C10- Integumentary Flashcards
Impaired skin integrity
Break or disruption of skin or tissues
Impaired skin integrity causes: (external)
Hyperthermia
Hypothermia
Chemical
Mechanical
Humidity/moisture
Radiation
Medication
Impaired skin integrity causes: (Internal)
Altered metabolic or nutrition state
Altered circulation
Sensation
Pigmentation
Immune deficit
Altered fluid status
Factors placing a person at risk for skin alterations
Age
Changes in health status
Therapeutic measures can cause skin problems
Lifestyle variables
Wound definition
Disruption or break in normal integrity of skin
Acute wound
Heal within days to weeks
Wound edges are well approximated
Chronic wound
Do not progress through the normal sequence of repair
Wound edges often not approximated
Normal healing time is delayed
Often remain in inflammatory phase of healing
Open wound
Occur from intentional/unintentional trauma
Skin surface broken (portal of entry for microorganisms)
Bleeding
Tissue damage
Increased risk for infection
Delayed healing
Closed wound
Occurs from a blow, force, or strain
Skin surface not broken
Soft tissue damage
Internal injury and hemorrhage may occur
Intentional wound
Result of planned invasive therapy or treatment
Wound healing process:
Skin reflects condition of body
Adequate blood supply
Proper nutrition
Primary intention
Wound edges are well approximated
Secondary intention
Edges not well approximated
Take longer to heal and often develop scar tissue
Tertiary intention
Wounds left open for several days to allow edema or infection to resolve
Or fluid to drain
Then they are closed
Local factors
Factors that occur directly in the wound
Ex: pressure, maceration, trauma, edema, infection, excessive bleeding, necrosis, biofilm
Systemic factors: definition and examples
Not related to wound itself but prolong wound healing
Ex: age, circulation and oxygenation, nutritional status, medications, health status, adherence to treatment plan
What type of organ is skin?
Sensory organ
Psychological effects of wounds?
Pain
Anxiety & fear
Changes in body image
What are the 4 phases of wound healing?
Hemostasis
Inflammatory
Proliferation
Maturation/Remodeling
Blood clotting, platelet activity, brief vasoconstriction and increased capillary permeability are actions of which phase of wound healing?
Hemostasis
How fast is the inflammatory response?
Immediate
Which cells may be activated in the inflammatory phase?
Leukocytes
Macrophages
Epithelial cells
What type of reaction does the inflammatory phase produce?
Generalized (mild fever, increase WBC, malaise)
How long does it take for proliferation to begin? How long does it last?
Within 2-3 days
Lasts 2-3 weeks
Common phrase associated with proliferation
“Fill the divot”
3 step associated with proliferation
Fibroblasts deposit fibrin
Blood flow reinstituted
Granulation tissue formed
When does Maturation/Remodeling begin? How long does it last?
Begins ~3 weeks
Lasts for months or years
Maturation/remodeling three steps
Collagen remodeled
More collagen deposited (compressing vessels)
Scar develops (avascular collagen)
Which “intention” takes the longest to remodel?
Secondary intention
Color classification system for wound beds (RYB)
Red=protect
Yellow=cleanse
Black=debride
Red wound bed color indicates?
Ready for healing and responding to treatment
Granulation tissue
Good wound bed
Yellow wound bed indicates?
Non-viable tissue needs debridement
Slough or tissue with poor blood supply
Black wound bed indicates?
Necrotic tissue (eschar)
DEBRIDE dead tissue
Peri-wound is defined as
Tissue surrounding the wound
What are we assessing for peri-wound skin?
Intact?
Color?
Characteristics
-erythema (redness around wound)
-induration (increase in fiber elements in tissue)
-inflammation
Exudate means?
Drainage
Terms defining the amount of exudate drainage coming out of the wound
Scant
Minimal
Moderate
Copious
Characteristics of exudate
Color
Odor
Type
Serous wound drainage
Clear, watery plasma
Purulent wound drainage
Thick, yellow, green, tan, or brown
Serosanguineous wound drainage
Pale, red, watery:
Mixture of serous and sanguineous
Sanguineous wound drainage
Bright red
Indicates active bleeding
Infection signs and symptoms my occur ________-______ days after inury
2-7 days
Infection produces an increase of:
Purulent drainage
Increased drainage
Pain
Redness and swelling (in and around wound)
Elevated temp and WBC count
Greatest risk for hemorrhage when?
In the first 48 hours after surgery
-check wound frequently (2X shift)
-look for hematoma
Hemorrhage treatment
Apply added pressure on the site and contact provider
Dehiscence is?
Partial or total separation of the wound layers
-suture line pops open
Evisceration is?
Complete separation and protrusion of the viscera and organs through incision
Abscess and fistula are formed by:
Collection of infected fluid not draining
-abnormal passage/tunnel (organ to skin)
This results from delayed healing
What four things would a nurse identify during a wound assessment?
Type of wound/cause
Appearance of wound
Stage of a pressure ulcer wound
Wound complications
Nurse would also assess (Pain, Vital signs, fever, labs)
R.I.C.E. Wound healing
R- rest
I- Ice/ immobilization
C- compression
E- elevation
** oxygenation and infection control **
What are pressure injuries?
Localized damage to the skin and underlying tissue that usually occurs over a bony prominence or is related to the use of a medical device
Who is at risk for pressure injuries?
Older adults
Spinal cord & brain/neurological injuries
Pressure injury assessment
Measure:
-size
Shape
Length and width
Unit label (inch, cm, mm)
Depth
-insert sterile moistened swab into wound
Measure depth on swab
Nursing management of pressure injuries
Assess/monitor healing process
Role of nutrition
Pain assessment/management
Support surfaces and positioning
Cleansing debridement and dressings
