Ch 32: Skin integrity and wound care Flashcards

1
Q

What is the skin in reference to infection

What does a skin integrity protect from

What is contained within the dermis

What does the subcutaneous tissue contain more of and what does it ensure

A

The skin is the first line of defense

The skin integrity protects from potential or life-threatening conditions

Within the dermis we have

  • nerves
  • sweat glands
  • sebaceous glands
  • hair follicles

subcutaneous tissue:
-contains more circulation V dermis
-ensures nutrients for healthy skin and hair


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2
Q

What are the functions of the skin and mucous membranes

Barrier
Sweat/shiver
Body image
 touch
Produced by sun
Immune 
meds 
Excretions

A

*Protect: barrier V water microorganisms damaging UV rays

Temperature regulation: sweat/shiver

Psychosocial: self-esteem

sensation

vitamin D production: stimul by sun

immunologic : triggers immunological responses when been broken

absorption: meds
* *elimination: excrete water, electrolytes, and nitrogenous wastes in sweat

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3
Q

Within factors that affect the skin:
how do we defend against harmful agents

what is resistance affected by and how

why must we ensure intake in healthy diet

what type of circulation is needed

A

Unbroken and healthy skin/mucous membranes defend v harmful agents

Resistance to injury affected by age: loss of collagen

Ensuring intake and healthy diet to be resistant the injury

Adequate circulation needed to meeting cell life

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4
Q

What is the skin of someone who is younger than 2YOA look like

What does the skin become with age

As we age what is attributed to easily damaged skin (tears)

 what does impaired circulation and collagen formation lead to

A

Skin is thin and weak leading to high risk of infection due to easily injured

Child can becomes increasingly resistant to injury infection with age

With age: epidermal cell Maturation is prolonged leading to easily damaged skin

Circulation and collagen formation impaired = ⬇️ elasticity ⬆️ tissue damage from pressure

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5
Q

Give a few examples regarding older age related changes

Sub q
Sweat
Melanocyte results
Tears

A

TThinning of subcutaneous tissues

decreased sweat gland activity (don’t bathe as much)

melanocytes ⬇️=⬆️ melanomas risks

collagen fibers disorganized increasing tears and irritation

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6
Q

Who is most susceptible to skin injuries

Define a wound

What is the difference between mechanical and physical injuries

What does care of a wound depend on

A

You’re very thin and obese patients most susceptible to injury

 wound: breaker destruction in normal skin integrity

Mechanical: surgical incision
physical injury: burn

Care of wound depends on wound type

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7
Q

Intentional V unintentional

Opened v closed wounds

Acute V chronic

What does a complex result from and how does it develop

A

Intentional: planned/invasive therapy
Unintentional: trauma accident

Opened: skin surface broken

closed: soft tissue damaged
- from blow

Acute: short
Chronic: over three months

Complex: results from multiple things gets progressively worse

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8
Q
Define:
Incision 
contusion 
abrasion 
laceration
 puncture 
 penetration 
avulsion
A

Incision : Aligned wound edges
contusion : Bruise with blunt instrument
abrasion : scraping of epidermal skin
laceration: tear in skin and tissue 🚫aligned
puncture :
penetration : For an object entering skin in lodging
avulsion: tearing of structure from natural position

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9
Q

What is the most important principle of wound healing how does a body respond to trauma to any of its parts

What kind of blood flow is essential for wound healing

What health states may prolong healing

A

Wound healing #1 hand hygiene!!

Body responds systematically to trauma

Ensure adequate blood flow proper nutrition (⬆️ proteins)for wound healing 

Diabetics and her problems me prolong healing



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10
Q

What are the phases of wound healing briefly describe each

A

Wound healing:

  1. Hemostasis: IMMEDIATE constriction of blood vessels and clotting
  2. Information: 2 to 3 days white blood cells move to wound
  3. Proliferation phase: several weeks new tissue built (granulation)
  4.  Maturation: collagen remodeled and scar
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11
Q

Give related information for hemostasis

What is hemostasis
Give the definition
What is formed? 
what are 3 characteristics
What is simulated 
A

Hemostasis = immediate

Definition: blood vessels constrict blood clotting begins,
Exudate formed with  swelling and pain, red

Platelets stimulate cells to migrate and participate in other phases

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12
Q

Give over related information for the inflammatory phase

How long does it last
Give definition
What is ingested what is released
 what is the body response

A

Lasts 2 to 3 days

Definition: white blood cells (leukocytes/macrophages) moved to wound

White blood cells ingest debris released growth factor that attracts fibroblast to fill wound

:think inflammation: GENERALIZED BODY RESPONSE 

  • fever/chills
  • fatigue
  • malaise
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13
Q

Give all related information for the proliferation phase

How long does it last
Give the definition
What is formed and what does that form

A

Lasts several weeks

Definition: new tissue built to fill wound by fibroblasts

Granulation tissue (pink) forms foundation for scar tissue 
-New tissue new blood cells
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14
Q

Give all related information for the maturation phase of wound healing

A

Final: begins three weeks post injury ➡️for months and years

Definition: collagen remodeld (scar formed) scar becomes flat thin white

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15
Q

What are local factors affecting wound healing

A
Pressure
Desiccation: dehydration
Maceration: overhydration = breakdown of skin
Necrosis
 edema
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16
Q

 what are systemic factors affecting wound healing

(Think overall body what do we do that we’re not conscious of in regards to wounds)

A

Age: children healthy adults more rapidly

Circulation oxygenation
-if no blood flow there is a wound healing delay

Nutritional status

Wound etology: affects wound processes

Health status
-cortical steroids/radiation delay healing
-non-adherence to treatment plan

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17
Q

Define wound complications:

Infection
 hemorrhage 
dehiscence
 evisceration
 fistula
A

Infection: failure of immune system to control microorganisms

Hemorrhage: hematoma (bleeding)

***Dehiscence: partial or total separation of wound layers due to stress
on wound

***Evisceration: wound completely separates leads to protrusion of vicera (orgs)

Fistula: infection that develops into an abscess where internal protrudes from skin by pressure

18
Q

What do you do in the event there is dehiscence or evisceration

A
#1 get sterile towel moisturize with 0.9% normal saline/NaCl
-Will keep organ moisturized and free of microorganisms
19
Q

What is the definition of a pressure injury

why does it happen

What does it lead to

How do you prevent pressure injuries 

A

Pressure injury: LOCALIZED Damage to skin and underlying tissue over bony prominence
-May be related to medical device

Occurs due to the compression of soft tissue and bony prominence for prolonged period of time

Lead to:

  • Decreased comfort/disfigurement
  • decreased QOL
  • healthcare expenditures

Turn the patient every two hours to prevent pressure injuries

20
Q

What is the main factor for pressure injuries
-what can this factor lead to

A
#1!!! External pressure
\:weight is not evenly distributed  over small area of bony prominence without Cushing

External pressure leads to colon

  • ischemia
  • hypoxia
  • edema
  • inflammation
  • necrosis
  • ulcer
21
Q

What are other factors that lead to the development of a pressure injury

Rubbing
What prevents a person from being mobile
Moist

A

•Friction and shearing: two surfaces rubbing together
-WRINKLES IN SHEET!

  • Chronic illness/ immobility/near muscular disorders due to bedbound
  • Moisture fecal and urinary incontinence



22
Q

 give the four stages of the pressure injuries +2 additional stages describe each

A

Stage 1: intact skin non-blanchable

Stage 2: partial thickness( to dermis) blister to

Stage 3: full thickness to subcutaneous layer

Stage 4: full thickness to muscle or bone, tunneling slough eschar

Unstageable: full thickness full of eschar looks like necrosis (black)

Deep tissue pressure injury: intact but non-blanchable DEEP red/maroon/purple
-very deep injury

23
Q

If you discover a pressure injury what must you do

What does the (PUSH) pressure ulcer scale for healing help do

A

If you discover a pressure injury you must measure the injury

  • Size: width and length
  • depth: use sterile cotton swab Measure on swab
  • follow tunneling or undermining

The (PUSH)
Guides measurements and help categorize pressure injuries



24
Q

What can pressure injuries cause

A

Pain
anxiety/fear
decrease in activity
change in body image

25
Q

How do you clean a pressure injury/wound

-when do you clean it
-what do you use and what direction do you go in/ drying
-What liquid is used
-
What do you want to report

A

Clean with each dressing change

New gauze each wipe from top to bottom
-or center to out

Normal Saline to irrigate and clean

Dry top to bottom with gauze sponge

report drainage and necrotic tissue

26
Q

 describe the types of wound drainages

Serous
sanguinous
Serosanguinous
purulent

A

Serous : clear serum portion of blood
-watery

sanguinous: Red like blood large amounts of RBC
-bright: fresh:: dark: old

Serosanguinous: Make sure of serum and red blood cells
-PINK

purulent: sick liquefied dead tissue debris, white blood cells,
- indicates dead and live bacteria

27
Q

What is the purposes of wound dressings

Inf
Drainage
Bal
Healing
Protect
A

Eliminate, prevent, control infection

absorb drainage

Maintain balance of moisture in wound

simulate/optimize healing response

Protect from further injury


28
Q

What are signs of infection

A
Swollen, 
deep red in color: hot 
increased drainage possibly purulent 
ODOR
Separated wound edges/dehiscence
29
Q

What are figure 8 turns in bandages used for

A

Figure eights Used for more complicated wounds

30
Q

Types of drainage systems
Open and closed systems
-Give an example of each and what they do and how they do it

A

Open: Penrose drain
-an increase risk of infection due to opening of tube to the environment

Closed system: uses (-) PRESSURE
•Jackson-Pratt drain: ball that sucks drainage
must drain in 1 to 2 days
Stop straining if fool

•Hemovac: accordian relieves pressure and drainage from patient


31
Q

What do heat and cold promote

What do heat and cool depend on

A

Heating Cold promote wound healing

Heat and cold depend on:

  • method and ration
  • degree of temperature
  • age and physical condition
  • amount of body surface covered in application
32
Q

What is the affects of applying heat

A

Heat dilates peripheral blood vessels

  • ⬆️ circulation
  • ⬆️metabolism
  • ⬆️capillary probability
  • ⬇️ blood viscosity

Relaxes muscle tension relieves pain

33
Q

What is the outcomes of promoting more circulation

A

We can generate new skin and have better injury outcomes with heat promoting circulation

34
Q

What are three devices used to apply heat

A
Hot Water bags 
electrical heating pads 
hot packs 
warm moist conpresses
 sitz baths
 warm soaks
35
Q

What are the effects of appkying cold

A

Constrict peripheral blood vessels
Reduces muscle spasm
Promote comfort
⬇️ pain and swelling

36
Q

What are devices to apply cold

A

Ice bags/cold packs
Hypothermia blankets
Call converses

37
Q

Describe the color classification of open wounds and what we must do in relation to the color

What is treated first as most severe what a treated last

What do mixed wounds contain

A

RYB
R= red ➡️we must protect (gently cleanse)
Y= yellow ➡️we must cleanse (purulent)
B = black ➡️debride

Black is most severe treated first red least severe treated last

Mixed wounds contain components of red yellow and black


38
Q

What is the most important assessment during the pressure injury assessment

In a pressure injury assessment what else do we look for
-move?
Nutrution
Labs 
Moist?
Existing
Pain
A

Most important: Braden/Norton scale
-sensory perception, activity, mobility, nutrition, moisture, friction shearing

 other assessments we look for:
-mobility WE CAN MOVE PT IF PT CANT 
-nutritional status
• albumin, pre-albumin, lymphocytes count, hemoglobin A-1 C, glucose
-Moisture and incontinence
-existing pressure injuries
• if already have one pressure injury patient is at an increase risk for developing another
-pain assessment :
•patient will move in pain increasing risk for pressure injury

39
Q

Give related nursing diagnosis for skin integrity and wound care

A

Disturbed body image
Deficient knowledge related to wound care
Impaired skin/tissue integrity

Risk for infection/impaired skin integrity

40
Q

What are gonna do to prevent pressure injuries

What do we wanna avoid (2)
Protect? 
Asses
Turn 
Clean
A

DO NOT MASSAGE RED/ BONEY PROMINENCES

  • Minimize skin injury from friction sheering
  • protect skin from moisture
  • assess nutritional status (protein and calories)

Turn the patient every two hours

Assess/ clean skin routinely

41
Q

What are things you want to teach patience for pressure injuries at home

A

At home teach patients #1 intervention is handwashing

How to care for wounds/signs and symptoms to be alert for

Change positions frequently

Monitor fecal and urinary status