Ch 32: Skin integrity and wound care Flashcards
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
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

What are the functions of the skin and mucous membranes
Barrier Sweat/shiver Body image touch Produced by sun Immune meds Excretions 
*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
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
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
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
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

Give a few examples regarding older age related changes
Sub q
Sweat
Melanocyte results
Tears
TThinning of subcutaneous tissues
decreased sweat gland activity (don’t bathe as much)
melanocytes ⬇️=⬆️ melanomas risks
collagen fibers disorganized increasing tears and irritation
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
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
Intentional V unintentional
Opened v closed wounds
Acute V chronic
What does a complex result from and how does it develop
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
Define: Incision contusion abrasion laceration puncture penetration avulsion
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
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
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

What are the phases of wound healing briefly describe each
Wound healing:
- Hemostasis: IMMEDIATE constriction of blood vessels and clotting
- Information: 2 to 3 days white blood cells move to wound
- Proliferation phase: several weeks new tissue built (granulation)
-  Maturation: collagen remodeled and scar
Give related information for hemostasis
What is hemostasis Give the definition What is formed? what are 3 characteristics What is simulated 
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
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 
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
Give all related information for the proliferation phase
How long does it last
Give the definition
What is formed and what does that form
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
Give all related information for the maturation phase of wound healing
Final: begins three weeks post injury ➡️for months and years
Definition: collagen remodeld (scar formed) scar becomes flat thin white
What are local factors affecting wound healing
Pressure Desiccation: dehydration Maceration: overhydration = breakdown of skin Necrosis edema
 what are systemic factors affecting wound healing
(Think overall body what do we do that we’re not conscious of in regards to wounds)
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
Define wound complications:
Infection hemorrhage dehiscence evisceration fistula
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
What do you do in the event there is dehiscence or evisceration
#1 get sterile towel moisturize with 0.9% normal saline/NaCl -Will keep organ moisturized and free of microorganisms
What is the definition of a pressure injury
why does it happen
What does it lead to
How do you prevent pressure injuries 
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
What is the main factor for pressure injuries
-what can this factor lead to

#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
What are other factors that lead to the development of a pressure injury
Rubbing
What prevents a person from being mobile
Moist
•Friction and shearing: two surfaces rubbing together
-WRINKLES IN SHEET!
- Chronic illness/ immobility/near muscular disorders due to bedbound
- Moisture fecal and urinary incontinence

 give the four stages of the pressure injuries +2 additional stages describe each
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
If you discover a pressure injury what must you do
What does the (PUSH) pressure ulcer scale for healing help do
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

What can pressure injuries cause
Pain
anxiety/fear
decrease in activity
change in body image
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
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
 describe the types of wound drainages
Serous
sanguinous
Serosanguinous
purulent
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
What is the purposes of wound dressings
Inf Drainage Bal Healing Protect
Eliminate, prevent, control infection
absorb drainage
Maintain balance of moisture in wound
simulate/optimize healing response
Protect from further injury

What are signs of infection
Swollen, deep red in color: hot increased drainage possibly purulent  ODOR Separated wound edges/dehiscence
What are figure 8 turns in bandages used for
Figure eights Used for more complicated wounds
Types of drainage systems
Open and closed systems
-Give an example of each and what they do and how they do it
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

What do heat and cold promote
What do heat and cool depend on
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
What is the affects of applying heat
Heat dilates peripheral blood vessels
- ⬆️ circulation
- ⬆️metabolism
- ⬆️capillary probability
- ⬇️ blood viscosity
Relaxes muscle tension relieves pain
What is the outcomes of promoting more circulation
We can generate new skin and have better injury outcomes with heat promoting circulation
What are three devices used to apply heat
Hot Water bags electrical heating pads hot packs warm moist conpresses sitz baths warm soaks
What are the effects of appkying cold
Constrict peripheral blood vessels
Reduces muscle spasm
Promote comfort
⬇️ pain and swelling
What are devices to apply cold
Ice bags/cold packs
Hypothermia blankets
Call converses
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
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

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
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
Give related nursing diagnosis for skin integrity and wound care
Disturbed body image
Deficient knowledge related to wound care
Impaired skin/tissue integrity
Risk for infection/impaired skin integrity
What are gonna do to prevent pressure injuries
What do we wanna avoid (2) Protect? Asses Turn Clean
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

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