Administer analgesics

Nutritional supplements

Analgesics

Antimicrobials

Clean and/or debride:

•Prescribed dressing

•Surgical intervention

•Proteolytic enzymes

(In addition to stage 3 interventions)

Nonadherent dressing changes

Skin grafts, specialized therapy such as hyperbaric oxygen

Sensory Perception

Moisture

Activity

Mobility

Nutrition

Friction and Shear

16-18

13-15

10-12

less than 9

16-18

› Regular turning schedule- INSPECT skin (bed- q2h, chair- q1h)

› Enable as much activity as possible

› Protect the heels

› Use pressure redistribution surfaces

› Manage moisture, friction and shear  (cream or powder)

› Advance to a higher level of risk if other major risk factors are present

15-13

SAME AS AT RISK PLUS:

Position patient at 30 degree lateral incline using foam wedges

12-10

SAME AS MOD RISK PLUS:

In addition to regular turning schedule Make small shifts in their position frequently

less than 9

SAME AS HIGH RISK PLUS:

Add a pressure redistribution surface for patients with severe pain or with additional risk factors.