Integumentary Alterations Flashcards
What would you use between skin folds & why?
Interdry; it will get rid of the moisture
Intertriginous dermatitis
inflammation of skin where 2 surfaces rub together
what 4 main things contribute to pressure injuries?
pressure, shear, friction, moisture, & nutrition
Tissue ischemia
decreased blood flow to tissues
How does moisture put you at risk of pressure injury?
it softens the skin, reducing resistance to pressure or shearing
Shearing
Force exerted against skin
Friction injury
surface damaged caused by skin rubbing against another surface (elbows & heels rubbing against sheets)
how does protein deficiency increase risk of breakdown?
- It causes edema, which contributes to less oxygen & nutrients
- need protein to heal
what lab value tells you a patient may have malnutrition?
Albumin (3.5-5)
Stage 1 pressure injury
Skin is intact, but has an non-blanchable red area
Hyperemia
Increased blood flow to the area
Stage 2 pressure injury
- Dermis is exposed, partial thickness skin loss
- may also appear as an intact or ruptured blister
Stage 3 pressure injury
- Full thickness lost, adipose tissue visible
- granulation tissue, slough, eschar, epibole, undermining & tunneling are present
Granulation tissue
Red, shiny, moist tissue part in base of wound that helps the healing process
Slough
Stringy white, yellow, brown, or green material attached to tissue that is part of an inflammatory process
(looks like ligaments)
Stable Eschar
Dry gangrene from lack of blood flow that causes skin to be black/green (necrotic tissue)
Why is it so important to move a patient q2h when they have a wound?
Wounds need blood supply!!!
How do you treat eschar?
Gently trim the edges, keep dry & redistribute pressure
(DO NOT remove the black, it is a protectant covering)
Epibole
Closed or rolled wound edges; usually light in color, raised, round, & hard
When will epibole not heal?
When it is dry & looks like a callus
Undermining
Pocket underneath the wound’s edge due to tissue erosion
Tunneling
A tunnel through the muscle or subc tissue (can be more than 1)
Stage 4 pressure injury
Full thickness of skin is lost; Fascia, muscle, ligament, cartilage & bone exposed (also has the same characteristics of stage 3)
Why does having a stage 4 pressure injury put you at risk for osteomyelitis?
Because the infection may spread to the bone
Deep tissue pressure injury
- Looks like a big bruise (don’t mistake with normal bruises!)
- Persistent, non blanchable, deep red/maroon/purple discoloration
What does it mean when the skin is non blanchable?
The capillaries are damaged :(
Unstageable pressure injury
Full thickness & tissue lost; Completely covered by slough or eschar
How does an altered microclimate contribute to mechanical device pressure injuries?
Heat & humidity develops between the device and the skin which makes it more prone to breakdown
What signs of healing are normal?
Slight redness & edema
What is the inflammatory response of partial thickness wound repair?
- brief, lasts about 24 hours
- erythema & edema present
- WBC come together at the incision site to continue the healing process, then the epidermis gets thicker (will look pink)
- may form scab if the exudate dries (cells, proteins)
What is the homeostasis phase of full thickness wound repair?
clot forms to stop bleeding and start healing
You have a patient who just had an appendectomy. You check their labs, and their WBC count is 13,000. Why is infection not a concern at this moment?
WBC count will be high after a surgery, because it means the wound is trying to heal.
In order for tissue to be strong for healing, you need collagen. What would you increase in diet in order to bring in the collagen?
PROTEIN!!!!!!!!!!
Nurses should never change the initial surgical dressing, but it is crucial to…
Reinforce it by applying more pads, gauze, & taping them on as tight as possible to put pressure and keep the clot intact.
Internal Hemorrhage s/s
can cause hypovolemic shock
swelling of affected area, decreased BP, increased HR, might feel firm or have a swelling/mass depending on severity
S/S of an infected wound
- green, yellow, or brown foul-smelling drainage
- elevated WBC
- fever, malaise
- painful to the touch
- swelling & redness beyond wound edges
what does a wound need in order to heal?
blood supply, oxygen, WBC
What would you do if you suspect an infection & are waiting for a drainage culture?
Administer broad spectrum antibiotics until results are back, get temp q4h
What are findings for a traumatic wound infection?
- very high WBC count
- foul odor, purulent drainage
Dehiscence
- edges are not together, held by retention sutures
- partial or total separation of layers of skin in a wound
- most often in abdominal surgical wounds after sudden strain (coughing, vomiting, sitting up)
Mike just had surgery on his abdomen and the physician used retention sutures. He has has had a cough for a couple of days. What is an intervention to decrease his risk of dehiscence?
cough pillow, put hands on incision, abdominal binder, incentive spirometer
What type of drainage from a wound shows a huge risk of dehiscence?
Serosanguineous drainage
(pink = not good!!!)
What are some foods to ensure proper nutrition?
foods high in protein: eggs, chicken, fish, beef, nuts, whole grains, beans, chickpeas, ensure shakes
How to prevent pressure injuries
- turn & reposition every q1-2h
- use lift sheets and devices to prevent rubbing
- raise HOB no more than 30 degrees or at lowest tolerated level to prevent sliding & shearing
- use overlay pads
What do you do 30 mins prior to a dressing change?
Administer analgesics
Serous drainage
yellow clear, watery plasma
Sanguineous drainage
fresh bleeding (could be hemorrhage)
Purulent drainage
- thick yellow, green, or brown
- indicates dead or living organisms & WBC
- WBC will prob be around 20,000
Penrose drain
goes in between layer of gauze, very soft & pliable tubing
Jackson Pratt
Has a squeezable bulb that hangs outside the body. Squeezing it creates pressure which pulls out fluid.
What if a drain stops suddenly? What is this a sign of & what should you do?
Could be blocked from a clot; look at I&O
Hemovac
Round cylinder that has tubing going into the wound. The spring in it expands when emptying.
How would you assess a sutured wound?
- inspect staples and sutures for irritation
- make sure edges are approximated
- is there any drainage?
- look for continued swelling (could mean the sutures are too tight)
Sutures
Thread or wires that sew body tissue together
Why do you get 2 different wound cultures?
some bacteria grows without oxygen (anaerobic) and some grow with (aerobic)
How do you promote wound healing?
debridement - only on dead tissue; make sure they are eating enough protein
Pressure dressing
exerts localized downward pressure over an actual or potential bleeding site
Dry dressing
promotes healing by allowing wound to heal by primary intention and absorb minimal oozing
Moist dressing
lightly packed into wound, fosters normal healing, acts like a sponge absorbing excessive drainage while maintaining a moist environment. (best for wound healing by secondary intention)
Wet to Dry
- keeps wound moist so cells grow
- damp gauze placed on a wound and removed after the dressing dries
How do you cleanse a wound?
- Go from least contaminated to most, then side to side
- Use a different 4x4 for each stroke
- Clean incision first, then the drain (circle out)
- Always use sterile glove when packing
Wound irrigation
Fill syringe with water and apply GENTLE pressure
What are signs of an infection when you have a rash?
Fever, cough, enlarged lymph nodes
Contact dermatitis
- itchy rash caused by exposure to allergen, chemical, or mechanical irritation
Treatment for contact dermatitis
- Avoid scratching
- Wash with mild soap
- Apply cool, damp compress
- Oatmeal bath
- Meds if severe
Hydrocortisone (topical)
anti-inflammatory med
apply to intact skin only - do not apply to infected or open wounds
Prednisone (systemic & oral)
- patient must stay on it
- makes skin paper thin
- increases risk of infection
Diphenhydramine (Benadryl) - Topical or systemic oral
- relives redness, edema, pruritis
- may make patient drowsy
- can cause urinary retention
Yeast infection
Caused by overgrowth of fungus, usually in genitals, mouth, skin
potential side effect of antibiotics
What side effects happen from taking too many antibiotics?
Thrush & vaginal yeast infection from normal bacteria being killed
Melanoma
very severe skin cancer - travels all throughout body
not associated with sun exposure
