Exam 3: Skin assessment and wound care Flashcards
Skin and Aging
Decreased elasticity and collagen Thinning of underlying tissue Easily torn Co-morbidities and poly-pharmacy Decreased inflammatory response Decreased subcutaneous layer over bony prominences Malnutrition
Wounds heal from
the bottom up and the sides in
Last place to heal is the
Center of the wound
Healing times vary
On circulation and ease of blood movement
Final remodeling of wounds occurs
6-12 months
Sun exposure of wounds
Hyperpigmentation
When to clean wound?
If it is
- Dirty
- Deep
- Open
- Dry
- Wet
Wound
Disruption in integrity and function of tissues in the body
acute wound
Trauma/surgical
Chronic wound care
Prolonged healing r/t vascular compromise, inflammation, repetitive insults to issue
primary intention
sutured/staples, quick healing, minimal scarring
Secondary intention
Tissue loss/contamination, slower, moderate, scarring
Tertiary intention
Contaminated wound allowed to remain open until risk of infection resolved
Wounds are classified by
Onset
Process
Depth
Color
Partial thickness wound repair
Inflammatory response
Epithelial proliferation and migration
Reestablishment of the epidermal layers
Full-thickness wound repair
Hemostasis
Inflammatory
Proliferative
Maturation
Hemorrhage
- Externally or internally
- Surgical drain to remove fluid in underlying tissue
- Risk is greatest first 24-48 hours after surgery/injury
Infection
- Contaminated vs infected # bacteria present
- Chronic wounds are colonized with bacteria
- Bacteria inhibits wound healing
- 4-5 days post surgery
- —-Fever, tenderness and pain at wound site, elevated WBC
- —-Purulent drainage
Dehiscence
- Partial or total separation of wound layers
- Coughing, vomiting, sitting up
- Splint/bandage wounds to prevent
Evisceration
- -Protrusion of visceral organs
- -Emergency
- -Use sterile towels soaked in saline
Pressure ulcer
Pressure sore, decubitus ulcer, or bed sore
Pathogenesis of pressure ulcers
- Pressure intensity
- Tissue ischemia
- Pressure duration
- Tissue tolerance
Stage 1 pressure ulcer
Intact skin with non-blanchable redness
Stage 2 pressure ulcers
Partial-thickness skin loss involving epidermis, dermis, or both
Stage 3 pressure ulcers
Full-thickness skin tissue loss with visible fat
stage 4 pressure ulcers
Full-thickness tissue loss with exposed bone, muscle, or tendon
Beyond stage 4 pressure ulcer
Deep tissue pressure injury
Unstageable pressure injury
Deep tissue pressure injury (DTPI)
- Persistent non-blanchable deep red, maroon, or purple
- Skin may be intact or nonintact
- Intense and/or prolonged pressure and shear forces down deep.
- May/may not open up.
Unstageable pressure injury
- Obscured full-thickness skin and tissue los
- Obscured because of slough or eschar are present
What do you want to avoid with wound healing
Hemorrhage
Infection
Risk assessment for pressure ulcers
Braden scale
— sensory, moisture, activity, mobility, nutrition, friction/shearing
Prevention of pressure ulcers
- Beds, mattresses, good hygiene, good nutrition (check labs), adequate hydration, impeccable nursing care.
- Time and amount of pressure = key variables
- Increases hospital Length of Stay (LOS) = $$$
- Pain/suffering
Factors influencing pressure ulcer formation and wound healing
Nutrition Tissue perfusion Infection Underlying heath status Age Use of steroids Site of wound Mechanism of injury
Infection prolongs
Inflammatory phase and delays healing
Aging dermis tends to
not support sutures well
Wound prevention
- Skin care
- Continence Management
- Positioning
- Support surfaces
- –Low-air-loss mattress/overlay
- –Non-powered: cushions, foam
- –Air-fluidized beds: change load distribution/pressure
- –Lateral rotations: passive turning
Assessment of skin/wounds
Through the patient’s eyes: impact, OLDCART
Assess skin at intake into facility/care
Appearance
Drainage:
—Amount
—Color
——Serous/Sanguinous/Serosanguinous/Purulent
—Odor
—Consistency
—Cultures
Peri-wound: tissue surrounding actual wound
Risk factors for pressure ulcers
Impaires sensory perception Alterations in LOC Impaired mobility Shear Friction Moisture Nutrition Hydration
Wound cultures
Clean wound surface with a non-antiseptic solution Use sterile swab from culturette tube Moisten swab with normal saline Rotate swab in open wound Reinsert into transport tube.
Wound management
Debridement Closures Protection Education Nutritional status
Debridement (removal of nonviable, necrotic tissue)
Mechanical, autolytic, chemical, or sharp/surgical
Sharp/surgical only w/NP or CWN, not general nurses
Wet to dry dressing
Closures
Sutures, staples, steri strips, derma bond adhesive
Protection
dressings and wraps
Nutritional status
- Caloric needs
- Albumin/pre-albumin
- Can lose up to 50 G of protein /day from weeping ulcer
- Hemoglobin maintain> 12 if possible
First aid for wounds
Hemostasis
Cleaning
Protection
Ways to control bleeding
Allow puncture wounds to bleed
Do not remove a penetrating object!
Purposes of dressing
- Protect from microorganism contamination
- Aid in hemostasis
- Absorb drainage and debriding a wound
- Support or splint the wound site
- Protect from seeing the wound (if distressing)
- Promote thermal insulation of the wound.
Types of dressing
Gauze Self-adhesive/transparent film Hydrocolloid dressings Hydrogel Foam Alginate Composite dressings
Wound devices
Penrose drain
Jackson-Pratt drainage
V.A.C (vacuum assisted closure)
VAC: Vacuum assisted closure
- Reduces edema/swelling
- Improves circulation to the wound
- Facilitates wound healing and decreases duration of wounds.
- Drawback: Risk for bleeding
