Ch 48 Skin integrity and wound care

Question 1

What is a pressure injury?

Answer 1

When pressure occludes capillaries causing tissue ischemia which, when prolonged & exceeds normal pressure, causes tissue death.

Question 2

What variables affect how pressure injuries happen?

Answer 2

Pressure duration- low pressure for a long time, high pressure for a short​ time

Tissue tolerance-endurance of tissue to shear, friction, moisture.

Ability of skin to redistribute pressure. ​

Question 3

Name six risk factors for pressure injury development:

Answer 3

Impaired Sensory Perception​ - ↓ pain, pressure​

Impaired Mobility​ - ↓ ability to change position​

Altered LOC​ - ↓ sensation, mobility, communication​

A position or movement that increases shear​ - Force exerted against the skin ​

An appliance or movement that increases Friction​ - Two surfaces rub against each other​

Moisture​ - Reduces the skin’s resistance to other forces​

Question 4

What are the six stages of pressure injuries?

Answer 4

Stage 1​ -Non-blanchable erythema (redness) of intact skin​

Stage 2​ - Partial-thickness skin loss with exposed dermis; blister (intact or ruptured)​

Stage 3​ - Full-thickness skin loss; subq tissue visible​

Stage 4​ - Full-thickness skin and tissue loss​

Deep tissue pressure injury (DTPI)​ - Localized area of non-blanchable dark discoloration, or epidermal separation with dark wound bed or blood-filled blister​

Unstageable pressure injury​ - Tissue damage fully obscured by slough or eschar​

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Question 5

In addition to body weight, what other factors can cause skin wounds during hospitalization?

Answer 5

Medical devices pressing or rubbing on the skin

Medical adhesives

Question 6

What are the three types of wound healing?

Answer 6

Primary Intention​ - Wound approximated (closed)​Epithelization​ ; Surgical wound that is sutured/stapled/glued​

Secondary Intention​ - Wound not approximated (open)​
Granulation & Epithelization​ ; Surgical wound with tissue loss/infection​

Tertiary Intention​ - Wound purposefully left open​
Observation of infection​; Dog bite, foreign body laceration​

Question 7

How do stage 1 and 2 pressure injuries heal differently than stage 3 and 4 pressure injuries?

Answer 7

Partial-thickness wound repair (i.e. Stage 2 pressure injury): inflammatory response, epithelial proliferation and migration, and reestablishment of the epidermal layers​

Full-thickness wound repair (i.e. Stage 3 & 4 pressure injuries):​
Hemostasis- control blood loss​
Inflammatory- redness, edema, warmth, and throbbing​
Proliferative- 3 to 14 days filling with granulation and wound resurfacing by epithelialization​
Remodeling & Maturation- final stage can last more than a year, reorganization of collagen scar for strength​

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Question 8

What are four types of wound drainage?

Answer 8

Question 9

What is the Braden scale?
Is a higher or lower number better?
Below what score should you begin extra interventions?

Answer 9

An assessment tool for risk of pressure injuries.
Lower
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Question 10

What factors influence wound healing?

Answer 10

Nutrition: need calories, protein, Vitamins A & C, Zinc, Copper, fluids (Table 48.6) (may need diet/supplement)​

Tissue perfusion: oxygen essential so risk w/ Diabetes or PVD (may need supplemental O2)​

Infection: prolongs inflammatory and subsequent phases and causes further tissue destruction​

Age: Increased age delays wound healing phases​

Psychosocial Impact: body image and sexuality can cause stress​

Delayed healing w/ obesity, smoking, inactivity, radiation, immunosuppression, meds​

Question 11

What are six nursing diagnosis that are common with impaired skin integrity and wounds?

Answer 11

Impaired Skin Integrity​

Risk for Impaired Skin Integrity​

Risk for Infection​

Acute or Chronic Pain​

Impaired Mobility​

Impaired Peripheral Tissue Perfusion​

Question 12

What positioning measures can you take to reduce pressure injuries?

Answer 12

Turn q 1-2 hours in bed, or shift q 15 min while in chair. Protect bony prominences. HOB & hips 30 degree lateral position max​

Question 13

What are the seven purposes of wound dressings?

Answer 13

Protects wounds from contamination​

Aids in hemostasis ​

Promotes healing by absorbing drainage and debriding wounds​

Supports or splints wound site​

Protects client from seeing wound​

Promotes thermal insulation of wound surface​

Provide moist environment​

Question 14

How is a surgical dressing different from other dressings?

Answer 14

Surgical dressing: Sterile technique! ​

First dressing usually done by Surgeon​

Until dressing removed by surgeon, nurse assesses the dressing surface and reinforces as needed. DO NOT REMOVE.​

Question 15

What are the steps for emptying wound drainage devices?

Answer 15

open port, pour into calibrated cup, cleanse port w/ alcohol, compress and close. Document: color, type, amount of drainage​

Question 16

What are the effects of heat therapy?

Answer 16

Vasodilation​

Reduced blood viscosity​

Reduced muscle tension​

Increased tissue metabolism​

Increased capillary permeability​

Need periodic removal of heat for full effect​

Question 17

What are the effects of cold therapy?

Answer 17

Vasoconstriction​

Local anesthesia​

Reduced cell metabolism​

Increased blood viscosity​

Decreased muscle tension​

Don’t use for more than 30 minutes at a time