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nursing technologies > 4.2 Fundamentals of Skin Integrity/Wound Care > Flashcards

4.2 Fundamentals of Skin Integrity/Wound Care Flashcards

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1
Q

Skin Functions

A
  • Protection from microorganisms
  • Body temperature regulation (constriction and dilation of blood vessels and raising hair for insulation)
  • Psychosocial changes (self esteem and appearance)
  • Sensation of touch, pressure, temperature
  • Vitamin D production
  • Immunologic processes when break in skin
  • Absorption of medications (local/systemic)
  • Elimination of water and electrolytes through perspiration
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2
Q

Causes of Alterations to Skin

A
  • Age causes decrease in resistance to injury due to loss of integrity of subcutaneous tissues.
  • Adequate nutrition, hydration, and circulation aids in health of skin cells and ability to resist injury
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3
Q

Causes of Alterations to skin

A
  • Thin/Obese more susceptible to skin injury
  • Fluid loss during illness causes skin dehydration
  • Skin appears lose and flabby
  • Excessive perspiration during illness predisposes skin to breakdown. Jaundice causes yellow itchy skin.
  • Disease of skin (eczema, psoriasis) cause lesions that require special care and may also open wounds from scratching
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4
Q

Types of wounds (Intentional/Unintentional)

A

Intentional
- Planned, carefully created for therapeutic purpose (Surgery)
- Wound edges are clean and come together easily
Unintentional
- Unplanned (accident/trauma)
- Jagged edges (do not come together easily)
- Higher chance of uncontrolled bleeding and infection

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5
Q

Open/Closed wounds

A

Open
- Wound edges are not approximate when treated
- Maybe left open due to significant tissue damage or to help clean wound and not trap infection under.
- Takes longer to heal.
Closed
- Trauma is under surface of skin (skin not broken)
- Ecchymosis (bruising) or hematomas.

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6
Q

Acute vs Chronic Wounds

A

Acute
- Heals quick (days to weeks)
- Edges well approximated and low risk of infection
Chronic
- Remain in inflammatory phase of healing and healing is delayed (More than 30 days)
- Healing delayed due to infection or issues with circulation

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7
Q

Partial/Full Thickness, Complex

A

Partial Thickness
- “Almost” all skin intact (loss of epidermis and dermis)
Full Thickness
- Skin, sweat glands, hair follicles gone. (subcutaneous)
- Muscle, bone, tendon exposed
Complex (Unstageable wound)
- So much damage to skin and deep tissues that true depth cannot be determined

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8
Q

Systemic Factors Affecting Wound Healing

A
  • Wounds heal fastest with good circulation and o2
    (Adequate blood flow is essential)
  • Children/Healthy adults heal faster than elderly
  • Nutrition (Protein) helps grow new tissue
  • Patients taking corticosteroids or post-op radiation therapy delay healing.
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9
Q

Wound Complications

A

Infection - Contamination of wound
Hemorrhage - Excessive bleeding at injury site
Dehiscence - Opening of wound after it has already partially healed. Due to poor tissue integrity or infection under scar.
Evisceration - Open wound with expulsion of organs (intestines)
Fistula Formation - Opening between 2 organs (ex. vagina and rectum if wound has not repaired properly)

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10
Q

Psychological Effects of Wounds

A

Psychological effects of wounds becoming worse or delayed healing

  • Increased pain
  • Anxiety/fear that wound will not get better
  • Inability for patient to continue ADL’s independently
  • Large wound/scar may alter self esteem
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11
Q

Phases of Wound Healing (Bleeding)

A

Hemostasis

  • Begins immediately after injury
  • Blood vessels constrict and clotting occurs using platelets. Surrounding tissue swell to stop bleeding.
  • Accumulation of tissues (exudate) cause redness and heat to the area.
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12
Q

Phases of Wound Healing (Inflammatory)

A
  • Begins 24 hours after damage occurs. (Lasts 2-3 days)
  • White blood cells (leukocytes) come to wound and ingest bacteria
  • Macrophages ingest cell debris to allow new epithelial cells to grow
  • Fibroblasts fill wound to allow cells to grow
  • Pain, heat, and swelling may occur at injury site
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13
Q

Phases of Wound Healing (Proliferation)

A
  • Begins after several days and lasts several weeks
  • Fibroblasts and collagen produced to reform blood vessels and endothelial cells.
  • Newly grown capillaries bring oxygen and nutrients to area and make new tissue (granulation tissue) (scar)
  • Time for granulation to fill wound depends on size
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14
Q

Types of Proliferation Healing

A

Primary Intention
- Edges are approximated and only small amount of granulation tissue needed
Secondary Intention
- Wounds edges are not approximated. Takes longer to heal as wound is open
Tertiary Intension
- Wound left open on purpose to drain

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15
Q

Phases of Wound Healing (Maturation)

A
  • Begins weeks after surgery and can continue for months
  • New collagen continues to grow and develop.
  • Scar thins and becomes normal tissue.
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16
Q

Local Factors Affecting Wound Healing

A
  • Pressure on skin can cause hypoxia, ischemia and eventually necrosis due to no blood flow in area
  • Avoid patients having pressure on one part of body
  • Medical devices can also cause pressure resulting in ulcerations
    (Oxygen tubing on back of ears, cast, or orthopedic devices).
  • Problem is averted by turning patient every 2 hours so blood returns to affected area.
  • Assessment of pressure points
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17
Q

Friction and Shear

A

Friction
- Can be caused by patient sliding against bed sheets
Shear
- One layer of skin sliding against another layer causing skin to separate.
- Blood vessels break and cause damage plus decreased blood flow to area.
- Happens when patients are dragged up in bed and skin sticks to sheet. Underlying tissue slump down in bed with body due to gravity.

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18
Q

Pressure Injury/Pressure Ulcer

A
  • First sign is blanching (paleness/whitening) of skin
    (under pressure and becomes ischemic)
  • As pressure continues area will become red which may fade if pressure is relieved
  • Dark skinned patients are difficult to assess. Heat is better determinant
  • If pressure and decreased blood flow continues, tissue damage will eventually occur.
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19
Q

Stages of Pressure Ulcers

A

Stage 1
Lightly pigmented. Nonblanchable erythema of intact skin
Stage 2
Partial thickness skin loss with exposed dermis
Stage 3
Full thickness skin loss not involving underlying fascia (connective tissue)
Stage 4
Full thickness and tissue loss
Unstageable
Obscured Full thickness and tissue loss

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20
Q

Deep Tissue Pressure Injury

A
  • Persistent nonblanchable deep red, maroon, or purple discoloration
    Factors contributing to pressure wound
  • Aging Skin, Chronic Illness, Immobility, Malnutrition, Fecal and Urinary Incontinence, Altered Level of Consciousness, Spinal Chord/Brain Injuries, Neuromuscular Disorders.
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21
Q

How to Prevent Pressure Injuries

A
  • Turn patient every 2 hours and assess areas patient was lying on. (Pay attention to skin with bony prominences)
  • Good hydration and nutrition to maintain skin integrity
  • Topical skin care and Incontinence management
  • Those who cannot move due to injury, neuromuscular disorders, or decreased consciousness are at greatest risk
  • Proper assessment of pressure points will prevent advancement of significant ulcers
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22
Q

Assessment of Pressure Sores

A
  • Size and depth of wound.
  • Presence of tunneling or sinus tracts.
  • Tools like Pressure Ulcer Scale for Heating 3.0 (PUSH)
  • Braden Scale
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23
Q

First Aid for Wounds

A

Step 1 - Control bleeding and allow hemostasis
- Punctures should be allowed to bleed to flush out pathogens.
- Do not remove penetrating objects
Step 2 - After hemostasis, do a basic clean from least contaminated area to surrounding skin.
- One swipe at a time with gauze saturated in NS or sterile water (New gauze each swipe)
Step 3 - Once clean dry area using gauze sponges in the same way
(Irrigation of wound is also done this way)
Step 4 - Bandage determined by time of wound
Report drainage or necrotic tissue

24
Q

Assessment of Patient

A
  • Assess situation and need for wound cleaning and dressing change. Confirm medical orders relevant to wound care
  • Assess patient comfort level and need for analgesics before wound care.
  • Assess current dressing (if there is one)
  • Assess excess drainage, bleeding, saturation of dressing, approximation wound edges, color of wound or surrounding area, and signs of dehiscence.
25
Q

Assessment of Patient (cont)

A
  • Assess for sutures, staples, or adhesive closure strips
  • Note stage of healing process and characteristics of drainage
  • Assess surrounding skin for color, temperature, edema, and ecchymosis (discoloration of skin) or maceration (skin broken down by moisture)
26
Q

Expected Outcomes of Wound Cleaning

A
  • Wound cleaned without contamination or trauma without damaging proliferative cells and newly formed tissues and without causing pain/discomfort
  • Wound shows progression of healing
  • Patient demonstrates understanding of need for wound irrigation.
27
Q

Assessment to Prevent Injury

A
  • Assess pressure points where blood circulation is decreased
  • Turn patient every 2 hours
  • Pad areas prone to pressure (elbows, hips, between knees, support body for proper alignment)
  • PUSH 3.0 and Braden Scale assess other factors contributed to injury (mobility, level of consciousness, moisture to skin, sensory perception, nutrition, friction/shearing)
28
Q

Assessment to Prevent Injury (cont)

A

Other Factors for Assessing Wound

  • Palpation for pain
  • Inspection of redness and exudate
  • Smelling odors related to infection
29
Q

Drainage of Wounds

A
  • Serous (Initial Bleeding)
  • Sanguineous (Bloody Discharge as Forming Clot)
  • Serosanguineous (Pink liquid of blood combined with fluid from surrounding tissue)
  • Purulent (Pus caused by infection)
  • Also check for sutures, staples, drains, manifestations of complications
30
Q

Assessment of Dressed Wound

A
  • If dressing on wound has drainage, outline and mark with date, time, and initials
  • Should always be re-assessed and re-marked
  • Stabilization of drainage may not need intervention but continuous drainage will need to be evaluated in detail
  • Surgical wounds with no dressing should be assessed for infection, approximation of edges and drainage.
  • Patient education (how to keep wound free from infection)
31
Q

Assessment of Open Wounds

A

Color of tissue indicates treatment necessary

Red - New blood vessels, dress and provide protection from further injury or infection
Yellow - Needs cleansing. Tissue is sloughing as it heals and needs to be removed to heal properly
Black - Necrotic tissue that needs debriding (removal)

Usually wounds are a mix of colors

32
Q

Presence of Infection

A
  • Wound is swollen
  • Wound is deep red
  • Wound feels hot on palpation
  • Drainage is increased and possibly purulent (pus)
  • Foul odor
  • Wound edges separated. Dehiscence (edges of wound no longer meet)
33
Q

Collection of Wound Culture

A

If wound is infected culture should be taken

  • Collect specimen before wound is cleaned
  • Obtained with cotton swab and placed in sterile tube
  • Strict Asepsis so pathogen in wound is isolated
34
Q

Wound Dressings

A
  • Provides physical/psychological/aesthetic comfort
  • Prevent/eliminate/control infection
  • Absorb drainage
  • Maintain moisture balance in wound
  • Protect wound from further injury
  • Protect skin surrounding wound
  • Debride (remove) damaged/necrotic tissue
  • Stimulate/optimize healing response
  • Ease of use and cost effective
35
Q

Types of Wound Dressings

A
  • First dressing removed in 24-48 hours
  • After time is determined by healing process
    3 TYPES OF DRESSINGS
  • Maintain moisture
  • Absorb moisture
  • Add moisture
    Number and type depend on location, size, type, depth of wound, presence of infection, need for debridement, and amount of drainage.
36
Q

Types of Wound Dressings (Telfa)

A
  • Non adherent dressing with shiny outer surface.
  • Used as absorbent material that does not stick to skin
  • Often used as first layer of dressing
37
Q

Types of Wound Dressing (Gauze)

A
  • Used for absorption and padding of wound
  • Can be applied directly to skin or on top of Telfa
  • Special pre-cut gauze used with peg tubes and tracheostomy.
  • Large padded dressing, Abdominal Pad (ABP) placed over small thin gauze to absorb drainage and protect wound
38
Q

Types of Wound Dressing (Transparent)

A
  • Transparent film, semipermeable and waterproof
  • Protects from contamination and ability to visualize wound
  • Used for peripheral IV sites, Central Venous lines, and healing wounds
39
Q

Securing Dressing

A
  • Bandages/Binders apply pressure for hemostasis (stop bleeding and repair damage)
  • Tape can be used to secure around the edges of a dressing that needs to be changed frequently
  • Large wounds that need to be changed frequently, removing tape can damage skin so bandages and binders are used
40
Q

Roller Bandages

A
  • Continuous strip of material wound onto itself
  • Gauze, elastic webbing, stretchable bandage
  • Hold with free hand and roll bandage around body with equal tension
41
Q

Circular Turn

A
  • Used to anchor a bandage.
  • Wrap bandage around, completely overlapping previous bandage turn.
  • Once circular turn anchors the bandage continue to ascend in spiral manner
42
Q

Spiral Turn/Figure 8 turn

A

Spiral - Useful for wrist, fingers and trunk

Figure 8 - Used for joints. Makes oblique overlapping turns that ascend and descend alternatively.

43
Q

Binders

A

Slings - Supports arm, folded triangle that ties behind neck
Straight Binders - Large pieces of material with support. Either pinned or Velcroed. Typical around chest/abdomen. When applying elastic bandage, check extremities for temperature/sensation change.

44
Q

Binders (cont)

A

T Binders - Used to secure dressing on rectum, perineum, and groin. Single T Binder for females, double T Binder for Males.
Montgomery Straps - Uses ties attached to adhesive backing to hold dressing in place
Abdominal Binder - Goes around abdomen.

45
Q

Types of Drainage Systems (Penrose Drain)

A
  • Hollow, soft, flexible, open ended rubber tubes used after surgery to allow fluid to drain passively via capillary action into absorbent dressing.
  • Held in place by safety pin placed on part outside of wound. (Prevents drain from slipping into body)
  • Patency and placement is assessed for this drain
46
Q

Closed systems

Jackson Pratt Drain/Hemovac Drain

A
  • Promotes healing through constant, controlled, uniform, low pressure suction to wound surface after surgery.
  • Results in reduction of bacteria and removal of excess fluid while providing moist wound healing environment.
  • Negative pressure on wound stimulates cell proliferation, increased blood flow to wound, and allows for growth of new blood vessels.
  • Assessment includes volume and character of drainage fluid every shift. Provider should be notified of abrupt changes in amount or color.
47
Q

Changing Dressings

A
  • Patients with large wounds may need pain medication before dressing change
  • ## Describe what will happen step by step and answering questions will alleviate anxiety.
48
Q

Wet to Dry Dressing Change

A
  • Removes drainage/necrosis from wound
  • Remove old dressing (make sure to count amount of gauze) Drop old dressings in RED BAG
  • Leaving gauze in can breed infection
  • After this, setup sterile field
  • When pouring liquids into container, ask partner to pour. Otherwise you can unglove, poor, and reglove
  • Clean from cleanest to dirtiest (middle of wound to outside)
  • Pack wet gauze (NS) into wound. Do not want to be super saturated
  • Pack dry gauze on top and then cover with ABD Dressing (Blue Line on Outside)
49
Q

Central Line Dressing

A
  • Very important to keep sterile because goes straight to heart
  • Patient needs a mask on as well as you
  • Take dressing off with regular clean gloves
  • Use swab to clean at insertion side then move outward then let it dry
  • Use sponge (chlorhexidine) for 30 seconds
50
Q

Removing Staples/Sutures

A

Sutures
- Grab knot of suture and pickup
- Cut suture close to skin on one side and pickup
(avoids bacteria from suture being pulled under skin)
Staples
- Use staple removing tool and snap in middle. 2 prongs underneath and 1 prong on top.
(After removal use sterile strips to hold suture and staples together)
- Patients can wash over strips and they are removed usually in 2-3 days.

51
Q

Heat Therapy

A
  • Assess for burns or tissue damage with prolonged use
    Heat application
  • Dilates peripheral blood vessels, increases metabolism, reduces blood viscosity, reduces muscle tension, relieves pain.
  • Vasodilation increases blood flow, oxygen, and nutrients to an area and removes waste.
  • Maximum effect time 20-30min
  • Applied by moist and dry methods.
52
Q

Cold Therapy

A
  • Constricts blood vessels, reduces muscle spasms, relieves pain.
  • Vasoconstriction reduces edema and inflammation
  • 60F for vasoconstriction
53
Q

Sitz Bath

A
  • Bowl of warm water to sit on.
  • Heat therapy to perineum or rectum
  • Put tube at bottom of bowl
  • Fill bowl with warm water
  • Clamp tube of bag closed.
  • Fill bag with warm water
  • Sit down and release clamp.
54
Q

Sitz Bath Assessment

A
  • Can patient ambulate to bathroom and maintain sitting position for 15-20 minutes
  • Inspect perineal/rectal area for swelling, drainage, redness, warmth, and tenderness
  • Assess bladder fullness and encourage patient to use bathroom before
55
Q

Electronically controlled cooling device

A
  • Constant cooling effect
  • Used for post-op patients and acute musculoskeletal injuries
  • Medical order required
  • Initial assessment of extremities involved and ongoing.
  • Ongoing monitoring of proper function and temperature regulation is necessary.

nursing technologies (17 decks)

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