Ch 32: Skin Integrity & Wound Care Flashcards
Braden Assessment Categories
- Sensory Perception
- Moisture
- Activity
- Mobility
- Nutrition
- Friction & Shear
What rating on Braden Assessment indicates at risk for pressure ulcers?
<18
Stage 1 Pressure Injury
skin is intact
nonblanchable redness
swollen tissue
darker skin (may appear blue/purple)
Stage 2 Pressure Injury
skin is NOT intact
partial thickness loss
no fatty tissue is visible
superficial ulcer
Stage 3 Pressure Injury
skin is NOT intact
full thickness SKIN loss
-damage to or necrosis of subQ tissue
-no bone, muscle, or tendon exposed
ulcer extend down to underlying fascia, but not through it
deep crater with or without tunneling
Stage 4 Pressure Injury
skin is NOT intact
full thickness TISSUE loss
-destruction of tissue
-bone, muscle or tendon exposed
deep pockets of infection and tunneling
Deep Tissue Injury (DTI)
skin is intact (unbroken)
tissue beneath the surface is damaged
appears purple or dark red
Unstageable Pressure Injury
stage cannot be determined due to eschar or slough covering the visibility of the wound
Serous Wound Drainage
primarily clear or straw in color
watery consistency
blister, superficial cut
Sanguineous Wound Drainage
contains RBCs
looks like blood
deep wounds, surgical wounds
Serosanguineous Wound Drainage
mixture of serum and RBCs
pink-tinged in color
thin and watery
sign of HEALING
Purulent Wound Drainage
made of WBCs, dead tissue debris, dead and living bacteria
brown, tan, green, yellow in color
thick milky consistency
considered an ABNORMAL finding (sign of INFECTION)
may also see fever, heat, swelling, redness, tender, increase pain
Abscess
collection of infected fluid that has not drained
Dehiscence
separation of layers of surgical wound
Desiccation
dehydration; process of being rendered free from moisture
Epithelialization
stage of wound healing in which epithelial cells form across the surface of a wound
Evisceration
protrusion of viscera through an incision
COMPLETE SEPARATION OF WOUND
Fistula
abnormal passage from an internal organ to the skin or from one internal organ to another
Granulation Tissue
new tissue that is pink/red in color and composed of fibroblasts and small blood vessels that fill an open wound when it starts to heal
red/beefy looking
Hematoma
localized mass of usually clotted blood
Ischemia
deficiency of blood in a particular area
Maceration
softening through liquid; OVERHYDRATION
Ecchymosis
bruising
Wound Healing Phases
- Hemostasis (bleeding, clear fluid, start of scabbing)
- Inflammatory Phase (acute inflammation)
- Proliferation Phase (granulation tissue forms)
- Maturation Phase (wound starts to look like adjacent tissue)
Wound Complications
Infection (bacteria enters wound area)
Hemorrhage (bleeding)
Dehiscence (splitting of wound)
Evisceration (complete separation of wound)
Fistula Formation
Dehiscence vs. Evisceration
D - separation or splitting open of layers of a surgical wound
E - extrusion of viscera or intestine through a surgical wound
Appearance of the Wound Characteristics
location
size (mm)
approximation of wound edges
peri-wound (around wound)
color
Wound Care/Dressing Changes
- Remove Dressing (gentle, edges first, pull in dir. of hair growth, stabilize skin while pulling tape back)
- Clean Wound (gentle, use mechanical/chemical force to remove debris, irrigate wound w/ what’s ordered)
- Apply Dressing (apply skin layer around wound (vaseline), ensure dressing is only on wound)
- Secure Dressing (self-adhesive (when possible), gauze roll, bandages, tape)
Dry Heat Therapy
bags of hot water
heating pads
hot packs
Moist Heat Therapy
warm washcloths
warm soaks
sitz bath (perineal area)
Dry Cold Therapy
ice bags
cold packs
frozen vegetables
Moist Cold Therapy
cool washcloths
lukewarm baths (soaks/sitz bath)
