Fundamentals 48- Skin and wound care Flashcards
Bed Bound Patients
Reposition Q 2 hours, more often if at high risk Place pillow between bony prominences, avoid positioning directly on trochanter, and 30 degree turn recommended dependent upon patient tolerance.
Bed bound Patients and heel protection:
Hell suspension/ suspend heels off bed with pillow.
Correct cause of incontinence if possible:
Offer frequent or timed toileting, keep toilet aids within easy reach, answer call lights promptly, rule out possible UTI, check for fecal impaction(frequent cause of fecal/urinary incontinence), discuss plan of care with physician and nutritionist to correct diet, and initiate measures to normalize stool frequency/consistency.
Incontinent associated dermatitis:
Urine: water saturates skin, increases risk of friction and erosion. Ammonia raises pH, promotes pathogenic growth, disrupts acid mantle, activates fecal enzymes.
Stool incontinent:
Fecal enzymes damage skin, promote erosion, worse in high volume diarrhea. GI bacteria may be pathogenic. Water overhydrates the skin.
Principles of dermatitis prevention:
Cleanse-routine daily cleansing for everyone; Moisturize-cleanse and moisturize after each major incontinent episode; Protect-apply moisture barrier for significant urine/stool/double incontinence.
Skin with too much moisture:
Is 5 times more likely to ulcerate than dry skin.
Skin with too little moisture:
Is 2.5 times more likely to ulcerate than healthy skin.
Manage nutrition:
Protein, and calories, multivitamin, vitamin C, zinc, hydration, dietician consult of course!
Factors that affect skin breakdown:
Mechanical, friction, shearing abrasion, pressure, cytotoxic, chemical incontinence, urine, bowel, and thermal.
Shearing and friction that cause skin breakdown:
Shearing from tape, and skins tears from drag/pulling across the bed sheets, etc., especially if patient is being moved incorrectly.
What is the impact that pressure ulcers have?
Pain, loss of dignity and quality of life, infection, chronic non-healing wound;, surgical procedures(debridement, fecal diversions, and amputation), loss of tissue strength, death-3 times increased mortality.
Financial impact of pressure ulcers:
Increased healthcare costs, prolonged length of stay(3.5 to 5 times), average cost to treat is $2,000 to 50,000 per ulcer, estimated 6.4 billion dollars spent each year to treat pressure ulcers. and treatment costs are 2.5 time the cost of preventive measures.
Impact of pressure ulcers on staff:
Increased staff workload, dressing changes, and antibiotic therapy and management, litigation due to neglect- awards can be as high as $60-$80 million, and considered elder abuse- monetary awards in addition to malpractice claim, up to $250,000.
How often must risk assessment be done?
It must be done on admission and at regular intervals. Use Braden scale risk assessment tool
What does the Braden Scale assess?
Sensory perception, moisture, activity, mobility nutrition, friction and shear.
How is the Braden scale used?
A risk number is given- the lower the number, the higher the risk. Interventions must be started on admission and re-assessed throughout hospital stay.
What is the cutoff score for onset of pressure ulcer risk with the braden scale?
The score ranges from 6 to 23 and the cutoff for the general adult population is 18.
What is a pressure ulcer?
Localized area of tissue breakdown resulting from compression of soft tissue between a bony prominence and an external surface.
What is the Iceberg effect?
Its when pressure is highest between the soft tissue and the bony prominence. Tissue injury starts at the bone/tissue interface and extends outwards. This accounts for the undermining commonly seen in pressure ulcers.
Pressure ulcer staging:
Staging is for pressure ulcers only. Staging describes only the level of tissue damage or loss and does not describe levels of progression or healing. Pressure ulcers stages cannot revers- a healing stage 3 does not become a stage 2.
Stage 1 pressure ulcer:
Non-blanchable erythema of intact skin. May include: discoloration, warmth/coolness, edema, or change in tissue consistency.
Stage II pressure ulcer:
Partial thickness loss of dermis: shallow open crater with red, pink wound bed that presents as: abrasion, open blister or shallow crater. May be painful.
One way blisters can develop:
Improperly fitted brace for foot drop.
Stage III pressure ulcer:
Full-thickness skin loss - subcutaneous fat may be visible, may extend down to but not through underlying fascia, may be shallow or deep, with/without undermining or tunneling, and eschar and/or slough may be present.
Stage IV pressure ulcer:
Full-thickness skin loss-Extensive destruction of tissue, with visible or palpable muscle, bone, tendon, may include undermining/sinus tracts and may be shallow or deep.
Unstageable ulcer:
ulcer bed is covered with eschar or slough so that full extent of injury cannot be assessed.
Suspected deep tissue injury:
Purple or maroon area of intact skin, or blood-filled blister due to damage of underlying tissue. May evolve into ulcer.
What are the four cardinal signs of inflammation, as described by the Roman physician and science writer Celsus?
Rubor(redness), tumor(swelling), calor(heat), and dolor (pain).
Proliferation :
To grow by rapid production of new parts, cells, buds, or offspring. This lasts 4-21 days-pink granulation tissue or epithelialization, contraction.
Remodeling of wound healing:
Can last up to 2 years
Basic repair of a wound:
Regeneration:
Age 18-25=21 days
Age 35>=42 days
Factors that affect wound healing:
Perfusion/oxygenation, nutrition, infection, corticosteroids, aging, diabetes, smoking.
Nursing measures to optimize wound repair /Pre-op:
Nutrition, reduce steroids, eliminate aspirin, patient education to reduce anxiety.
Post-op for wounds:
Pain control, warmth, hydration, supplemental oxygen, provide support binders.
Acute wounds:
Wounds with sudden onset includes superficial, penetrating, perforating, laceration, abrasion, contusion, skin tears, surgical wounds.
Chronic wounds;
Any acute wound that fails to heal, or pressure, venous, arterial, diabetic, and neuropathic wounds.
Surgical wounds healings occurs by:
Primary intention, secondary intention, and tertiary intention.
Different types of surgical wounds:
JP, Hemovac, autotranfusion device, penrose, suction catheter.
Remove dressing & assess:
Incision, drainage, signs of inflammation, replace dressing-sterile vs clean technique, and staple/suture removal.
Wound documentation:
Location, measurements in centimeters - length X width X depth, any tunneling/undermining, color of wound bed, condition of surrounding tissue/skin, drainage, odor, and pain.
Some nursing diagnosis for wounds:
Alteration in comfort
Impaired skin/tissue integrity
Risk for infection
Basic documentation of wounds:
What was observed, what interventions were performed, patient response to interventions.
What does undermining mean?
Tissue destruction to underlying intact skin along wound edges. Measure by using cotton tip applicator, mark distance between tip and wound edge, indicate the extent of undermining and location by using clock face.
What is tunneling/tracts:
A measurable tract extending from the wound bed. Measure by using cotton tip applicator, mark length between tip and wound edge, indicate location by using clock face.
Serous wound:
Is clear, water plasma.
Sanguineous wound
indicates fresh bleeding.
Serosanguineous wound
Is a pale, more watery drainage than sanguineous drainage.
Purulent wound
Is a thick, yellow, green, or brown drainage.
Exudate odor:
Foul smelling-expected in the presence of eschar or slough, and/ or infected wounds. Mild exudate may be associated with wound care products.
Wound bed appearance:
Red- usually indicated granulation tissue.
Yellow-slough-soft necrotic tissue
Black-Eschar-firm/hard necrotic tissue.
Universal principles of wound care:
Remove necrotic tissue(slough, eschar)
Treat infection
Fill dead space
Maintain most wound envrionment
Stool consistency varies with location;
Transverse=loose
Signmoid=formed
Location of Loop colostomy:
Location is usually in the transverse colon
Proximal opening = stool
Distal opening = mucus
Patient with an lleostomy:
Stool always loose
High enzyme & alkaline content
Permanent or temporary
May be loop
Urostomy(ileal conduit)
Ileum used to form reservoir
urine flow nearly constant
Mucus in urine normal
Always permanent
Care for a colostomy:
Measure stoma with measuring guide. Cut wafer to fit, allowing a little “wiggle room” no more than 1/8th inch. Opening may need to be oval. If measuring guide not available, cut small, try on for size, then enlarge opening as needed. Re-measure stoma at least weekly for 4-6 weeks post-op or until size has not changed in 2 weeks. Clean skin with water only( may use soap & water if takin a shower). When showering, leave appliance on or remove completely-do not remove pouch only. Do not use baby wipes or wipes of any kind to clean the skin!!
How to empty colostomy bag:
Empty at no more than 1/2 full Replace immediately if leakage occurs No need to rinse pouches lleostomy and urostomy will fill quickly-2 hours or less Empty gas as needed
Care for urostomy pouch at night:
Urostomy pouch should be attaché to drainage bag. Spout must be in open position when attached to drainage bag.
Wear time for pouch;
should GET 3-5 DAYS wear time. Instruct patient to change appliance 2 X week.
Contact WOCN nurse if changing more often.
