Ch 48: Skin & Wound Care Flashcards
pressure ulcer
localized injury to the skin and other underlying tissue, usually over a bony prominence, as a result of pressure or pressure in combination with shear and/or friction
tissue ischemia
pressure applied over a capillary exceeds the normal capillary pressure and the vessel is occluded for a prolonged period of time. if the pt has reduced sensation and cannot respond to the discomfort of the ischemia, tissue death can result.
blanching
normal red tones of the light-skinned patient are absent. it does not occur in pts with darkly pigmented skin.
Stage I Pressure Ulcer
nonblanchable redness of intact skin, usually a bony prominence. area may be painful, firm, soft, warmed, or cooler than adjacent tissue.
should use no dressing, transparent dressing, or hydrocolloid dressing to cover.
Stage II Pressure Ulcer
partial-thickness loss of dermis. presents as a shallow open ulcer with a red-pink wound bed without slough. may also present as an intact or open/ruptured serum-filled or serosangineous filled blister.
should use composite film, hydrocolloid, or hydrogel dressings to cover.
Stage III Pressure Ulcer
full-thickness tissue loss. subcutaneous fat may be visible, but bone, tendon, or muscle is NOT exposed. some slough may be present and it may include undermining and tunneling.
should use hydrocolloid, hydrogel covered with foam dressing, calcium alginate, gauze, or growth factors (with gauze) to cover.
Stage IV Pressure Ulcer
full-thickness tissue loss with exposed bone, tendon, or muscle. slough or eschar may be present. it often includes undermining and tunneling. depth varies by anatomical location.
should use hydrogen covered with foam dressing, calcium alginate, gauze, or growth factors (with gauze) to cover.
Unstageable/Unclassified
full-thickness tissue loss in which actual dept of the ulcer is completely obscured by slough and/or eschar in the wound bed. until enough slough and/or eschar are removed to expose the base of the wound, the tru depth cannot be determined; but it is either stage III or stage IV.
should use adherent film, gauze plus ordered solution, enzymes, or no dressing to cover.
Suspected Deep-Tissue Injury - Depth Unknown
purple or maroon localied area of discolored intact skin or blood-filled blister caused by damage of underlying soft tissue from pressure and/or shear. may be difficult to detect in pts w/ dark skin tones.
granulation tissue
red, moist tissue composed of new blood vessels, the presence of which indicates progression toward healing.
slough
soft yellow or white tissue, stringy substance attached to wound bed. must be removed before the wound is able to heal.
eschar
black or brown necrotic tissue, needs to be removed before healing can proceed.
exudate
the amount, color, consistency, and odor of wound drainage. excessive exudate indicates infection.
wound
disruption of the integrity and function of tissues in the body. ALL WOUNDS ARE NOT CREATED EQUAL!
approximated
closed
healing by primary intention
surgical incisions. skin edges are approximated, risk of infection is low, healing occurs quickly, minimal scar formation
healing by secondary intention
wound is left open until it becomes filled by scar tissue, takes longer to heal; thus chance of infection is greater. if scarring is severe, loss of tissue function is often permanent.
components of partial-thickness wound repair (3)
- inflammatory response: limited to first 24 hours after wounding. redness and swelling w/ moderate amount of serous exudate.
- epithelial proliferation (reproduction) & migration: start at both wound edges and epidermal cells lining epidermal appendates; quick resurfacing. open to air = 6-7 days. kept moist = 4 days.
- reestablishment of the epidermal layers: cells slowly reestablish normal thickness and appear as dry, pink tissue.
phases of full-thickness wound repair (4)
- hemostasis
- inflammatory phase
- proliferative phase
- remodeling
hemostasis
series of events designed to control blood loss, establish bacterial control, and seal the defect. injured blood vesselt constrict, and platelets gather to stop bleeding. clots form a fibrin matrix that later provides a framework for cellular repair.
inflammatory phase
damaged tissue and mast cells secrete histamine resulting in vasodilation of surrounding capillaries and exudation of serum and WBCs into damaged tissues. results in localized redness, edema, warmth, and throbbing.
within hours leukocytes (akaWBCs) arrive: neutrophils begin to ingest bacteria and small debris, monocytes transform into macrophages and clean wound of bacteria, dead cells, and debris via phagocytosis. as early as day 2 collagen is synthesized (main component of scar tissue).
proliferative phase
lasts from 3 to 24 days. filling of the wound w/ granulation tissue, contraction of the wound, and resurfacing of the wound by epithelialization. fibroblasts synthesize collagen which mixes w/ granulation tissue to support epithelialization. wound contracts and epithelial cells migrate from wound edges to resurface.
remodeling phase
sometimes takes place for more than a year, depending on depth and extent of wound. collagen scar reorganizes and gains strength for several months. usually scar tissue contains fewer pigmented cells (melanocytes) and has a lighter color than normal skin. in dark-skinned individuals the scar may be more highly pigmented than surrounding skin.
hemorrhage
bleeding from a wound site, normal during and immediately after initial trauma
hematoma
localized collection of blood underneath the tissues. appears as a swelling, change in color, sensation, or warmth or mass that often takes on a bluish discoloration.
purulent
odorous yellow, green, or brown colored drainage
dehiscence
the partial or total separation of wound layers. poor nutritional status, infection, and obesity are risk factors (obesity has higher risk b/c of constant strain placed on their wounds and poor healing qualities of fat tissue).
Braden Scale
pressure ulcer risk assessment tool. composed of six subscales: sensory perception, moisture, activity, mobility, nutrition, and friction/shear. the total score ranges from 6 to 23; a lower score indicates a higher risk for pressure ulcer development. the cutoff score for onset of pressure ulcer risk in the general adult population is 18.
abrasion
superficial wound with little bleeding and is considered a partial-thickness wound.
laceration
sometimes bleeds more profusely, depending on the depth and location of the wound.
puncture
wound that bleeds in relation to the depth and size of the wound. ex: a nail puncture does not cause as much bleeding as a knife wound.
serous
type of wound drainage: clear, watery plasma
serosanguineous
type of wound drainage: pale, pink, watery; mixture of clear and red fluid
sanguineous
type of wound drainage: bright red; indicates active bleeding
hemorrhage
bleeding from a wound site, normal during and immediately after initial trauma
hematoma
localized collection of blood underneath the tissues. it appears as a swelling, change in color, sensation, or warmth or mass that often takes on a bluish discoloration.
dehiscence
partial or total separation of wound layers. a pt who is at risk for poor wound healing (poor nutritional status, infection, or obesity) is at risk for dehiscence. Obese pts have a higher risk b/c of the constant strain placed on their wounds and the poor healing qualities of fat tissue.
evisceration
total separation of wound layers with protrusion of visceral organs through a wound opening. This is a surgical emergency because blood supply to the organs protruding through the wound is compromised.
penrose drain
drain that lies under a dressing; at the time of placement a pen or clip is placed through the drain to prevent it from slipping farther into the wound. it is usually the health care provider’s responsibility to pull or advance the drain as drainage decreases to permit healing deep within the drain site.
evacuator units
Hemovac or Jackson-Pratt. drains that exert a constant low pressure as long as the suction device (bladder or container) is fully compresses. often referred to as self-suction.
debridement
removal of nonviable, necrotic tissue. necessary to rid the wound of a source of infection, enable visualization of the wound bed, and provide a clean base necessary for healing.
autolytic debridement
uses synthetic dressings over a wound to allow the eschar to be self-digested by the action of enzymes that are present in wound fluids. accomplished by using dressings that support moisture at the wound surface. ex: transparent film, hydrocolloid dressings.
chemical debridement
debridement with the use of a topical enzyme preparation, Dakin’s solution, or sterile maggots.
surgical debridement
the removal of devitalized tissue by using a scalpel, scissors, or other sharp instrument.
purposes of dressings
protect from contamination aid in hemostasis promote healing support/splint the wound site protect pt's from seeing wound promote thermal insulation of wound surface provide moist environment
recommended protein intake necessary for healing
up to 1.8 g/kg/day
vacuum-assisted closure (V.A.C.)
device that assists in wound closure by applying localize d negative pressure to draw the edges of a wound together
steps to clean an incision or area surrounding a drain (3)
- clean in a direction from least contaminated (from wound/incision/isolated drain site to surrounding skin)
- use gentle friction when applying solutions locally to the skin
- when irrigating, allow the solution to flow from the least to the most contaminated area
irrigation
with an irrigating syringe, flush the area with a constant low pressure flow of solution. use a 35-mL syringe with a 19-gauge needle.
sutures
threads or metal used to sew body tissues together. available in silk, steel, cotton, linen, wire, nylon and Dacron.
drainage evacuators
convenient portable units that connect to tubular drains lying within a wound bed and exert a safe, constant, low-pressure vacuum to remove and collect drainage.
contraindications of heat therapy (2)
- acute, localized inflammation (ex: appendicitis b/c heat causes appendix to rupture)
- applying heat to large portions of the body with a pt w/ cardiovascular problems (massive vasodilation disrupts blood supply to vital organs)
contraindications of cold therapy (4)
- edematous injury site (retard circulation and prevents absorption of interstitial fluid)
- impaired circulation (further reduces blood supply to affected area)
- neuropathy (pt is unable to perceive temp)
- shivering (dangerously increase body temp)
effects of heat therapy
improved blood flow to injured part. prolonged exposure causes reflex vasoconstriction to control heat loss from the area, so periodic removal and reapplication is essential. continuous exposure causes damage to epithelial cells, localized tenderness, and even blistering
effects of cold therapy
diminishes swelling and pain. prolonged exposure results in reflex vasodilation - cells aren’t receiving adequate blood flow and nutrients which leads to tissue ischemia. the skin initially takes on a reddened appearance, followed by a bluish-purple mottling with numbness and burning pain. skin tissues freeze from exposure to extreme cold.
epidermis
top layer of the skin
dermis
inner layer of the skin that provides tensile strength and mechanical support
collagen
tough, fibrous protein
darkly pigmented skin
does not blanch
identify the pressure factors that contribute to ulcer development (3)
- pressure intensity
- pressure duration
- tissue tolerance
identify risk factors that predispose a pt to pressure ulcer formation (6)
- decreased mobility
- decreased sensory perception
- change in level of consciousness
- shear
- friction
- moisture
list the factors that influence pressure ulcer formation (5)
- nutrition
- tissue profusion
- age
- psychological impact of wounds
- infection
explain how mobility places a patient at risk for a pressure ulcer
potential effects of impaired mobility. muscle tone and strength
explain how body fluids place a patient at risk for a pressure ulcer
continual exposure of skin to body fluids especially gastric and pancreatic drainage increases the risk for breakdown.
low risk body fluids: saliva, serosanguineous fluid
moderate risk: urine, bile, stool, ascitic fluid, purulent wound drainage.
explain how nutritional status places a pt at risk for a pressure ulcer
malnutrition is a major risk factor; a loss of 5% of usual weight, weight less than 90% of ideal body weight, or a decrease of 10 lb in a brief period also increase risk.
explain how pain places a pt at risk for a pressure ulcer
maintaining adequate pain control and pt comfort increases pts willingness and ability to increase mobility, which in turn decreases pressure ulcer risk.
explain how a nurse would assess wound appearance
observe whether wound edges are closed. look for dehiscence and evisceration. the first 2-3 days the outer edges normally appear inflamed. within 7-10 days a normally healing wound resurfaces with epithelial cells and edges close.
explain how a nurse would assess the character of wound drainage
note amount, color, odor, and consistency. can weigh a the used dressing and compare it to the weight of a clean dressing of the same size.
1 g of drainage = 1 mL of volume of drainage
explain how a nurse would assess a wound drain
assess the number of drains, drain placement, character and volume of drainage, condition of collecting equipment (patency of drain tubing), security of drain and its location with respect to the wound.
explain how a nurse would assess wound closure
normally for the first 2-3 days after surgery the skin around sutures/staples is edematous. continued swelling may indicate that closures are too tight and the sutures can cut the skin leading to wound separation.
dermabond
tissue adhesive that forms a strong bond across opposed wound edges, allowing normal healing to occur below. can be used to replace small sutures, some surgeons use it on larger wounds where subcutaneous sutures are needed.. the dermabond is applied to the approximated tissue and the edges are held together until the solution dries.
mechanical debridement
use of wet-to-dry saline gauze dressing. place moistened gauze into the wound and allow the dressing to dry thoroughly before “pulling” the gauze that has adhered to tissue out of the pressure ulcer. not used routinely b/c the technique removes viable tissue.
list principles to maintain a healthy wound environment (6)
- manage infection
- cleanse the wound
- remove nonviable tissue
- manage exudates
- maintain wound in moist environment
- protect wound
explain the rationale for debriding a wound
debriding rids the wound of source of infection, enables visualization of wound bed, and provides a clean base necessary for healing.
identify the 4 methods of debridement (4)
- mechanic
- autolytic
- chemical
- sharp/surgical
list the purposes of dressings (7)
- protects wound from microorganism contamination
- aids in hemostasis
- promotes healing by absorbing drainage and debriding a wound
- supports or splints wound site
- protects pts from seeing the wound (if perceived as unpleasant)
- promotes thermal insulation of wound surface
- provides a moist environment
list the clinical guidelines to use when selecting the appropriate dressing (6)
- use a dressing that will continuously provide moist environment
- perform wound care using topical dressings as determined by assessment
- choose a dressing that keeps surrounding skin dry
- choose a dressing that controls exudate
- consider caregiver time, availability, and cost
- eliminate wound dead space by loosely filling all cavities with dressing material
list the advantages of a transparent film dressing (5)
- adheres to undamaged skin
- oxygen passes through; still a barrier to external fluids and bacteria
- promotes moist environment that speeds epithelial cell growth
- can be removed without damaging underlying tissue
- does not require secondary dressing
list the functions of hydrocolloid dressings (7)
- absorbs drainage via exudate absorbers in dressing
- maintains wound moisture
- slowly liquefies necrotic debris
- impermeable to bacteria and other contaminants
- self-adhesive and molds well
- acts as preventive dressing for high-risk friction areas
- may be left in place for 3-5 days minimizing skin trauma and disruption of healing
list the advantages of hydrogel dressing (4)
- soothing and can reduce pain
- provides moist environment
- debrides necrotic tissue (by softening necrotic tissue)
- does not adhere to wound bast and is easy to remove
list the guidelines to follow during a dressing change procedure (4)
- assess skin beneath tape
- perform thorough hand hygiene before and after wound care
- wearing sterile gloves before directly touching an open or fresh wound
- remove or change dressings over closed wounds when they become wet or if patient has signs or symptoms of infection and as ordered.
summarize the principles of packing a wound
- assess the size, depth, and shape of the wound
- moist dressing needs to be flexible and in contact with all of the wound surface
- do not pack tightly b/c overpacking causes pressure
- do not overlap the wound edges b/c it causes maceration of the tissue
describe how the wound vacuum-assisted closure (wound vac) device works
applies local negative pressure to draw the edges of a wound together by evacuating wound fluids and stimulating granulation tissue formation and reduces the bacterial burden of a wound and maintains a moist environment
identify 3 principles that are important when cleaning an incision
- cleanse in a direction from the least contaminated area to the surrounding skin
- use gentle friction when applying solutions locally to the skin
- when irrigating, allow the solution to flow from the least to the most contaminated area
summarize the principles of wound irrigation
use an irrigation syringe to flush the area with a constant low-pressure flow of solution of exudates and debris. never occlude a wound opening with a syringe.
explain the purpose for drainage evacuation
portable units that connect tubular drains lying within a wound bed and exert a safe, constant low-pressure vacuum to remove and collect drainage
explain the benefits of binders and bandages
- create pressure over a body part
- immobilize a body part
- support a wound
- reduce or prevent edema
- securing a splint
- securing dressings
list the nursing responsibilities when applying a bandage or binder
- inspect the skin for abrasions, edema, discoloration, or exposed wound edges
- covering exposed wounds or open abrasions with a sterile dressing
- assessing the condition of underlying dressings and changing if soiled
- assessing the skin for underlying areas that will be distal to the bandage for signs of circulatory impairment
list the factors that influence heat and cold tolerance
- better able to tolerate short exposure to temp extremes
- neck, inner aspect of wrist and forearm, and perineal region are more sensitive to temp variations
- body responds best to minor temp adjustments
- pts have less tolerance to temp changes to which a large area of the body is exposed
- tolerance to temp variations changes with age
- physical conditions that reduce the reception or perception of sensory stimuli (ex: diabetic neuropathy)
- uneven temp distribution suggests that the equipment is not functioning properly
explain the rationale for warm, moist compresses
improve circulation, relieve edema, and promote consolidation of pus and drainage
explain the rationale for warm soaks
promote circulation, lessens edema, increases muscle relaxation, and provides a means to debride wounds and apply medicated solutions
explain the rationale for sitz baths
the pelvic area is immersed in warm fluid, causing wide vasodilation
explain the rationale for commercial hot packs
disposable hot packs that apply warm, dry heat to an area
explain the rationale for cold, moist, and dry compresses
relieves inflammation and swelling
explain the rationale for cold soaks
immersing a body part for 20 minutes
explain the rationale for ice bags or collars
used for muscle sprain, localized hemorrhage, or hematoma
list the questions to ask if the identified outcomes were not met
- was the etiology of the skin impairment addressed?
- was wound healing supported by providing the wound base with a moist, protected environment?
- were issues such as nutrition assessed and a plan of care developed?
Mr. Post is in a Fowlers position to improve his oxygenation status. The nurse notes that he frequently slides down in the bed and needs to be repositioned. Mr. Post is now at risk for developing a pressure ulcer on his coccyx because of:
- Friction
- Maceration
- Shearing force
- Impaired peripheral circulation
- Shearing force.
Rationale: the force exerted parallel to the skin resulting from both gravity pushing down on the body and resistance between the patient and the surface.
Which of the following is not a subscale on the Braden scale for predicting pressure ulcer risk?
- Age
- Activity
- Moisture
- Sensory perception
- Age
Rationale: age is not a subscale. Perception, moisture, activity, mobility, nutrition, friction, and shear are the subscales.
Which of these patients has a nutritional risk for pressure ulcer development?
- Patient A has an ablumin level of 3.5.
- Patient B has a hemoglobin level within normal limits.
- Patient C has a protein intake of 0.5 g/kg/day.
- Patient D has a body weight that is 5% greater than his ideal weight.
- Patient C has a protein intake of 0.5 g/kg/day.
Rationale: The recommended protein intake of adults is 0.8 g/kg/day. A higher intake of up to 1.8 g/kg/day is necessary for healing.
Mr. Perkins has a stage II ulcer on his right heel. What would be the most appropriate treatment for this ulcer?
- Apply a heat lamp to the area for 20 minutes twice daily.
- Apply a hydrocolloid dressing and change it as necessary.
- Apply a calcium alginate dressing and change when strikethrough is noted.
- Apply a thick layer of enzymatic ointment to the ulcer and the surrounding skin.
- Apply a hydrocolloid dressing and change it as necessary.
Rationale: stage II ulcers should be treated with hydrocolloid or hydrogel dressings.
