Integumentary Flashcards
Risk factors for impaired skin integrity
nutrition age mobility hydration sensory perception moisture vascular integrity disease
Reduce risk for impaired skin integrity
proper nutrition and hydration hygiene turning q2h proper lifting special mattress pillows protect bony prominence
Stage I pressure ulcer
intact, nonblistered skin
nonblanchable erythema
Stage II pressure ulcer
partial thickness wound
does not extend deeper than dermis
shallow, superficial with pink wound bed
Stage III pressure ulcer
full thickness wound
extends into SQ tissue but not deeper
undermining or tunneling may be present
Stage IV pressure ulcer
Exposure of muscle, bone, connective tissue
Unstageable pressure ulcer
full thickness wound
amount of necrotic tissue makes it impossible to assess depth and underlying structures
Dehiscence
partial or complete separation of tissue layers during healing process
Evisceration
Total separation of tissue layers allowing protrusion of visceral organs
factors affecting wound healing
age
nutrition
disease process
infection
nursing interventions to prevent dehiscence or evisceration
splinting or using binder while coughing, deep breathing, movement
What do you do if dehiscence or evisceration occurs?
cover wound with gauze moistened with normal saline and notify dr
Diet for wound healing
high protein, carbs, vitamins with moderate fat intake
30-35 kcal/kg/day
1.25–1.5 g protein/kg/day
What size needle/syringe do you need to get enough pressure to debride wound?
19g
30 mL syringe
Primary intention
ends are approximated
heals quickly
minimal scarring
ex: paper cut or surgical incision
Primary intention healing phases
Initial: approximated edges, clot forms, plt release GF
Granulation: migration of fibroblast, secretion of collagen, wound is fragile; wound is pink and vascular
Maturation: remodeling of collagen and strengthening of scar
Secondary intention
Heal upward from bottom and inward from sides
cannot be approximated
much larger scar d/t more granulation tissue
Tertiary intention
occurs when contaminated wound is left open and closed after control of infection
results in larger and deeper scar
3 phases of wound healing
Inflammatory
Proliferative
Maturation
What happens during inflammatory phase?
bleeding, coagulation
release of GF and cytokines
increase of pain, redness, warmth, swelling
Macrophages and neutrophils at site
What happens during the proliferative phase?
angiogenesis fibroblasts produce GF, synthesize collagen fills bed with granulation tissue resurface wound with skin bleeds easily bumpy appearance
What happens during the maturation phase?
remodeling phase
scar tissue forms and strengthens
Documentation of a wound
color of wound bed and periwound COCA of drainage type of tissue in wound (granulation, eschar, slough, SQ) s/sx infection width, length, depth, undermining depth
Film dressing
used as a secondary dressing for autolytic debridement
adheres to the damaged skin
barrier to fluid and bacteria
allows wound to breathe; O2 can pass through
promotes moist environment
What dressing would you use if wound has excessive exudate?
transparent film or hydrocolloid
What type of dressing would you use for a clean stage I pressure ulcer?
transparent film to protect from shear/friction
hydrocolloid
What type of dressing would you use for a clean stage II pressure ulcer?
composite film
hydrocolloid
hyrdrogel
What type of dressing would you use for a clean stage III pressure ulcer?
hydrocolloid
hydrogel covered with foam dressing
calcium alginate
gauze with normal saline
What type of dressing would you use for a clean stage IV pressure ulcer?
hydrogel covered with foam dressing
calcium alginate
gauze with normal saline
What type of dressing would you use for an unstageable pressure ulcer covered in eschar?
adherent film (softens eschar)
gauze with ordered solution
enzymes
