Chapter 48 Skin Integrity & Wound Care Flashcards
What is the largest organ in the body?
The skin
Skin the largest organ in the body constitute the___% of the total adult weight
15 %
The skin is a _____ _____ against disease - causing organisms.
protective barrier
The skin functions are:
Pain
Temperature
Touch
The skin synthesizes
Vitamin D
Nurse responsibilities regarding skin are:
- assess & monitor skin integrity
- Identify problems
- Planning, implementing, & evaluating interventions to maintain skin integrity.
Aspects to assess dark skin
- difficult to detect cyanosis.
- be aware of situations that produces changes in skin tone such us inadequate lightning.
- examine body sites with least melanin (under arm).
- evaluate pigmented skin color specific changes.
The factors that contribute to skin breakdown are:
- Impaired sensory perception
- impaired mobility
- alteration in level of consciousness.
- shear
- Friction
- Moisture
Body fluids that has high risk skin breakdown:
Gastric Drainage.
Pancreatic Drainage.
Body fluids that has moderate risk for skin breakdown
Bile, stool, urine, ascetic fluid, purulent drainage.
Impaired skin integrity related to unrelieved, prolonged, pressure referred to:
pressure ulcer or pressure sore
decubitus ulcer,
bed sore
Localized injury to the skin and other underlying tissue, usually over a bone prominence
Pressure ulcer
Nurse should assess pressure ulcers at regular intervals using systematic parameters:
- Wound healing
- plan appropriate interventions
- evaluate progress.
Pressure in combination with friction results in
Pressure ulcer
what would you document about a pressure ulcer:
- Depth of tissue involve (stage)
- Type and % of tissue in wound bed
- wound dimensions
- exudate description
- Condition of surrounding skin.
Stage of Ulcer non blanchable redness of intact skin, painful, warmer or cooler than adjacent tissue. Firm or soft
Pressure Ulcer stage 1
stage of ulcer partial thickness skin loss or blister involving epidermis, dermis or both/ Shiny, dry shallow ulcer
Pressure ulcer stage 2
Stage of ulcer that is Full-thickness skin loss (Fat visible) tissue loss
Pressure Ulcer Stage 3
Stage of ulcer Full-thickness tissue loss with (Exposed bone, muscle, or Tendon.)
Pressure ulcer stage 4
What is the major cause of the formation of a pressure ulcer?
- Pressure Intensity
- Pressure Duration
- Tissue Tolerance
Risks for pressure ulcers:
Nutrition
- Impaired sensory perception
- Impaired mobility
- Alteration in the level of consciousness
- Presence of a cast
- Secondary to an illness
- Shear
- Friction
- Moisture
What nurses should do to prevent pressure ulcer?
Skin care
- Positioning
- Use of support surfaces
Disruption of the integrity and function of tissues in the body.
A wound
T or F. Non 2 wounds are the same
true
what are complications regarding wounds?
- Hemorrhage
- Hematoma:
- Infection (second most common HAI)
- Dehiscence:
- Evisceration: protrusion of visceral organs through a wound opening.
there are 2 types of dressing:
- Clean
2. Sterile
Who is at risk for a pressure ulcer development?
- Any patient experiencing decreased mobility
- Decreased sensory perception
- Fecal or Urinary Incontinence
- Poor nutrition
Normal Capillary pressure ranges between:
15 to 32 mm Hg
Tissues receive oxygen and nutrients and eliminate metabolic wastes through_____.
Blood
Any factor that interferes with ____ flow in turn interferes with cellular metabolism and the function of life of the cells.
Blood
Prolonged, intense pressure affects cellular metabolism by decreasing or obliterating blood flow, resulting in tissue ______ and ultimately tissue death.
ischemia
If the pressure applied over a capillary exceeds normal capillary pressure and the vessel is occluded for a prolonged period of time, what can occur?
Tissue ischemia.
If the patient has reduced sensation and cannot respond to discomfort of the ischemia, what will be the result?
If the patient has reduced sensation and cannot respond to discomfort of the ischemia, what will be the result?
After a period of tissue ischemia, if the pressure is relieved and the blood flow returns, what color does the skin turn?
Red. Hyperemia (redness)
Blanching occurs when the normal red tones of the light-skinned patient are ____.
Absent
Evaluate an area of hyperemia by pressing a finger over the affected area. If it blanches (turns lighter in color) and the erythema returns when you remove your finger….
the hyperemia is transient and is an attempt to overcome the ischemic episode, thus called blanching hyperemia
If the erythematous area does not blanch (non blanching erythema) when you apply pressure….
Deep tissue damage is probable.
Clinical implications of pressure
- Evaluating the amount of pressure (checking skin for reactive hypermia)
- Determining the amount of time that a patients tolerates pressure (checking to be sure after relieving pressure that the affected area blanches.)
Systemic factors such as ___ ___ ___ affect the tolerance of the tissue to externally applied tissue.
Poor nutrition
- Hydration status
- Low BP
is the sliding movement of skin and subcutaneous tissue while the underlying muscle and bone are stationary.
Shear force
Example: _____ _____ occurs when the head of the bed is elevated and the sliding of the skeleton starts, but the skin is fixed because of friction with the bed.
Shear force
Force of two surfaces moving across one another such as the mechanical force exerted when skin is dragged across a coarse surface such as bed linens.
Friction
What is the difference between shear and friction injuries?
Friction injuries affect the epidermis or top layer of the skin, Shear do not.
The denuded skin appears red and painful and is sometimes referred to as “sheet burn.”
Friction
A friction injury usually occurs in:
Patients who are restless
-Those whose skin is dragged rather than lifted from the bed surface during position changes.
Immobilized patients who are unable to perform their own hygiene needs depend on the nurse to?
Keep the skin dry and intact.
Skin moisture originates from:
- wound drainage
- excessive perspiration
- fecal or urinary incontinence
Can you stage an ulcer covered with necrotic tissue?
No, because the necrotic tissue is covering the depth of the ulcer. Necrotic tissue must be debrided or removed to expose the wound base to allow for assessment.
Definition for an ulcer that is unstageable/unclassified
in which the base of the wound cannot be visualized and a definition of tissue injury in which the depth of the injury is unknown.
Depth of tissue involvement is?
Staging
red, moist, tissue composed of new blood vessels.
Granulation tissue
Soft yellow of white tissue is a slough
(stringy substance attached to wound bed)
Black or brown necrotic tissue is ____. Thick layer of dead dry tissue that covers a pressure ulcer or
eschar
Measure depth of an ulcer in the wound bed with?
Cotton-tipped applicator
Wounds are usually easily cleaned and repaired. Wound edges are clean and intact.
Acute wound
Continued exposure to insult impedes wound healing.
Chronic wound
Primary intention (healing process) Like a surgical incision.
Healing occurs by epithelialization; heals quickly with minimal scar formation.
Secondary Intention (wound edges not approximated) Like pressure
Wounds heal by granulation tissue formation, would contraction, and epithelialization.
Tertiary Intention (wound left open for several days, then wound edges are approximated)
Closure of wound is delayed until risk of infection is resolved.
Wound exudate should describe:
- the amount
- color
- consistency
- odor of wound drainage
Excessive exudate indicates the
infection
Skin surround the wound asses for:
Redness
- Warmth
- Maceration
- Edema (swelling)
- Presence of any of these factors indicates wound deterioration.
What differentiates contaminated wounds from infected wounds?
Amount of bacteria present.
A patient who is at risk for dehiscence
- poor nutritional status
- infection
- obesity
When this appear, the nurse should places sterile towels soaked in sterile saline over the extruding tissues to reduce the chances of bacterial invasion and drying of the tissues. Surgical emergency.
When evisceration occurs
Braden scale six subscales:
- sensory perception
- moisture
- activity
- mobility
- nutrition
- friction/shear
To keep nutritional maintenance we required
1500 kcal/day
Physiological processes of wound healing depend on:
- protein
- vitamins (especially A & C)
- trace minerals zinc and copper
Protein formed from amino acids acquired by fibroblasts from protein ingested in food.
Collage
To synthetize collagen we need:
Vitamin C
The vitamin that reduce the negative effect of steroids on wound healing is
Vitamin A
Wound remodeling & immune function. Tissue repair and growth.
Protein
antioxidant
Vitamin E
wound closure, epithelialization, inflammatory response, angiogenesis, collagen formation. *can reverse steroid effects on skin and delayed healing.
Vitamin A
Collagen synthesis, capillary wall integrity, fibroblast function, antioxidant
Vitamin C
Collagen formation
Protein Synthesis
Cell membrane & host defenses
Zinc
Essential fluid environment for all cell function
Fluid
Calories provide the energy source needed to support….
the activity of wound healing.
When repositioning an immobile patient, the nurse notices redness over a bony prominence. What is indicated when a reddened area blanches on fingertip touch?
Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode.
Which type of pressure ulcer is noted to have intact skin and may include changes in one or more of the following: skin temperature (warmth or coolness), tissue consistency (firm or soft)
Stage I
When obtaining a wound culture to determine the presence of a wound infection, from where should the specimen be taken?
Wound after it has first been cleaned with normal saline
After surgery the patient with a closed abdominal wound reports a sudden “pop” after coughing. When the nurse examines the surgical wound site, the sutures are open, and pieces of small bowel are noted at the bottom of the now-opened wound. Which corrective intervention should the nurse do first?
Cover the area with sterile, saline-soaked towels and immediately notify the surgical team; this is likely to indicate a wound evisceration
Which description best fits that of serous drainage from a wound?
Clear, watery plasma
For a patient who has a muscle sprain, localized hemorrhage, or hematoma, which wound care product helps prevent edema formation, control bleeding, and anesthetize the body part?
Ice bag
Which skin care measures are used to manage a patient who is experiencing fecal and urinary incontinence?
Using an incontinence cleaner, followed by application of a moisture-barrier ointment
A dressing that forms a gel that interacts with the wound surface is called
hydrocolloid dressing
Which of the following is an indication for a binder to be placed around a surgical patient with a new abdominal wound?
Reduction of stress on the abdominal incision
When is an application of a warm compress indicated? (Select all that apply.)
To relieve edema;
To improve blood flow to an injured part
What is the removal of devitalized tissue from a wound called?
Debridement
Name the three important dimensions to consistently measure to determine wound healing.
Width, Length, and Depth
What does the Braden Scale evaluate?
skin integrity risk
that the tissue over the sacrum is dark, hard, and adherent to the wound edge. What is the correct stage for this patient’s pressure ulcer?
Unstageable
Name one intervention and the rationalization to use that intervention to reduce the likelihood of a shear injury to a patient.
transfer device can pick up a patient and prevent his or her skin from sticking to the bed sheet as he is repositioned. A second intervention would be to position the patient with the head of the bed to be elevated at 30 degrees, which prevents him or her from sliding. A third intervention would be to educate the patient and his or her caregiver on the importance of not sliding on the sheets when repositioning.
