Ch 32 Skin integrity/Wound care Flashcards
1
Q
How to treat venous ulcers?
A
Treat wound with compression bandages
2
Q
How to treat arterial ulcers?
A
- Surgical removal of blockage
- Low cholesterol diet
3
Q
Factors affecting Skin Integrity:
A
- State of health
- Immobility (friction and shearing = bed linens)
- Incontinence
- Decreased sensory perception
- Poor nutrition (low level albumin –> edema because fluid is not retain in vessels)
- Peripheral vascular disease
- Diabetes
- Dehydration
- Skin moisture (vitamin C is essential to skin elasticity)
4
Q
People at greater risk for Skin Breakdown?
A
- Children < 2 years old
- Older adults
- Thin patients
- Obese patients
5
Q
Incision
A
Cutting or sharp instrument: wound edges in close approximation and aligned.
6
Q
Contusion
A
Blunt instrument:
- overlying skin remains intact,
- w/ injury to underlying soft tissue
- possible resultant bruising and hematoma
7
Q
Abrasion
A
Friction, rubbing or scraping epidermal layer
8
Q
Laceration
A
Tearing of skin
- w/ blunt or irregular object
- often w/ loose flaps of skin
9
Q
Puncture
A
Blunt or sharp instrument puncturing skin, intentional or accidental.
10
Q
Penetrating wound
A
Foreign object entering the skin or mucous membrane and lodging in underlying tissue - possible scattered fragments
11
Q
Avulsion
A
Tearing a structure from normal anatomical position
- possible damage to blood vessels, nerves and other structures.
- Vitamin B essential for nerve function
12
Q
Microbial
A
Secretion of exotoxins or release of of endotoxins by living organisms.
13
Q
Chemical
A
Toxic agents such as drugs, alcohols, metals and substances released from cellular necrosis.
14
Q
Thermal
A
High/low T *, cellular necrosis as a possible result.
15
Q
Irradiation
A
Ultraviolet light or radiation exposure.
16
Q
Pressure ulcers
A
Compromised circulation secondary to pressure combined w/ friction.
17
Q
Venous ulcers
A
Injury or poor venous return, resulting from incompetent valves or obstructions.
18
Q
Arterial ulcers
A
Injury and underlying ischemia resulting from atherosclerosis or thrombosis.
19
Q
Diabetic ulcers
A
Injury and underlying diabetic neuropathy, peripheral arterial disease, diabetic foot structure.
20
Q
Wound Classifications:
1) Intentional
A
Surgical (planned, clean, low risk of infection)
21
Q
Wound Classifications
2) Unintentional
A
Accidental (contamination and infection are likely)
–> delay healing
- If skin is not broken, internal injury –> risk of internal hemorrhage = ecchymosis and hematomas
22
Q
Other Wound Classifications:
A
Open = portal of entry, can be unintentional or intentional
Closed = damaged soft tissue
Acute = heals w/out difficulty - low risk of infection
Chronic = does not heal - high risk of infection
Skin thickness loss
23
Q
What is desiccation?
A
Process of a wound drying up –> causes a crust over the wound site (localized dehydration)
24
Q
What is maceration?
A
Over hydration of the cells related to fecal or urinary incontinence that can lead to impaired skin integrity.
25
What is "Primary Intention"?
- Clean
- Approximated edges
- Little tissue loss
- Minimum scaring
- Wound closure performed with SUTURES, staples or adhesive
26
What is "Secondary Intention"?
- Edges not proximate
- Form granulation tissue
- Surgeon may pack wound w/ gauze or use of drainage system
- Longer healing
- More scar tissue
* Often are large open wounds caused by trauma.
27
What is "Tertiary Intention"?
- Wound is purposely left OPEN
| - Cleaned, debrided, observed before closure (heart surgeries)
28
Phases of Wound Healing:
| 1) Inflammatory
- 0 to 4-6 days
- pain, heat, redness and swelling (s x s)
- phagocytosis (leukocytes and macrophages)
- epithelialization
S x S:
- elevated T *
- increase in WBCs
- generalized malaise
29
Phases of Wound Healing:
| 2) Proliferation
- phase begins w/in 2 or 3 to day ~ 21
- new tissue is formed by fibroblasts
- granulation and revascularization
- wound becomes lighter in color
- systemic symptoms disappear
- HIGH need of adequate nutrition, oxygen, prevention of strain of wound tissue.
30
Phases of Wound Healing:
| 3) Maturation
- day 21 to 1-2 years (ex: burn victims)
- collagen deposition and remodeling
- scar tissue becomes smaller
- keloid scars (hyper reaction of scaring)
31
What cell count increases during a viral infection?
Lymphocytes
* Monocytes help remove bacteria w/ in 12 h.
- If leukocyte shift to the R --> Viral
- If leukocyte shift to the L --> Bacterial
32
What is "Dehiscence"?
Partial or total separation of wound layers as a result of excessive stress on wounds that are not healed yet.
* Once dehiscence occurs, wound is treated as an open wound.
- -> Cover w/ sterile 0.9% NaCl and notify physician!
33
What is "Evisceration"?
The wound completely separates w/ protrusion of viscera through incisional area.
* If dehiscence or evisceration occur on an abdominal wound = Emergency!!
Place pt in low Fowler's
34
How do wound complications manifest themselves as?
1) Infection:
- occurs w/in day 2-7
- S x S = purulent drainage, increase drainage, pain, redness, swelling, ^ Temp and WBCs
2) Hemorrhage
3) Dehiscence
4) Evisceration
5) Fistula formation= internal organ passage to the outside of body
35
Wound complications can cause:
- healing DELAY
- risk of infection
- fluid and electrolyte imbalance
- skin breakdown
36
What is "Hyperemia"?
Blanchable reddening of the skin that occurs when pressure is removed. * Not a pressure ulcer.
--> usually fades w/in 60-90 min after repositioning
37
Braden Scale risk levels:
```
19-23 Not at risk
15-18 Low risk
13-14 Moderate risk
10-12 High risk
< or = 9 Very high risk
```
38
Stage I Pressure ulcer characteristics:
```
Intact skin w/ nonblanchable redness of a localized area usually over a bony prominence.
S x S =
- pain
- firm
- soft
- warm
- cooler
```
39
Stage II Pressure ulcer charecteristics:
Involves partial thickness loss of dermis presenting as a shallow open ulcer w/ a red pink wound bed, w/out slough.
Can be shiny or dry and can also present as an intact or open/rupture serum-filled blister.
40
Stage III Pressure ulcer characteristics:
Presents w/ full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but bed wound is still present.
--> may include undermining and tunneling.
41
Stage IV Pressure ulcer characteristics:
Involves full thickness tissue loss w/ exposed bone, tendon, or muscle. Slough or eschar may be present on some part of the wound and often include undermining and tunneling.
42
Unstageable Pressure ulcer characteristics:
The base if the ulcer is covered by slough (yellow, tan, grey, green or brown) and/or eschar (tan, brown or black) in the wound bed, which makes the depth of the wound impossible to measure until debridement.
43
Lab values indicating pt at risk for pressure ulcers:
Albumin: < 3.2 mg/dL (norm 3.5-5.5)
Prealbumin: < 19 mg/dL (norm 16-40)
Glucose: > 120 mg/dL (norm 70-120)
Lymphocytes: < 1800/mm3 (norm 1000-4000)
44
Assessment for Skin Integrity:
- Mobility
- Nutritional status
- Moisture and incontinence
- Braden scale score
45
RYB Open Wound Classification:
```
RED = Proliferative stage of healing
YELLOW = Presence of exudate or slough
BLACK = Presence of eschar --> necrosis
```
46
What is drainage?
The formation of exudate resulting from the inflammatory response, and which drains from the wound.
47
Types of drainage (exudate):
- Serous = composed primarily of the clear serous portion of the blood and from serous membranes --> clear and watery
- Sanguineous =consists of large # of RBCs and looks like blood
- Serosanguineous = mixture of serum and RBCs --> light pink
- Purulent = made up of WBCs, liquified dead tissue debris, and both dead and live bacteria.
48
Common types of drains:
| 1) Penrose
Open drainage system:
| - Provides sinus tract --> after incision and drainage of abscess in abdominal surgery.
49
Common types of drains:
| 2) T-tube
For bile drainage --> after gallbladder surgery
50
Common types of drains:
| 3) Jackson-Pratt (JP)
Closed drainage system:
| - Decrease dead space by collecting drainage --> after breast removal, or abdominal surgery.
51
Common types of drains:
| 4) Hemovac
Closed drainage system:
| - Decrease dead space by collecting drainage --> after abdominal or orthopedic surgery.
52
Common types of drains:
| 5) Gauze, iodoform gauze, Nugauze
Allow healing from base of wound --> infected wounds, after removal of hemorrhoids as well.
53
Wound Assessment:
- Drainage = color, amount, consistency, odor, type of exudate
- Pain = administer pain medication if necessary
- Closure material = sutures, staples, fibrin sealant
- Drains/ tubes = open drains (Penrose), closed drains (JP, Hemovac), wound pouch, vacuum-assisted closure (wound VAC)
- Vital signs, lab values
- Patient response
54
What does an open drainage system do?
Promotes drainage passively, empties into absorptive dressing.
Ex: Penrose drain
55
What does a closed drainage system do?
Collects drainage by connecting to a reservoir to maintain constant low suction.
Ex: JP and Hemovac
56
Dehiscent wound dressing requires?
Sterile practice when changing dressing, with sterile 0.9% NaCl
57
Regular wounds require?
Standard precautions and use of sterile 0.9% NaCl.
58
What is an important key in wound care?
Keep a moist environment to promote the best healing possible, and avoiding window panning dressing to allow air contact.
59
What are a few key points in taping guidelines in regards to dressings?
- Use porous hypoallergenic tape
- less is best
- DO NOT occlude air circulation unless contraindicated
- Avoid frequent removal
60
When should a dressing be changed?
- When ordered
- When wet through
- When medication or special agent no longer effective
61
What type of wound is the "No touch technique" applied?
- Low risk wounds
- Stable wounds
- Chronic wounds
62
What should be documented when changing a dressing?
- any drainage (kind, amount...)
- wound appearance
- presence of drains
- dressing material used
- tape/binder used
- surrounding skin appearance
- patient response
* Complicated wound care should be detailed on care plan
63
What is the proper way to apply bandages?
Distal to proximal (away from heart to closest to heart)
64
What are a few necessary assessments that need to be performed by the nurse, when using bandages and binders?
- assess for pain and edema
- perform a neurovascular check distally
- replace soiled/damp bandages promptly
65
What regulates the body T *?
Hypothalamus
66
Effects of heat therapy?
- vasodilation which dissipates heat
- accelerate inflammatory response (faster delivery of leukocytes and nutrients)
- also increases tissue metabolism
- pain relief (as well as chronic pain)
- decrease of venous congestion
- decrease of blood viscosity, muscle tension and spasms
- treat infections, surgical wounds, inflamed tissue, arthritis
67
Important guidelines about heat therapy?
- MD order
- max temperature 105-110* F (all ages)
- max time of 20-30 min per application
* Caution with "Rebound Phenomenon" if kept longer than 45 min!
68
What are the different types of heat sources?
| 1) Dry heat
- hot water bags
- electric pads
- aqua thermos pads (K pads)
- heat lamps (pressure ulcers)
- hot packs ("crack")
69
What are the different types of heat sources?
| 2) Moist heat
- sterile warm compresses --> will promote circulation and reduce edema if elevated (max 30 min)
- Sitz baths --> good for hemorrhoids (15-20 min)
- warm soaks - may need sterile tubs (15-20 min)
70
Effects of cold therapy?
- vasoconstriction
- decrease of blood flow, muscle spasms
- decrease pain and edema
- increase coagulation at wound site = decreases bleeding
- treats trauma, muscle sprains, chronic pain syndrome
71
Important guidelines about cold therapy:
- MD order
- coldest temperature is 15 * C (60* F)
- limit exposure to 20-30 min
- WAIT 1 hour before reapplication
* Caution w/ "Rebound Phenomenon" --> tissue injury, vasodilation, increase BP
72
What are the different types of cold sources?
| 1) Dry cold
- ice bags - 30 min on, 1 h off
- cold packs
- hypothermia blankets - pad or blanket that circulates cool fluid
73
What are the different types of cold sources?
| 2) Moist cold
- cold compresses
| - on for 20 min, repeat every 2-3 hours
74
Nursing considerations for heat and cold therapies?
- Review MD order
- Explain procedure to pt
- Consider pre-analgesia
- Use correct T *!
- Monitor time
- Assess skin FREQUENTLY and patient response
75
Unexpected situations and associated interventions?
| 1) Wound description is not accurate w/ previous documented assessment
- Assess pt for S x S of pain, malaise, fever, and parasthesia
- Report abnormal findings to physician
- Document event in patient's record
- Obtain wound culture (if wound became purulent)
- Implement any changes to wound care
76
Unexpected situations and associated interventions?
| 2) When removing pt's dressing, the assessment reveals presence of eschar:
- Notify wound care specialist (different care might be needed or debridement)
- eschar must be removed (unless on heels) for proper staging of wound
77
Unexpected situations and associated interventions?
| 3) Wound dressing is dry upon assessment
- Reduce time intervals between dressing change
| * Caution to not delay wound healing
78
Unexpected situations and associated interventions?
| 4) Patient experiences pain
- Stop procedure and administer an analgesic as ordered
- Assess pain level
- Document so analgesic will be administer prior to dressing change
79
Unexpected situations and associated interventions?
| 5) Wound is bleeding upon assessment
- Stop procedure
- Assess pt for other S x S
- Obtain vital signs
- Report findings to physician
- Document event in pt's record
80
What is Negative-pressure wound therapy used for? (NPWT)
It promotes wound healing and wound closure through application of negative pressure on the wound bed, often used to treat wounds failing to heal such as pressure ulcers, arterial, venous and diabetic ulcers.
* NPWT is NOT used when presence of active bleeding, wounds w/ exposed blood vessels, organs or nerves.
80
What is a transparent dressing used for (Tegaderm)?
- Used for wounds w/ minimal drainage
- Allows exchange of oxygen btw wound and environment
- Protects against contamination (waterproof)
80
What is a Hydrocolloid dressing used for?
- Used for partial and full thickness wounds
- Minimal to moderate absorption of drainage
- Maintain a moist wound environment
- Occlusive or semi-occlusive limiting exchange of oxygen
80
What are Hydrogels used for?
- Necrotic wounds
- Minimal absorption of drainage
- Facilutate auto lyric debridement
80
What are Alginates used for?
- Infected and non-infected wounds, tunneling wounds
- Absorb exudate
- Maintain a moist environment
- Requires secondary dressing
80
What are foams used for?
- Used for wounds w/out eschar
- Maintain moist environment
- Do not adhere to wound
- Highly absorbent
- Used around tubes and drains
80
What would be a contraindication for use of cold therapy on an injury?
Diabetes
81
Scenario = The RN walks in her patient's room and finds the patient's JP drain on the floor. What is the FIRST thing the nurse needs to do?
Check incision drain site for bleeding.
