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Nursing 120 - Fundamentals of Nursing - Taylor > Chapter 32 - Skin Integrity and Wound Care > Flashcards

Chapter 32 - Skin Integrity and Wound Care Flashcards

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1
Q

Body Defenses Against Injury

A

Primary-nervous, respiratory, GI, Integumentary

Secondary-vascular

Tertiary-Immune

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2
Q

Layers of Skin

A

Functions

Protection, Temperature Regulation, Sensation, Absorption, Elimination, Vit D production, Immunological

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3
Q

Factors Affecting Skin Integrity

A 
Developmental considerations
State of health
Immobility
Incontinence
Decreased sensory perception
Poor nutrition
Peripheral vascular disease
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4
Q

Common Types of Wounds

A 
Incision
Contusion
Abrasion
Laceration
Puncture
Penetrating 
Avulsion
Chemical
Thermal
Irradiation

hematoma tends to be larger and palpable

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5
Q

Wound Classification

A

Intentional-planned, clean, decreased risk
Unintentional-accidental, contaminated, increased risk of infections
Open-intentional or unintentional, increased risk of infection
Closed-damaged sof tissue
Clean vs. Contaminated vs. Infected
Acute-usually heals w/in days to weeks, decreased risk of infection
Chronic-longer healing time, increased risk of infection
Skin Thickness loss

venous ulcer treatment - compression
arterial ulcer treatment - plasty or surgical intervention

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6
Q

Principles of Healing

A

+Recovery is dependent on

  • Extent of damage
  • General state of health
  • Proper nutrition
  • Adequate blood supply

+Intact skin and mucous membranes are best defense against microorganisms.
+Healing is promoted when wound is free of foreign material
+Body responds systemically to local trauma

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7
Q

Wound Healing Process

A

Primary Intention-clean, approximate edges, little tissue loss, minimal scarring, wound closure is performed w/sutures, staples or adhesive

Secondary Intention-edges are not approximated, form granulation tissue, surgeon may pack the wound with gauze or use drainage system, longer healing time, more scar tissue

Tertiary Intention-wound is purposely left open, cleaned, debrided and observed before closure.

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8
Q

Phases of Wound Healing-Hemostasis

A

Occurs at time of injury
Blood vessels constrict, clotting begins
Blood vessels dilate, ↑ capillary permeability (results in heat and redness)
Exudate formation (causes swelling & pain)

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9
Q

Phases of Wound Healing-Inflammatory

A 
Day 0 to 4-6
Stages
Inflammation (pain, heat, redness & swelling)
Phagocytosis (leukocytes, macrophages
Epithelialization begins
Systemic symptoms
Elevated temperature
↑ WBC & Erythrocyte Sedimentation Rate (ESR)
Generalized malaise

WBC - banded are immature (know by lab test differentials)

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10
Q

Phases of Wound Healing-Proliferation (Fibroblastic)

A

To day ~ 21
New tissue is built by action of fibroblasts
Revascularization and granulation
Wound is lighter in color
Systemic symptoms disappear
Need adequate nutrition, oxygen, prevention of strain of wound tissue

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11
Q

Phases of Wound Healing-Maturation (Remodeling)

A

Day 21 to 1-2 years
Collagen deposition and remodeling
Scar tissue becomes smaller
Keloid scars

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12
Q

WBC Differentials

A 
-Basophils (1%)
Release histamine and heparin
-Eosinophils (2-4%)
Counteract histamine
-Neutrophils (60-70%)
Phagocytosis
-Lymphocytes (20-25%)
Produce antibodies
-Monocytes (3-8%)
Phagocytosis of large particles

OR

N-60
L-30
M-6
E-3
B-1
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13
Q

Local Factors Affecting Wound Healing

A 
Type, size, location of wound
Pressure
Hydration
Trauma
Edema
Infection
Necrosis
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14
Q

Systemic Factors Affecting Wound Healing

A 
Age 
Oxygenation & Circulation
Nutritional status 
Wound condition
Health status
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15
Q

Wound Complications

A
  • Infection
  • Within 2 – 7 days
  • S&S: purulent drainage, ↑ drainage, pain, redness, swelling, ↑ temp, ↑ WBC
  • Septicemia vs. Sepsis
  • Hemorrhage
  • Dehiscence (↑ pain, ↑ serosanguineous fluid ~ days 4 & 5)
  • Evisceration (risk factors? What to do?)
  • Fistula Formation
  • Infections: red, discharge, edema, warm, odor
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16
Q

Wounds: Psychological Effects

A

Pain
Anxiety/Fear
Body Image Alterations

17
Q

Pressure (Decubitus) Ulcers

A

Causes
External Pressure (applied over an area, may form in 1-2 hrs)
Friction (two surfaces rub against each other)
Shearing (one layer of tissue slides over another layer)
Risks
Immobility
Nutrition and Hydration
Moisture
Mental status
Age
Braden Scale

18
Q

Braden Scale

A 
19-23   Not at risk
15-18   Low risk
13-14   Moderate risk   
10-12   High risk	
 ≤ 9      Very high risk
19
Q

Open Wound Classifications

RED

YELLOW

BLACK

MIXED

A

RED-proliferative stage, granulation, PROTECT

YELLOW-purulent oozing, CLEANSE

BLACK

MIXED

20
Q

Principles of chronic wound care

A

Keep wound debrided of non-viable tissue and cleansed of foreign debris
Provide a moist environment
Prevent further injury
Provide essential substrates for healing

21
Q

Wound Assessment

A 
Appearance 
Location and Size
Approximation of wound edges
Erythema, bruising
Swelling
Temperature
If wound open:
Tunneling or Undermining
R,Y,B,  or mixed
Odor
22
Q

Wound Assessment

A

Drainage-amount, consistency, color
***exudate: serous, serosanguineous, sanguineous, purulent
Pain

Closure material
Sutures
Staples
Fibrin sealant

23
Q

Wound Assessment

A 
Drains/tubes
Open drain systems (Penrose)
Closed drain systems ( J-P, Hemovac) 
Wound pouch
Vacuum-assisted closure (Wound VAC)
Systemic evaluation
V.S., labs
Patient response
24
Q

Wound Drains Assessment

A

Open drainage systems
Promote drainage passively, empties into absorptive dressing
Penrose drain

Closed drainage systems
Connect to reservoir to maintain constant low suction
Jackson-Pratt
Hemovacs

25
Q

Wound Photography

A

Have patient lying in same position each time photo is taken
The photo is taken from the same distance
Place a sign with name, MRN, date, measurement tool next to wound when photo is taken. ( this information will be part of photo)
Any hands in photo must be gloved
Patient genitalia must be draped

26
Q

Cleaning Agents

A

Normal Saline-best choice but not bacteriocidal

Betadine-surgical and procedural preps, infected wounds, retards healing

Hydrogen Peroxide-germicidal, debrides, removes blood clots, retards healing

Dakin’s Solution-germicidal, controls odor, very irritating to skin, retards healing

Proteolytic enzymes-chemical debridement

Dermal wound cleanser-gentle cleanser prayed into wound

27
Q

Purposes of Dressings

A 
Comfort
Debridement
Infection protection/control
Absorption
Maintain moisture
Protect wound
Protect skin
28
Q

Examples of Wound Dressings

A 
Transparent films
Hydrocolloids
Hydrogels
Alginates
Foams
Collagens
Nonadherent dressings
Gauze dressings for packing
29
Q

Taping Guidelines

A 
Use porous hypoallergenic tape
Tape width - usually 1”
Less is best
Do not occlude air circulation
Rotate sites
Use skin sealant first
Avoid frequent removal
Don’t restrict movement
Don’t encircle extremity
Pull toward dsg to remove. Support skin.
30
Q

When should dressings be changed?

A

When ordered
When wet through
When medication or special agent no longer effective

31
Q

No Touch Technique

A

Combination of sterile and non-sterile methods
Appropriate for low risk wounds
Uses clean gloves
Avoids touching side or part of dressing that come in contact with wound
Chronic wound
Nearly healed
Low risk wound

32
Q

Removing Staples and Sutures

A 
Staple removal
Use of staple remover
Remove every other staple
Use of steri strips
Suture removal
Use of suture removal kit
Scissor/blade
Cut below the knot
Pull through the healed wound only the portion of the suture that has been inside the tissue
33
Q

Documentation

A 
Describe:
Any drainage (kind, amount)
Wound appearance
Presence of drains
Dressing material used
Tape/binder used
Surrounding skin
Pt response
Complicated wound care detailed on care plan
34
Q

Sterile Wound Dressing

A

Set up Sterile Field

Clean wound and apply dry/sterile dressing

Clean wound and apply saline-moistened dressing

Collect a wound culture

Nursing 120 - Fundamentals of Nursing - Taylor (15 decks)

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