32 Skin Integrity + Wound Care

Question 1

Factors that affect skin integrity

Answer 1

• age, amt of underlying tissues, + illness all affect resistance to injury
• nourished/hydrated body cells
• good circulation

Question 2

which age groups have thin skin?

Answer 2

infants, kids under 2 yrs, and older adults

Question 3

Wound

Answer 3

break or disruption of normal integrity of skin and tissues

Question 4

Partial-thickness

Answer 4

all or portion of dermis is intact

Question 5

Full-thickness

Answer 5

• entire dermis, sweat glands, + hair follicles are severed

- possibly exposed bone, tendon, or muscle

Question 6

Unstageable

Answer 6

full-thickness loss where depth cannot be determined due to slough or eschar
-may involve deep tissue injury

Question 7

Stages of Wound Healing

Answer 7

1 Hemostasis
2 Inflammatory Phase
3 Proliferation Phase
4 Maturation Phase

Question 8

Hemostasis

Answer 8

occurs immediately after initial injury

• bld vessels CONSTRICT, clotting begins (pltlet activn + clustrng)
• bld vessels then DILATE to incr permeability (plasma + bld components leak into area, form EXUDATE)
• exudate buildup causes swelling+pain
• incr circ leads to heat + redness

Question 9

Inflammatory Phase

Answer 9

• last 2-3 days
• WBC (leuk ingest bacteria + debri; + macrphg come later + stay longer + release growth factors)
• pain, heat, redness, swelling
• patient has incr temp, leukocytosis, + malaise

Question 10

Proliferation Phase

Answer 10

• lasts several weeks
• GRANULATED TISSUE-new tissue built to fill the wound
• FIBROBLASTS are connectv tissue cells that synth + secrete collage + produce specialized growth factors
• –induce bld vessel formation + incr endothelial cells
• CAPILLARIES grow across the wound (bring O2 + nutrients)
• COLLAGEN synth peaks at 5-7 days

Question 11

Maturation Phase

Answer 11

• 3 weeks after injury
• collagen is remodeled making the wound stronger + more like adjacent tissue
• scar becomes flat + thin

Question 12

if 3 stages of wound healing are identified, then…

Answer 12

hemostasis occurs w inflammatory phase

Question 13

if 3 stages of wound healing are identified, then…

Answer 13

hemostasis occurs w inflammatory phase

Question 14

Nutrients for Wound Healing

Answer 14

requires adequate proteins, carbs, fat, vitamins, + minerals

• vit A C
• Zinc

Question 15

Vitamins A + C for wound healing

Answer 15

for epithelialization + collagen synthesis

Question 16

Zinc

Answer 16

for proliferation in cells

Question 17

Zinc

Answer 17

for proliferation in cells

Question 18

Dehiscence

Answer 18

partial or total separation of wound layers as a result of excessive stress on wounds that arent healed

Question 19

Evisceration

Answer 19

most serious complication of dehiscence

-potrusion of a viscera

Question 20

what to do when dehiscence occurs

Answer 20

cover wound area w sterile towels moistened w sterile 0.9% NaCl soln

• notify healthcare provider
• medical emergency

Question 21

what to do when dehiscence occurs

Answer 21

cover wound area w sterile towels moistened w sterile 0.9% NaCl soln

• notify healthcare provider
• medical emergency

Question 22

Pressure Injury

Answer 22

new term for pressure ulcer

• localized damage to skin + underlying tissue
• develop when soft tissue is compressed bw BONY prominence + external surface for prolonged period
• may occur fr soft tissue undergoes pressure w shear/friction

Question 23

Risk Factors for pressure injury

Answer 23

• mobility + activity limitations are required conditions*
• poor skin hygiene
• diabetes mellitus
• diminished sensory perception/pain awareness
• fractures
• hx of corticoid therapy
• hx of pressure injury
• significant obesity or thinness
• term illness/dying process
• microvasc dysfunction

Question 24

Stage 1 Pressure Injury

Answer 24

defined, localized area of intact skin w NONBLANCHABLE ERYTHEMA

• area may be painful, firm, soft, warmer, or cooler than surrounding skin
• color changes DO NOT include purple/maroon

Question 25

Stage 2 Pressure Injury

Answer 25

involved partial-thickness loss of dermis - presents shallow, open ulcer or ruptured/intact serum-filled blister - fat is NOT exposed - granulation, slough, eschar NOT present

Question 26

Stage 3 Pressure Injury

Answer 26

full-thickness tissue loss - subcutaneous fat may be visible - epibole (rolled wound edges) may occur - may have undermining, tunneling - bone, tendon, muscle is NOT exposed

Question 27

Stage 4 Pressure Injury

Answer 27

full-thickness tissue loss w exposed or palpable bone, cartilage, ligament, tendon, fascia, or muscle -slough, eschar, epibole, undermining, tunneling may be present

Question 28

Deep Tissue Pressure Injury

Answer 28

persistent non-blanchable maroon/purple color

Question 29

Types of Wound Drainage

Answer 29

- serous drainage - sanguineous drainage - serosanguineous drainage - purulent drainage

Question 30

Serous Drainage

Answer 30

clear watery serous portion of blood fr serous membranes

Question 31

Sanguineous Drainage

Answer 31

large number of RBC + looks like blood | bright red=fresh, darker=older

Question 32

Serosanguineous Drainage

Answer 32

mixture of serum + RBC | -light pink to blood-tinged

Question 33

Purulent Drainage

Answer 33

WBC, liquefied dead tissue debris, both dead + live bacteria | -thick, musty/foul odor, dark yellow to green color depending on causative agent

Question 34

Open System Drains

Answer 34

1 Gauze | 2 Penrose

Question 35

Closed System Drains

Answer 35

1 Chest Tube 2 Hemovac 3 Jackson-Pratt 4 T-tube

Question 36

Gauze

Answer 36

allows healing fr base of wound | -gauze dressing packed loosely so wound is allowed to drain

Question 37

Penrose

Answer 37

drains blood + fluid open drainage systm consisting of soft rubber tube that provides sinus tract ex) drainage for abscess in ab surgery

Question 38

Chest Tube

Answer 38

mediastinal placement to drain blood - used after cardiac surgery - different fr chest tube used in pleural space

Question 39

Hemovac

Answer 39

neg-pressure suction device | -drains blood + fluid

Question 40

Jackson-Pratt

Answer 40

bulb suction device to drain blood + fluid

Question 41

T-tube

Answer 41

t shaped tube placed in the COMMON BILE DUCT | -collects bile after gallbladder surdery

Question 42

open vs closed wound care

Answer 42

open wound

Question 43

Wound Culture Collection

Answer 43

``` 1 assess for pain 2 prep items, adjust bed, position 3 remove old dressing w clean gloves 4 inspect COCA 5 doff gloves + HH 6 clean wound using NONantimicrobial cleanser 7 don clean gloves 8 obtain swabs on culturette tube 9 use area that is free fr necrotic tissue, apply sufficient pressure to express fluid ```