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NURS 105 > Chapter 48: Skin Integrity and Wound Care (IRAT/GRAT #3) > Flashcards

Chapter 48: Skin Integrity and Wound Care (IRAT/GRAT #3) Flashcards

1
Q

stratum corneum

A

the thin outermost layer of the epidermis which allows for evaporation of water and permits absorption of certain topical medications

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2
Q

dermis

A

inner layer of the skin

protects underlying muscles bones and organs

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3
Q

pressure ulcers

A

localized injury to the skin and underlying tissue, usually over a body prominence as a result of pressure combination with shear and/or friction

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4
Q

What patients are at risk for pressure ulcers?

A

any patient experiencing decreased mobility, decreased sensory perception, fecal or urinary incontinence and/or poor nutrition

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5
Q

Pressure Ulcer: Pathogenesis (3 Factors)

A
  1. Pressure Intensity
  2. Pressure Duration
  3. Tissue Tolerance
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6
Q

Tissue ischemia

A

occurs when the normal capillary pressure and the vessel is occluded for prolonged periods of time.

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7
Q

What happens if a patient cannot respond to the discomfort of ischemia?

A

tissue ischemia and tissue death result

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8
Q

Hyperemia

A

redness over a pressure point from a prolonged position

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9
Q

Pressure Intensity includes

A
  1. hyperemia
  2. blanching
  3. non-blanchable hyperemia
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10
Q

blanching

A

pressing into a hyperemic area and having the affected skin turn white in color (lighter skinned individuals)

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11
Q

non-blanchable hyperemia

A

deep tissue damage is probable (stage 1 pressure ulcer)

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12
Q

pressure duration

A

either low pressure over a prolonged period of time OR intensity pressure over a short period

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13
Q

Common locations for pressure ulcer formation in a supine position

A
  1. occiput
  2. scapula
  3. sacrum
  4. heels
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14
Q

Common locations for pressure ulcer formation in a lateral position

A
  1. ear,
  2. acromion process
  3. elbow
  4. trochanter
  5. medial & lateral condyle
  6. medial & lateral malleolus
  7. heels
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15
Q

Common locations for pressure ulcer formation in a prone position

A
  1. elbow
  2. ear, cheek, nose
  3. breasts (female)
  4. genitalia (male)
  5. iliac crest
  6. patella
  7. toes
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16
Q

Tissue Tolerance

A

the ability of the tissue to endure pressure

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17
Q

Tissue Tolerance is dependent on

A
  • integrity of the tissue and supporting structures
  • extrinsic factors of shear, friction and moisture
  • nutritional status
  • age
  • hydration
  • low blood pressure
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18
Q

Risk Factors for the formation of pressure ulcers

A
  1. impaired sensory perception
  2. impaired mobility
  3. alteration in LOC
  4. shear
  5. friction
  6. moisture
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19
Q

impaired sensory perception include

A

pain and pressure

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20
Q

alterations in LOC include

A

confusion, aphasia, coma

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21
Q

shear

A
  • gravity pulling the bony skeleton towards the foot of the bed while the skin remains against the sheets.
  • outer layers of the skin may appear intact.
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22
Q

friction

A

force of two surfaces moving across one another

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23
Q

Unstageable/Unclassified Pressure Wound

A
  • until the slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) is removed, a pressure wound cannot be staged.
  • however it is most likely a Stage III or IV
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24
Q

What wounds are staged?

A
  • only pressure wounds are staged.

- diabetic ulcers and stasis ulcers are not staged!

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25
Q

Deep tissue injury

A
  • purple or maroon in color

- localized area of discolored intact skin or blood filled blister

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26
Q

A deep tissue injury may

A
  • be preceded by tissue that is painful, firm, mushy, boggy, warm or cooler to the touch
  • be difficult to detect in dark skin
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27
Q

Granulation Tissue

A
  • red
  • moist
  • composed of new blood vessels
  • progression toward healing
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28
Q

Slough

A
  • stringy substance attached to a wound bed

- requires debriding

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29
Q

Eschar

A
  • black, brown, tan, or necrotic tissue

- must be debrided

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30
Q

Exudate

A
  • wound drainage

- describe amount, color, consistency and odor

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31
Q

Wound classification systems enable the nurse to do what?

A

understand the risks associated with a wound and implications for healing

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32
Q

Wound Classification Systems describe:

A
  1. state of skin integrity
  2. cause of the wound
  3. severity or extent of tissue injury or damage
  4. cleanliness
  5. descriptive qualities of wound tissue (i.e color)
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33
Q

Wound Classification

A

classified by the amount of tissue loss

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34
Q

Wound Classification includes

A
  1. Partial Thickness Wounds

2. Full Thickness Wounds

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35
Q

Partial Thickness Wounds

A
  • involves only a partial loss of skin layers (epidermis, superficial dermal layer).
  • healing is by regeneration
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36
Q

Partial Thickness Wound Characteristics

A
  • shallow in depth
  • moist
  • painful with red wound base
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37
Q

Full Thickness Wounds

A
  • involves total loss of the skin layers (epidermis and dermis)
  • heals by forming new tissue.
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38
Q

Full Thickness Wound Characteristics

A
  • depth varies

- extends into the subcutaneous layer

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39
Q

Process of Wound Repair includes

A
  1. primary intention

2. secondary intention

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40
Q

Primary Intention

A
  • skin edges are approximated (surgical incisions)
  • risk for infection is low
  • healing occurs quickly w/ minimal scar formation
41
Q

Secondary Intention

A
  • involves loss of tissue (burn, pressure ulcer, severe laceration)
  • wound is left open until it becomes filled by scar tissue
42
Q

Healing of partial thickness wounds involve what 3 components?

A
  1. inflammatory response
  2. epithelial proliferation and migration
  3. reestablishment of the epidermal layers
43
Q

epithelial proliferation and migration

A
  • starts at the wound edges and the epidermal cells
  • allows for quick resurfacing
  • epithelial cells begin to migrate across the wound bed soon after wound occurs
44
Q

reestablishment of the epidermal layers

A
  • left open to air: resurfaces in 6-7 days

- keep moist: resurfaces in 4 (ish) days: epidermal cells only migrate across a moist surface

45
Q

Healing of full thickness wounds involve what 4 phases?

A
  1. hemostasis phase
  2. inflammatory phase
  3. proliferative phase
  4. maturation or remodeling phase
46
Q

Hemostasis Phase

A

blood vessels constrict and platelets gather to stop bleeding

47
Q

Inflammatory Phase

A

include mast cells, neutrophils and monocytes

48
Q

function of neutrophils

A

ingests bacteria and small debris

49
Q

function of monocytes

A

transforms into macrophages -> cleans the wound of bacteria, dead cells and debris by phagocytosis

50
Q

function of mast cells

A

secretes histamine -> vasodilation -> WBCs to damaged tissues = localized edema, redness, warmth, throbbing

51
Q

Proliferative Phase

A

-lasts 3-24 days

52
Q

Main activities of the Proliferative Phase include

A
  1. filling of the wound with granulation tissue
  2. contraction of the wound
  3. resurfacing of the wound by epithelialization (fibroblasts synthesize collagen providing strength and structural integrity to a wound)
53
Q

In a clean wound, what happens during the Proliferative Phase?

A
  • vascular bed is reestablished (granulation tissue)
  • the area is filled with replacement tissue (collagen, contraction, and granulation tissue)
  • surface is repaired (epithelialization)
54
Q

Impairment in wound healing during the proliferative stage is usually related to

A

age, anemia, hypoproteinemia and zinc deficiency.

55
Q

Maturation or Remodeling Phase

A
  • maturation, the final stage of healing

- may take place over a year

56
Q

What are some complications of wound healing?

A
  • hemorrhage
  • infection
  • dehiscence
  • evisceration
57
Q

dehiscence

A

total or partial separation of wound layers

58
Q

evisceration

A

protrusion of visceral organs

59
Q

How does fatty tissue effect wound closure?

A

contains poor blood supply which can be a challenge in wound closure due to the extra pressure on the incision

60
Q

What is the major nursing priority related to caring for pressure ulcers?

A

PREVENTION.

  • important indicator of nursing quality
  • use of a standardized tool is essential.
61
Q

Braden Scale

A

widely used risk assessment tool composed of 6 subscales

62
Q

What are the 6 subscales of the Braden Scale?

A
  1. sensory perception
  2. moisture
  3. activity
  4. mobility
  5. nutrition
  6. friction/shear
63
Q

Very high risk on Braden Scale is a score of

A

9 or less

64
Q

High risk on Braden Scale is total score of

A

10-12

65
Q

Moderate risk on Braden scale is a total score of

A

13-14

66
Q

Mild risk on Braden Scale is a total score of

A

15-18

67
Q

No risk on Braden Scale is a total score of

A

19-23

68
Q

Factors Influencing Pressure Ulcer Formation

A
  1. Nutrition
  2. Tissue Perfusion
  3. Infection
  4. Age
69
Q

Nutrition

A
  • 1500 cal/day
  • protein (for the formation of collagen)
  • vitamins (A and C)
  • trace minerals (zinc and copper)
70
Q

Tissue Perfusion

A

adequate amounts of oxygenated blood

71
Q

How does infection affect wound healing?

A
  • prolongs inflammatory phase
  • delays collagen synthesis
  • prevents epithelialization
  • increases production of proinflammatory cytokines (leads to more tissue destruction)
72
Q

Psychosocial Impact of Wounds

A
  • body image changes

- self-concept (scars, drains, odor from drainage, temporary or permanent prosthetic devices)

73
Q

Nursing Process: Assessment

A
  • skin
  • predictive instrument for pressure ulcer risk (braden scale)
  • mobility
  • nutritional status
  • body fluids (moisture)
  • pain
  • wound
74
Q

Wounds are usually assessed under what 2 conditions?

A
  1. at the time of injury before treatment

2. after therapy

75
Q

Wound Characteristics Include

A
  1. appearance
  2. wound drainage and character
  3. drains
  4. wound closures: staples, steri-strips, dermabond
  5. need for wound cultures: aerobic and anaerobic
76
Q

Nursing Process: Diagnosis

A
  • Risk for infection
  • Imbalanced Nutrition
  • Acute or Chronic Pain
  • Impaired Physical Mobility
  • Impaired Skin Integrity
  • Risk for Impaired Skin -Integrity
  • Ineffective Peripheral Tissue Perfusion
77
Q

Acute Wound

A

requires immediate intervention

78
Q

Chronic Wound

A

the patient’s hygiene may be more important

79
Q

Preventative Practices:

A
  • skin care practices (clean, dry, moisturized)
  • elimination of shear
  • positioning/movement
80
Q

Major Nursing Priority

A

promotion of wound healing

81
Q

Prevention of Wounds

A
  1. skin care and management of incontinence
  2. positioning
  3. mechanical loading and support devices (proper positioning and use of therapeutic surfaces/beds)
  4. education
82
Q

No single device eliminates the

A

effects of pressure on the skin

83
Q

Acute Care Management

A
  • documentation

- wound management

84
Q

Documentation of Wounds

A
  • photo documentation to establish baseline then periodically to track healing (or lack of healing)
  • may be performed by the RN or wound ostomy RN according to hospital policy
85
Q

Wound Management

A

maintain a healthy wound environment

86
Q

Maintaining a healthy wound environment

A
  • Prevent and manage infection
  • Clean the wound *only with noncytotoxic wound cleaners
  • Remove nonviable tissue. (debridement)
  • Maintain a moist environment
  • Eliminate dead space
  • Control odor
  • Eliminate/minimize pain
  • Protect the wound and periwound skin
87
Q

Debridement

A

removal of nonviable necrotic tissue

88
Q

Debridement includes

A
  1. mechanical debridement
  2. autolytic debridement
  3. chemical debridement
  4. surgical debridement
89
Q

mechanical debridement

A

wet to dry saline gauze, wound irrigation, whirlpool treatments

90
Q

autolytic debridement

A
  • synthetic dressings to allow eschar to be self-digested by the action of enzymes.
  • hydrocolloid dressings, transparent film
91
Q

chemical debridement

A

topical enzyme preparation: dakin’s solution, sterile maggots

92
Q

surgical debridement

A

using a scalpel, scissors or other sharp instrument

93
Q

Nursing Process: Collaboration

A

-utilize resources: interdisciplinary health care professionals

94
Q

Collaboration: Interdisciplinary health care professionals

A
  • Health care provider
  • Wound care nurse specialist
  • Physical therapist
  • Occupational therapist
  • Nutritionist
  • Case Manager
  • Pharmacist
95
Q

Nursing Process: Dressings

A
  • follow institutional policy and procedure
  • consider medicating the patient 30” before a dressing change
  • wound vac
  • hot and cold packs
96
Q

Nursing Process: Evaluation

A
  • response to nursing therapies
  • was the goal reached?
  • was the etiology of the skin impairment addressed? pressure, friction, shear, moisture
  • photo documentation
97
Q

excessive exudate may be a sign of

A

infection

98
Q

Characteristics of Secondary Intention

A
  • takes longer to heal
  • increased risk for infection
  • increased scarring
  • severe scarring may lead to loss of tissue function

NURS 105 (10 decks)

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