Exam 2 module 3 part 5 Flashcards
Skin and Wound Healing Ch 32
What is skin integrity?
The preservation of all layers of the skin being intact.
What is a wound?
A disruption in the normal skin integrity.
How are skin integrity and wounds related?
They are opposites.
What factors affect skin integrity?
Factors include age and mobility.
What is the epidermis?
The outer portion of the skin.
How many layers does the epidermis have?
Four or five layers.
What is the stratum corneum?
The outermost layer of the epidermis composed of dead cells.
What is the function of the stratum corneum?
It restricts water loss and prevents fluids, pathogens, and chemicals from entering the body.
What is the stratum germinativum?
The innermost layer of the epidermis that produces new cells.
What are keratinocytes?
Protein-containing cells in the dermis that provide strength and elasticity to the skin.
What do melanocytes produce?
Melanin, a pigment that gives skin its color.
What is the function of Langerhans cells?
To phagocytize foreign material and trigger an immune response.
Where is the dermis located?
Below the epidermis and above the subcutaneous tissue.
What type of tissue is the dermis made of?
Irregular fibrous connective tissue.
What structures are found within the dermis?
- Sweat glands
- Sebaceous (oil) glands
- Ceruminous (wax) glands
- Hair and nail follicles
- Sensory receptors
- Elastin
- Collagen
What is the subcutaneous tissue composed of?
Connective and adipose tissue.
What are the functions of the subcutaneous layer?
- Provides insulation
- Offers protection
- Serves as a reserve of calories
What influences the distribution of subcutaneous tissue?
- Sex hormones
- Genetics
- Age
- Nutrition
True or False: Age does not affect skin integrity.
False
Fill in the blank: The _______ is the outermost layer of the epidermis.
stratum corneum
Fill in the blank: The _______ layer is composed primarily of connective and adipose tissue.
subcutaneous
What is vernix caseosa?
A creamy substance that protects an infant’s skin
Vernix caseosa varies in amount at birth
How does an infant’s skin differ from an adult’s skin?
Thinner and more permeable
This predisposes infants to skin breakdown, such as diaper rash
What developmental aspect of infants affects thermoregulation?
Underdeveloped subcutaneous layer and sweat glands
Infants must be swaddled to maintain body heat
What happens to the skin texture of children as they age?
Becomes coarser due to exposure to sun and environmental elements
Infants and young children initially have smooth skin
What hormonal changes occur during adolescence that affect skin?
Increased sex hormones lead to sebaceous and sweat gland activity
This can result in perspiration, odor, and acne
What skin changes may occur in women due to high estrogen levels?
Softening of connective tissue, striae, and darkening of the skin
Commonly seen on the face, areolae, nipples, vulva, and umbilicus
What skin condition affects up to 85% of older adults?
Xerosis
Characterized by itchy, red, dry, scaly, cracked, or fissured skin
What happens to the dermal layer of older adults’ skin?
Loses elasticity due to collagen changes
This increases the risk of skin breakdown and prolongs wound healing
How does aging affect wound healing in older adults compared to young adults?
Regeneration of healthy skin and healing is significantly slower
Chronic diseases in older adults can further interfere with healing
What are some chronic diseases that can interfere with skin healing?
- Diabetes
- Liver dysfunction
These conditions can predispose to infections and affect blood-clotting factor synthesis
What is a key risk factor for immobility-related pressure injury?
Inability to move independently or lack of sensation
Pressure from the body weight can lead to skin tissue injury
List some conditions that increase the risk for immobility-related pressure injury.
- Paralysis
- Extreme fatigue
- High-risk pregnancy
- Sedation
- Casts
- Traction
- Altered sensory perception
These conditions can prevent movement and increase pressure on the skin
What does skin condition reflect?
A person’s overall nutritional status
Nutritional intake affects the skin.
What is essential to maintaining skin integrity?
Adequate intake of protein, cholesterol, calories, fluid, vitamin C, and minerals
These nutrients contribute to skin health.
Why is protein important for the skin?
It maintains the skin, repairs minor defects, and preserves intravascular volume
Adequate protein levels are critical for skin health.
What happens when protein levels decline?
- Skin injury is slow to heal
- Minor defects cannot be repaired
- Edema develops
Fluid leaks from the vascular compartment of dependent areas.
How does edema affect the skin?
- Decreases skin elasticity
- Interferes with oxygen diffusion
- Prone to breakdown
Edema is excess fluid in the tissues.
What is the consequence of low cholesterol levels?
Predisposes patients to skin breakdown and inhibits wound healing
Low-fat tube feedings may lead to deficiencies.
What role do fats play in wound healing?
Provide fuel for wound healing and maintain a waterproof barrier in the stratum corneum
Cholesterol, fatty acids, and linoleic acid are important.
What happens with inadequate calorie intake?
The body uses proteins for energy, making them unavailable for building and maintenance functions
This leads to catabolism.
What are the effects of prolonged malnutrition?
- Weight loss
- Loss of subcutaneous tissue
- Muscle atrophy
- Decreased padding between skin and bones
This predisposes skin to pressure injuries.
Which nutrients are involved in collagen formation and maintenance?
- Vitamin C (ascorbic acid)
- Zinc
- Copper
A deficiency can delay wound healing.
What can poor skin turgor indicate?
Dehydration
Skin turgor reflects the hydration status of the skin.
What does edema result from?
Overhydration
Both dehydrated and edematous skin are prone to injury.
What conditions make skin more prone to injury?
- Pressure
- Shearing
- Friction
- Moisture
Both dry and overhydrated skin are at risk.
What condition developed on the patient’s bony prominences?
Pressure injury
What are the contributing factors for the development of pressure injury?
Immobility, friction, shear, postoperative drainage
What is the population targeted in the PICOT framework?
Malnourished adults
What is the intervention in the PICOT framework?
Nutritional supplements
What is the comparator in the PICOT framework?
Diet without supplements
What is the expected outcome of the intervention in the PICOT framework?
Improved (or faster) healing time
Fill in the blank: The PICOT framework includes Population, Intervention, Comparator, Outcome, and _______.
Time
What is diminished tactile sensation?
A reduced ability to sense touch, heat, and pressure in affected areas
Patients with conditions like peripheral vascular disease, spinal cord injury, diabetes, cerebrovascular accident, trauma, or fractures often experience diminished tactile sensation.
What are the risks associated with diminished sensation?
Increased risk of skin breakdown, burns, unnoticed cuts or wounds, and inability to feel pressure
Patients may not shift position to relieve pressure or notice constricting footwear or clothing.
How does impaired cognition affect pressure injury risk?
Increased risk due to lack of awareness of the need to reposition
Conditions such as Alzheimer disease and dementia can lead to cognitive impairment.
What is impaired arterial circulation?
Restriction of activity, production of pain, and muscle atrophy due to reduced blood flow
Impaired arterial circulation can result in thin tissue that may lead to tissue death.
What is impaired venous circulation?
Engorged tissues with high levels of metabolic waste, leading to edema, ulceration, and breakdown
This occurs when blood flow back to the heart is inadequate.
What is the main cause of chronic wounds?
Circulatory impairment
Both arterial and venous circulation issues interfere with tissue metabolism and delay wound healing.
Fill in the blank: Patients with diminished sensation are less able to sense a _______.
hot surface
True or False: Cognitive impairment can be easily recognized in patients.
False
What should caregivers do to help manage patients with impaired cognition?
Talk to families or caregivers and review the patient’s health history
This helps adjust the plan of care.
List some conditions that can lead to diminished tactile sensation.
- Peripheral vascular disease
- Spinal cord injury
- Diabetes
- Cerebrovascular accident
- Trauma
- Fractures
What happens to tissue due to impaired venous circulation?
Tissue becomes engorged, susceptible to edema, ulceration, and breakdown
What are some effects of medications on skin integrity?
Medications can cause pruritus, dermatoses, photosensitivity, alopecia, or pigmentation changes
These effects can impair skin integrity or delay healing.
How do blood pressure medications affect blood flow?
They decrease the amount of pressure required to occlude blood flow, creating a risk for ischemia
Ischemia is insufficient blood supply to tissues.
What is the impact of anti-inflammatory medications on wound healing?
They inhibit wound healing
Examples include over-the-counter NSAIDs and steroids like prednisone.
What is the effect of anticoagulants on tissue injury?
They can lead to extravasation of blood into subcutaneous tissue, causing hematomas
Anticoagulants include heparin and warfarin.
Which class of medications delays wound healing due to toxicity?
Chemotherapeutic agents
Methotrexate is an example.
What types of medications can increase sensitivity to sunlight?
Certain antibiotics, psychotherapeutic drugs, and chemotherapy agents
This increases the risk for sunburn.
What severe skin condition can be triggered by certain antibiotics and psychotherapeutic drugs?
Stevens-Johnson syndrome
This condition is characterized by severe rash and skin peeling.
Fill in the blank: Several herbal products, such as those containing lavender and tea tree oil, _______ but dry out the skin.
cleanse
These products can cleanse the skin while also leading to dryness.
What is the effect of excessive exposure to moisture on the skin?
Leads to maceration and increases the likelihood of skin breakdown
Maceration refers to the softening of the skin due to prolonged moisture exposure.
What are the most common sources of moisture that lead to skin damage?
Incontinence and fever
Bowel incontinence is particularly troublesome due to the presence of digestive enzymes and microorganisms.
What is the consequence of bowel incontinence on the skin?
Can lead to excoriation, moisture-associated skin damage, dermatitis, pressure injury, and infection
Excoriation refers to the denuding of superficial skin layers.
How does fever contribute to skin issues?
Leads to sweating and increases metabolic rate, raising tissue demand for oxygen
Increased oxygen demand is especially problematic with circulatory impairment or pressure-induced tissue compression.
What does contamination of a wound refer to?
Presence of microorganisms in the wound
All chronic wounds are considered contaminated.
What is colonization in the context of wound care?
Microorganisms increase in number but cause no harm
Colonization can occur from surrounding skin, the external environment, and internal sources like the GI system.
What is critical colonization?
When bacteria begin to overwhelm the body’s defenses
Signs include increased drainage, foul odor, color change of the wound bed, new tunneling, or absent/friable granulation tissue.
What does infection imply in wound care?
Microorganisms are causing harm by releasing toxins, invading tissues, and increasing metabolic demand
Infection makes the skin more vulnerable to breakdown and impedes healing.
True or False: Infection in the skin can allow bacteria to access systemic circulation.
True
If not controlled, bacteria can enter the bloodstream.
What risks are associated with tanning?
Increases the risk for skin cancer and drying the skin
Tanning exposes the skin to ultraviolet radiation.
How can excessive skin cleansing affect the skin?
May impair skin integrity and lead to drying
Frequent bathing and use of soap remove skin oils.
What are the consequences of insufficient skin cleansing?
Contributes to excessive oiliness, clogged sebaceous glands, and inadequate removal of microbes
This can lead to infections on wounds or lesions.
How does regular exercise benefit the skin?
Improves circulation, necessary for skin integrity and wound healing
Circulation is vital for delivering nutrients and oxygen to skin tissues.
What role does a nutritious diet play in skin health?
Provides nutrients needed to maintain skin integrity
Nutrients are essential for skin repair and health.
How does smoking affect the skin?
Compromises oxygen supply, delays wound healing, and interferes with vitamin C absorption
Vitamin C is necessary for collagen formation.
What risks do body piercings and tattoos pose?
Risk for infection and scarring
Common complications include local inflammation, allergic reactions, and skin infections.
What are the common bacterial infections associated with body piercings?
Staphylococcus and Pseudomonas strains
These bacteria are often found at or near the site of body piercings.
What systemic infection can result from unsterile tattooing conditions?
Hepatitis C
Unsterile conditions can lead to serious infections.
What complications can arise from oral piercings?
Gingivitis, damage to teeth and gums, choking, difficulty eating, and changes in speech
Oral piercings can lead to various oral health issues.
What can prolonged bleeding during tongue piercing indicate?
A punctured blood vessel
Prolonged bleeding can be a serious complication.
What should patients do before getting a tattoo or piercing?
Become informed about the procedure and aftercare, and find reputable tattoo artists/piercers
Knowledge and safety are key to minimizing risks.
What is a wound?
A disruption in the normal integrity of the skin
Wounds may be intentional (surgical) or unintentional (cuts, pressure injuries)
How are wounds classified?
According to length of time and condition of the wound
Factors include contamination and severity
What defines a closed wound?
No breaks in the skin
Examples include contusions and tissue swelling from fractures
What is an open wound?
A break in the skin or mucous membranes
Includes abrasions, lacerations, puncture wounds, and surgical incisions
What is a compound fracture?
A fracture that leads to an open wound caused by the projection of bone through the skin
This type of injury can create significant complications
What are acute wounds?
Wounds expected to be of short duration that heal spontaneously
They go through three phases: inflammation, proliferation, and maturation
What characterizes chronic wounds?
Wounds that exceed the expected length of recovery due to interrupted healing
Examples include pressure injuries and diabetic ulcers
List factors that can stall the healing of chronic wounds.
- Infection
- Continued trauma
- Ischemia
- Edema
These factors can lead to prolonged recovery times
What are clean wounds?
Uninfected wounds with minimal inflammation
They may be open or closed and do not involve certain tracts that harbor microorganisms
True or False: Clean wounds involve the gastrointestinal, respiratory, or genitourinary tracts.
False
Clean wounds do not involve these systems, which frequently harbor microorganisms
Fill in the blank: Chronic wounds may linger for _______ or even years.
months
Unless properly diagnosed and treated, chronic wounds can persist for long durations
What is an abrasion?
A scrape of the superficial layers of the skin; usually unintentional but may be performed intentionally for cosmetic purposes to smooth skin surfaces.
Also see excoriation.
Define abscess.
A localized collection of pus resulting from invasion from a pyogenic bacterium or other pathogen; must be opened and drained to heal.
What is a contusion?
A closed wound caused by blunt trauma; may be referred to as a bruise or an ecchymosis.
Describe a crushing wound.
A wound caused by force leading to compression or disruption of tissues, often associated with fracture; usually minimal or no break in the skin.
What is an excoriation?
A superficial wound, usually self-inflicted due to excessive scratching or mechanical force.
What characterizes an incision?
An open, intentional wound caused by a sharp instrument.
Define laceration.
The skin or mucous membranes are torn open, resulting in a wound with jagged margins.
What is a penetrating wound?
An open wound in which the agent causing the wound lodges in body tissue.
Describe a puncture wound.
An open wound caused by a sharp object; often there is collapse of tissue around the entry point, making this wound prone to infection.
What is a tunnel wound?
A wound with entrance and exit sites.
What are clean-contaminated wounds?
Surgical incisions that enter the GI, respiratory, or genitourinary tracts with increased risk of infection but no obvious infection.
These wounds are at risk due to their nature of entering areas that are normally not sterile.
What characterizes contaminated wounds?
Open, traumatic wounds or surgical incisions with a major break in asepsis and high risk of infection.
Contaminated wounds often involve exposure to pathogens.
Define infected wounds.
Wounds with bacteria above 100,000 organisms per gram of tissue.
Presence of beta-hemolytic streptococci in any number is also considered an infection.
List signs of wound infection.
- Erythema and swelling around the wound
- Fever
- Foul odor
- Severe or increasing pain
- Large amount of drainage
- Warmth of the surrounding soft tissue
These signs indicate potential complications in wound healing.
What is a major determinant of wound healing time?
Depth of the wound and location.
Deeper wounds take longer to heal, and wounds in areas of pressure or movement heal slower.
How does circulation affect wound healing?
Wound healing is more difficult in areas of poor circulation, such as the feet in those with diabetes or congestive heart failure.
Adequate blood flow is essential for healing.
What are superficial wounds?
Wounds that involve only the epidermal layer of the skin, usually due to friction, shearing, or burning.
These wounds typically heal faster than deeper wounds.
Describe partial-thickness wounds.
Wounds that extend through the epidermis but not through the dermis.
These wounds can be more complex than superficial wounds.
What are full-thickness wounds?
Wounds that extend into the subcutaneous tissue and beyond.
The term ‘penetrating’ may be added if internal organs are involved.
What types of cells are involved in the wound healing process?
Epithelial cells, endothelial cells, inflammatory cells, platelets, fibroblasts
Fibroblasts are cells in connective tissue that produce fibrin.
What is the primary function of fibroblasts in wound healing?
To produce fibrin
Fibrin is essential for tissue repair and regeneration.
Does the wound healing process differ based on the type of injury or tissues involved?
No, the process is essentially the same regardless of the type of injury or tissues involved.
Fill in the blank: The wound healing process involves the migration of _______ into the wound.
cells
True or False: Wound healing is a uniform process across different types of injuries.
True
What is the role of platelets in the wound healing process?
To assist in tissue repair and regeneration
List the main cell types involved in the wound healing process.
- Epithelial cells
- Endothelial cells
- Inflammatory cells
- Platelets
- Fibroblasts
What do epithelial and endothelial cells contribute to during wound healing?
Tissue repair and regeneration
What is the primary cause of pressure injuries?
Pressure, shear, and friction resulting in tissue ischemia and injury
Pressure injuries are often located over bony prominences and can lead to serious tissue damage.
What are the common characteristics of arterial ulcers?
Located over lower leg, especially ankles, toes, side of foot, and shin; appears ‘punched out’, small and round with smooth borders; wound base usually pale; shiny, thin, dry surrounding skin; cool to touch; loss of hair in surrounding area; delayed capillary refill time; very painful, especially at night and with increased activity
Arterial ulcers are caused by inadequate circulation of oxygenated blood to the tissue.
Where are venous stasis ulcers typically located?
Around the inner ankle or in the lower part of the calf
Venous stasis ulcers are caused by incompetent venous valves, deep vein obstruction, or inadequate calf.
What is a distinctive feature of the surrounding skin of arterial ulcers?
Shiny, thin, and dry; cool to touch
This characteristic is due to inadequate blood flow and oxygenation.
True or False: The appearance of pressure injuries is uniform regardless of the stage.
False
The appearance of pressure injuries varies depending on the stage or tissue layers involved.
Fill in the blank: Arterial ulcers are very painful, especially at _______ and with increased activity.
night
What are the common symptoms of venous stasis ulcers?
Reddened or brown surrounding skin; edematous
These symptoms are due to fluid accumulation and poor circulation.
What is the wound base appearance of arterial ulcers?
Usually pale with or without necrotic tissue
Necrotic tissue may be present if the ulcer is severe.
What causes arterial ulcers?
Inadequate circulation of oxygenated blood to the tissue
This leads to tissue ischemia and subsequent damage.
What type of injury is characterized by tissue ischemia and injury due to pressure, shear, and friction?
Pressure injury
What causes venous stasis ulcers?
Incompetent venous valves, deep vein obstruction, or inadequate calf muscle function
Where are venous stasis ulcers usually located?
Around the inner ankle or in the lower part of the calf
What are the characteristics of the surrounding skin of venous stasis ulcers?
Reddened or brown and edematous
Describe the wound characteristics of venous stasis ulcers.
Usually shallow, with irregular wound margins
What does the wound bed of a venous stasis ulcer appear like?
Ruddy or beefy red and granular
What is the typical drainage level of venous stasis ulcers?
Moderate to heavy depending on the amount of edema
When does pain usually occur in patients with venous stasis ulcers?
With leg dependence and dressing changes
What causes a diabetic foot ulcer?
Narrowing of the arteries leading to reduced oxygenation to the feet
This results in delayed wound healing and tissue necrosis.
What are common symptoms of a diabetic foot ulcer?
Often painless; may include drainage, swelling, redness, and ulceration
Symptoms may vary but often include visible signs of ulceration.
Where do diabetic foot ulcers mainly occur?
On the plantar surfaces and toes (balls of the foot or underside of the toes)
These areas are prone to pressure and injury.
True or False: Diabetic foot ulcers are highly susceptible to wound infection.
True
This susceptibility is due to poor sensation, circulation, and immune protection.
Fill in the blank: Diabetic foot ulcers result in _______ due to poor sensation.
[wound infection]
Poor sensation contributes to the inability to detect injuries.
What are the types of healing wounds may undergo?
Regeneration, primary intention, secondary intention, tertiary intention
What characterizes regenerative or epithelial healing?
Occurs when a wound affects only the epidermis and dermis; no scar forms; new epithelial and dermal cells form skin indistinguishable from intact skin
Partial-thickness wounds heal by regeneration
Define primary intention healing.
Healing occurs with minimal or no tissue loss and well approximated edges; little scarring expected
A clean surgical incision is an example of primary intention healing
What is the strength of a scar formed by primary intention healing compared to original tissue?
80% as strong
Fill in the blank: A clean surgical incision heals by _______.
primary intention
What is secondary intention healing?
Healing that occurs when a wound involves extensive tissue loss or should not be closed.
What prevents wound edges from approximating in secondary intention healing?
Extensive tissue loss.
When should a wound not be closed?
When there is an infection.
How does a wound heal in secondary intention?
It heals from the inner layer to the surface by filling in with granulation tissue.
What is granulation tissue?
A form of connective tissue with an abundant blood supply.
What appearance may healing epithelial tissue have in a wound?
Small pink or pearl-like areas.
True or False: Wounds that heal by secondary intention heal more quickly.
False.
What are the risks associated with wounds healing by secondary intention?
More prone to infection and develop more scar tissue.
Fill in the blank: Wounds that heal by secondary intention heal _______.
more slowly.
What is tertiary intention healing also known as?
Delayed primary closure
Tertiary intention healing is a surgical technique used in wound management.
What occurs during tertiary intention healing?
Two surfaces of granulation tissue are brought together
This technique is applied after a period of healing by secondary intention.
When is tertiary intention healing used?
When the wound is clean-contaminated or contaminated
This approach is taken after initial healing by secondary intention.
What happens to the wound initially in tertiary intention healing?
It is allowed to heal by secondary intention
This phase is crucial before assessing for closure.
What conditions must be met before closing a wound in tertiary intention healing?
No evidence of edema, infection, or foreign matter
Ensuring these conditions helps reduce the risk of complications.
What technique is required during dressing changes for wounds healing by tertiary intention?
Strict aseptic technique
This is necessary because these wounds are prone to infection.
How does scarring from tertiary intention healing compare to other healing types?
Less scarring than secondary but more than primary intention healing
Understanding scarring outcomes is important for patient expectations.
What are the three stages of wound healing?
Inflammatory, proliferative, maturation
How long does the inflammatory phase last?
1 to 5 days
What are the two major processes in the inflammatory phase?
Hemostasis, inflammation
What happens during hemostasis?
Blood and plasma leak into the wound, vessels constrict, platelets aggregate, and a blood clot forms
What characterizes the inflammatory reaction?
Edema, erythema, pain, temperature elevation, migration of white blood cells
What role do macrophages play in the inflammatory phase?
Engulf bacteria (phagocytosis) and clear debris
What forms a scab on the wound surface?
Plasma proteins, fibrin, and debris
What is the main purpose of the scab?
Seals the wound and helps prevent microbial invasion
Fill in the blank: The inflammatory phase consists of _______ and inflammation.
[Hemostasis]
What is the Proliferative Phase in wound healing?
Occurs from days 5 to 21, where cells fill the wound defect and resurface the skin.
This phase involves key processes like fibroblast migration and collagen formation.
What role do fibroblasts play in the Proliferative Phase?
Fibroblasts migrate to the wound and form collagen, adding strength to the healing wound.
Fibroblasts are a type of connective tissue cell.
What is granulation tissue?
A tissue that forms during the Proliferative Phase, characterized by its ability to bleed readily and be easily damaged.
Granulation tissue is vital for wound healing.
What process occurs as the clot or scab is dissolved?
Epithelial cells begin to grow into the wound from surrounding healthy tissue, sealing over the wound (epithelialization).
Epithelialization is crucial for restoring skin integrity.
When does the Maturation Phase of wound healing begin?
It begins in the second or third week and continues even after the wound has closed.
This phase is also known as remodeling.
What happens to collagen fibers during the Maturation Phase?
Initial collagen fibers are broken down and remodeled into an organized structure, such as scar tissue.
This remodeling increases the tensile strength of the wound.
How long does the Maturation Phase last?
It lasts for 3 to 6 months after the wound has closed.
This phase is important for the final strength of the healed tissue.
What are the two types of wound healing that may involve closure methods?
Primary and tertiary intention
Wound healing by primary intention involves direct closure, while tertiary intention involves delayed closure.
What are adhesive strips used for in wound closure?
They are used for:
* Closing superficial low-tension wounds
* Closing the skin on wounds closed subcutaneously
* Providing additional support after sutures or staples have been removed
An example of adhesive strips is Steri-Strips.
Fill in the blank: Adhesive strips are used to close _______ wounds.
superficial low-tension
True or False: Adhesive strips can only be used on wounds that have not been sutured.
False
Adhesive strips can also be used after sutures or staples have been removed.
What is one benefit of using adhesive strips on wounds that have been closed subcutaneously?
Aiding in healing and reducing scarring
What are adhesive strips used for?
Adhesive strips are often kept in place until they begin to separate from the skin on their own.
What is the traditional method for wound closure?
Sutures (stitches)
What do sutures create along the laceration or incision?
Small puncture wounds
What are the two types of sutures based on absorbency?
- Absorbent sutures
- Nonabsorbent sutures
Where are absorbent sutures typically used?
Deep in the tissues, such as to close an organ or anastomose tissue.
What is a characteristic of absorbent sutures?
They gradually dissolve and do not need to be removed.
Where are nonabsorbent sutures placed?
In superficial tissues
What is required for nonabsorbent sutures after placement?
Removal, usually by the nurse.
Fill in the blank: Suturing creates ______ along the track of the laceration or incision.
small puncture wounds
True or False: Nonabsorbent sutures are made of material that dissolves.
False
What material are surgical staples made of?
Lightweight titanium
What is one advantage of using surgical staples over sutures?
Lower risk of infection and tissue reaction
What is a downside of using surgical staples?
Some wound edges are more difficult to align
What are the most common sites for wound stapling?
- Arms
- Legs
- Abdomen
- Back
- Scalp
- Bowel
True or False: Wounds on the hands, feet, neck, or face should be stapled.
False
What type of wounds is surgical glue safe for?
Clean, low-tension wounds
What is an ideal use of surgical glue?
Wound closure method for skin tears
What are collaborative treatments necessary for?
Wounds that will not heal despite aggressive care
Name three surgical options used for complicated wounds.
- Extensive débridement
- Skin grafts
- Flap techniques
What is hyperbaric oxygen therapy (HBOT)?
Administration of 100% oxygen under pressure to a wound site
What are the effects of hyperbaric oxygen therapy (HBOT) on wound healing?
- Increases oxygen concentration in tissue
- Stimulates growth of new blood vessels
- Enhances WBC action
- Promotes development of fibroblasts
What does platelet-derived growth factor do in wound healing?
Augments the inflammatory phase and accelerates collagen formation
Fill in the blank: HBOT enhances _______ action in wound healing.
WBC
True or False: Flap techniques involve completely detaching tissue.
False
What is drainage that oozes from a wound or cavity called?
Exudate
Exudate is composed of serum, fibrin, and leukocytes.
What is serous exudate and what does it consist of?
Watery in consistency and contains very little cellular matter; consists of serum
Serum is the straw-colored fluid that separates out of blood when a clot is formed.
What type of exudate indicates damage to capillaries and is often seen with deep wounds?
Sanguineous exudate
Fresh bleeding produces bright red drainage, while older, dried blood appears darker.
What is serosanguineous drainage?
A combination of bloody and serous drainage
It is most commonly seen in new wounds.
What characterizes purulent exudate?
Thick, often malodorous drainage seen in infected wounds
It contains pus, which is a protein-rich fluid filled with WBCs, bacteria, and cellular debris.
What type of bacteria commonly causes purulent exudate?
Pyogenic bacteria
Examples include streptococci and staphylococci.
What color is pus typically, and what can change its color?
Normally yellow; can turn blue-green due to Pseudomonas aeruginosa
Presence of this bacterium can cause a change in color.
What does purosanguineous exudate indicate?
Red-tinged pus
It indicates that small vessels in the wound area have ruptured.
What are the phases of wound healing?
Inflammation, proliferation, maturation
What complications can interrupt the wound healing process?
- Hemorrhage
- Infection
- Dehiscence
- Evisceration
- Fistulas
What does hemorrhage imply?
Profuse or rapid loss of blood
What happens when a capillary network is interrupted?
Bleeding occurs
What is hemostasis?
Cessation of bleeding
How quickly does hemostasis usually occur after an injury?
Within minutes
What can delay hemostasis?
- Injury to large vessels
- Clotting disorder
- Anticoagulant therapy
What might indicate a problem if bleeding resumes after initial hemostasis?
- Slipped suture
- Erosion of a blood vessel
- Dislodged clot
- Infection
When is the risk of hemorrhage greatest following surgery or injury?
In the first 24 to 48 hours
What are the indicators of internal bleeding?
Swelling of the affected body part, pain, and changes in vital signs (decreased blood pressure, elevated pulse)
Internal bleeding refers to bleeding that cannot escape to the surface, leading to a hematoma.
What is a hematoma?
A red-blue collection of blood under the skin that forms due to bleeding that cannot escape to the surface
A large hematoma can cause pressure on surrounding tissues.
How does a large hematoma affect surrounding tissues?
It causes pressure on surrounding tissues
If located near a major artery or vein, it may impede blood flow.
What characterizes external hemorrhage?
Bloody drainage on dressings and in wound drainage devices
External hemorrhage is relatively easy to recognize.
What happens during a brisk external hemorrhage?
Blood often pools underneath the patient as dressings become saturated
It is important to look underneath the patient to assess the full extent of the bleeding.
How can microorganisms be introduced to a wound?
During an injury, during surgery, or after surgery
It is important to maintain sterile techniques during surgical procedures to minimize this risk.
What is a key indicator to suspect an infection in a wound?
A wound fails to heal
This can be a critical sign that the body is unable to recover from the injury due to infection.
List symptoms suggesting infection in a wound.
- Localized swelling
- Redness
- Heat
- Pain
- Fever (temperatures higher than 38°C [100.4°F])
- Foul-smelling or purulent drainage
- A change in the color of drainage
These symptoms can help healthcare providers assess the presence of an infection.
When do symptoms of infection typically occur in a contaminated or traumatic wound?
Within 2 to 3 days
Early detection of these symptoms is crucial for effective treatment.
When do signs and symptoms of infection usually appear in a clean surgical wound?
Usually not until the fourth or fifth postoperative day
Understanding the timeline of infection symptoms can aid in monitoring postoperative recovery.
What is dehiscence?
Rupture (separation) of one or more layers of a wound
When is wound dehiscence most likely to occur?
During the inflammatory phase of healing
What increases the risk of dehiscence after surgery?
Incisions that begin draining within 5 to 7 days
What are common causes of wound dehiscence? List at least three.
- Poor nutritional status
- Inadequate closure of the muscles
- Wound infection
- Increased tension on the suture line
- Obesity
Why are obese patients more likely to experience dehiscence?
Fatty tissue does not heal readily and increased tissue mass puts strain on the suture line
Which type of wounds are usually associated with dehiscence?
Abdominal wounds
What might patients report feeling during dehiscence?
A ‘pop’ or tear
What is a common nursing intervention for dehiscence?
Maintaining bedrest with the head of the bed elevated at 20° and the knees flexed
What should be done if dehiscence occurs?
Notify the provider of the dehiscence immediately
Fill in the blank: An immediate increase in _______ drainage often occurs with dehiscence.
serosanguineous
True or False: Wound infection is a common cause of wound dehiscence.
True
What activities can increase tension on the suture line, contributing to dehiscence?
- Coughing
- Lifting an object
- Sudden straining
What nursing intervention might be applied to prevent evisceration in cases of dehiscence?
Applying a binder, if necessary
but if evisceration occurs DO NOT put a binder on a patient.
What is evisceration?
Total separation of the layers of a wound with internal viscera protruding through the incision
Evisceration is considered a surgical emergency.
What should be done immediately in cases of evisceration?
Cover the wound with sterile towels or dressings soaked in sterile saline solution
This prevents the organs from drying out and becoming contaminated with environmental bacteria.
What is dehiscence?
Separation of one or more layers of a wound
Dehiscence is most common in the inflammatory phase of healing.
What is a fistula?
An abnormal passage connecting two body cavities or a cavity and the skin
Fistulas are most common in the gastrointestinal and genitourinary tracts.
What position should a patient be in during evisceration?
Stay in bed with knees bent to minimize strain on the incision
This positioning helps reduce pressure on the surgical site.
Should a binder be placed on a patient with evisceration?
No
A binder can increase pressure on the wound.
What should be done after an evisceration occurs?
Notify the surgeon and prepare the patient for surgery
Immediate surgical intervention is often required.
What is a fistula?
An abnormal passage connecting two body cavities or a cavity and the skin.
What often causes fistulas?
Infection or debris left in the wound.
What forms as a result of infection in the context of fistulas?
An abscess.
What happens to surrounding tissue when an abscess forms?
It breaks down, creating an abnormal passageway.
What can chronic drainage from a fistula lead to?
Skin breakdown and delayed wound healing.
What are the most common sites of fistula formation?
The GI and genitourinary tracts.
Fill in the blank: A fistula is an abnormal passage connecting two body cavities or a cavity and the _______.
skin.
True or False: Fistulas can only occur in the gastrointestinal tract.
False.
What is a chronic wound?
A chronic wound is one that has not healed within the expected time frame.
How long does it typically take for a wound to be considered chronic?
Wounds that do not heal within 2 to 4 weeks may be considered chronic.
What is a type of chronic wound?
Pressure injury is a type of chronic wound.
What factors contribute to pressure injury?
Factors include time, pressure, tissue tolerance, friction, shearing, moisture, nutrition, age, circulation, and underlying health status.
What does tissue tolerance depend on?
Tissue tolerance depends on friction, shearing, moisture, and nutrition.
What does time and pressure depend on?
Time and pressure depend on sensation and mobility.
Fill in the blank: A chronic wound is one that has not healed within the _______.
expected time frame.
True or False: All wounds that take longer than 2 weeks to heal are classified as chronic wounds.
False.
In semi fowlers position, where does pressure injry occur
over the bony prominences of Vertebrae, sacrum, pelvis, peels
lateral position, where pressure injury near
parietal and temporal bones, ear, shoulder, illium, greater trochanter, knee, malleolus
supine position, where pressure injury
back of head, scapulae, elbows, sacrum, heels
prone position, where pressure injury
cheek and ear, shoulder, breasts, genitalia, knees, toes
What is the primary focus of a physical assessment of skin integrity?
Skin inspection, mobility, and activity assessment
What areas should be routinely assessed for skin condition?
All areas of the body for skin color, integrity, temperature, texture, turgor, mobility, moisture, lesions, and hair distribution
What specific points should be checked for erythema, tenderness, or edema?
Pressure points
Why is it important to assess bony prominences in individuals ‘at risk’ for skin breakdown?
To prevent pressure injuries
Which garments should be included in the skin assessment?
Shoes, heel elevators, and antiembolism stockings
What is the risk for patients with some degree of immobility?
Higher risk for developing pressure injuries
What factors influence the frequency of wound assessments?
Condition of the wound, work setting, patient’s overall condition, underlying disease process, type of wound, and type of treatment
How often should wounds be assessed if providing wound care?
With every treatment
How should the location of a wound be described?
In anatomical terms
What is an example of describing a wound location?
A midsternal incision extending from the manubrium to the xiphoid process
What influences the rate of healing of wounds?
Location of the wound
True or False: Wounds in highly vascular regions heal slower than those in less vascular regions.
False
Fill in the blank: Wounds in highly vascular regions, such as the _______ or ________, heal more rapidly than wounds in less vascular regions.
[scalp], [hands]
Fill in the blank: Wounds in less vascular regions, such as the _______ or ________, heal more slowly.
[abdomen], [heel]
What happens to the skin when ischemia first occurs?
The skin over the area is pale and cool
What occurs when pressure is relieved from an ischemic area?
Vasodilation occurs, extra blood goes to the area, and the area flushes bright red (reactive hyperemia)
What does it indicate if the redness in an ischemic area does not disappear quickly?
Tissue damage has occurred
What are the first steps in skin care assessment?
Regular assessment of the skin for appearance, temperature, texture, and color
Why is adequate lighting important in skin assessment?
To detect subtle, early skin changes
What should be checked at pressure points?
Erythema, tenderness, or edema
What areas should be inspected for skin breakdown in patients with obesity?
Under breasts, in abdominal folds, and where there is skin-to-skin contact
What does the Braden scale assess?
Sensory perception, moisture, activity, mobility, nutrition, friction, and sheer
How does the score on the Braden scale relate to pressure injury risk?
The lower the score, the more likely the patient will develop a pressure injury
What is the Braden Q scale used for?
For children
What does the Norton scale assess?
Risk based on the patient’s physical condition, mental state, activity, mobility, and incontinence
How does the score on the Norton scale relate to pressure injury risk?
The lower the score, the higher the risk is for pressure injury
What does the PUSH tool measure?
The progression of a pressure injury
What factors are scored in the PUSH tool?
Surface area, exudate, and type of wound tissue
What happens to the PUSH score as the injured area heals?
The total score falls
What is the term for damage or risk associated with the outer layer of skin?
Impaired Skin Integrity
Refers to conditions where the skin is damaged or at risk of damage.
What does ‘Impaired Tissue Integrity’ refer to?
Actual or Risk for damage to body tissues
Indicates potential or existing damage to tissues in the body.
What is a potential complication that involves the invasion of pathogens?
Infection
Can be either actual or a risk factor in wound care.
What is the term for physical suffering or discomfort experienced by an individual?
Pain
A common concern in wound care management.
What psychological aspect may change due to a wound?
Altered Body Image
Refers to how an individual perceives their physical self after a wound.
Which adjunctive wound care therapy involves the surgical removal of damaged tissue?
Surgery
Includes procedures like excision, débridement, skin grafts, drains, and flaps.
What adjunctive therapy stimulates cellular growth and increases blood flow?
Electrical stimulation
Promotes healing by encouraging fibroblast development and collagen formation.
What therapy uses high oxygen under pressure to accelerate healing?
Hyperbaric oxygen therapy (HBOT)
Enhances white blood cell activity to improve healing.
What are naturally occurring proteins that promote cell growth and replication?
Tissue growth factors
Important for chronic wound healing, especially in diabetic patients.
What type of therapy uses sound waves to stimulate tissue metabolism?
Ultrasound
Aids in débridement and increases cell metabolism through vibration and heat.
What are bioengineered skin substitutes used for?
Temporary or permanent closure of partial- and full-thickness wounds
Made from human epidermis, dermis, animal cells, or synthetic materials.
What substance enhances wound healing by improving circulation?
Nitric oxide
Promotes fibroblast and collagen growth for skin and tissue repair.
What therapy uses irradiated maggots for precise débridement?
Maggot therapy
Effective as it targets and consumes only necrotic tissue.
What is the primary focus for at-risk patients regarding pressure injury?
Prevention strategies
Includes using visual cues to remind staff to implement these strategies.
How often should hospitalized patients be reassessed for pressure injuries?
Daily, at transfer or discharge, and if condition changes
At-risk patients should be assessed every 8-12 hours.
What is the reassessment schedule for nursing home residents regarding pressure injuries?
Weekly for the first 4 weeks; then quarterly; or if condition deteriorates
This schedule helps monitor ongoing risk.
How frequently should home patients be monitored for pressure injuries?
With every visit
Ensures continuous assessment of their condition.
What should be done to manage moisture in incontinence care?
Provide gentle cleansing, apply moisture barrier cream, use absorbent products
Consider pouching systems for persistent bowel incontinence.
What bathing considerations should be taken for diaphoretic patients?
They may need frequent bathing due to sweat irritation
Older adults typically do not require daily bathing.
What technique should be used when bathing fragile skin?
Gently bathe with minimum force and friction
Washcloths can be abrasive, so care is needed.
What type of soap should be used for bathing sensitive skin?
Mild, emollient cleansing soap
Rinse thoroughly and gently pat the skin dry.
What is the purpose of using a barrier cream?
To prevent skin damage in adults at risk for pressure injury
Especially for those with incontinent, edematous, or inflamed skin.
What should be avoided when massaging fragile skin?
Do not massage over bony prominences
This can irritate the area and lead to tissue injury.
What are the requirements for linens in patient care?
Keep linens soft, clean, dry, and free from wrinkles
Change them frequently to maintain skin integrity.
What is a hydrating dressing used for?
To reduce wound size using hydrocolloid or foam dressings.
Refer to Procedure 32-8 for application details.
What is the purpose of negative-pressure wound therapy?
To create a vacuum that reduces edema, promotes granulation tissue formation, removes exudate and infectious material, and stimulates blood vessel growth.
Refer to Procedure 32-6 for more information.
What is a silver dressing’s role in wound care?
Acts as a barrier to bacteria, eliminates bacterial biofilms, and can reduce prophylactic antibiotic use.
This helps in preventing antibiotic resistance.
How should a transparent dressing be applied?
Apply the clear film or drape free of wrinkles to create a seal for negative pressure.
Refer to Procedure 32-7 for application guidelines.
What is the recommended angle for the head of the bed (HOB) to minimize pressure and shear?
Limit the angle to no more than 30°.
What devices should be used to support patients in bed?
Lift devices, drawsheets, heel and elbow protectors, sleeves, and stockings.
What should never be done when moving a patient up in bed?
Never drag a patient up in bed.
What types of surfaces are included in support surfaces?
Specialty mattresses, integrated bed systems, mattress overlays consisting of air, gel, foam, and water.
What is the function of pressure-redistributing devices?
To redistribute pressure and moisture to prevent bacterial growth on the skin.
What should be used to raise the heels off the bed?
Products specifically designed for that purpose; pillows may not be effective.
What type of devices should be avoided for pressure redistribution in chairs and wheelchairs?
Avoid donut-type devices.
What is the primary reason for frequent position changes in patients at risk for pressure injury?
To prevent tissue damage from ischemia
Ischemia refers to insufficient blood supply to tissues, which can lead to tissue damage and pressure injuries.
How often should patients be turned to prevent pressure injuries?
At least every 2 hours
More frequent turning is required for patients with fragile skin or little subcutaneous tissue.
What is the recommended turning frequency for chair-bound patients?
Every hour, with weight shifts every 15 minutes
What is the ‘Rule of 30’ for positioning?
Elevate the head of bed at a 30° angle or less; side-lying at a 30° angle
This positioning helps avoid direct pressure on the trochanter.
List the key teaching points for preventing pressure injury for at-risk patients.
- Characteristics of healthy skin
- Appearance of skin with unrelieved pressure
- Skin protection and injury prevention
- Skin care and hygiene
What factors indicate a patient is at risk for pressure injury related to nutrition?
- Rapid weight loss
- Increased metabolic demands
- Limited intake
- Decreased serum albumin
What is the recommended daily caloric intake for patients at risk for pressure injury?
30-35 kcal/kg/day
What is the protein requirement for an undernourished patient with a wound?
2 g/kg
What dietary modifications may be necessary for frail patients?
Soft diet for patients who are frail or missing teeth
What supplemental nutritional methods may be used for patients with insufficient oral intake?
- Tube feeding
- Parenteral nutrition
- Dietary referral as needed
