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Nursing Technologies > 4.2 Fundamentals of Skin Integrity/Wound Care > Flashcards

4.2 Fundamentals of Skin Integrity/Wound Care Flashcards

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
Assessment of Patient (cont)
- 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
Expected Outcomes of Wound Cleaning
- 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
Assessment to Prevent Injury
- 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
Assessment to Prevent Injury (cont)
Other Factors for Assessing Wound - Palpation for pain - Inspection of redness and exudate - Smelling odors related to infection
29
Drainage of Wounds
- 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
Assessment of Dressed Wound
- 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
Assessment of Open Wounds
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
Presence of Infection
- 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
Collection of Wound Culture
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
Wound Dressings
- 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
Types of Wound Dressings
- 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
Types of Wound Dressings (Telfa)
- 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
Types of Wound Dressing (Gauze)
- 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
Types of Wound Dressing (Transparent)
- 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
Securing Dressing
- 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
Roller Bandages
- 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
Circular Turn
- 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
Spiral Turn/Figure 8 turn
Spiral - Useful for wrist, fingers and trunk | Figure 8 - Used for joints. Makes oblique overlapping turns that ascend and descend alternatively.
43
Binders
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
Binders (cont)
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
Types of Drainage Systems (Penrose Drain)
- 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
Closed systems | Jackson Pratt Drain/Hemovac Drain
- 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
Changing Dressings
- 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
Wet to Dry Dressing Change
- 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
Central Line Dressing
- 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
Removing Staples/Sutures
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
Heat Therapy
- 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
Cold Therapy
- Constricts blood vessels, reduces muscle spasms, relieves pain. - Vasoconstriction reduces edema and inflammation - 60F for vasoconstriction
53
Sitz Bath
- 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
Sitz Bath Assessment
- 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
Electronically controlled cooling device
- 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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