Lecture 10 - Wound Care (MEDSURG) Flashcards
What are the three layers of the skin?
Epidermis - Outer protective
Dermis/Corneum - Nourishing Layer
Subcutaneous/Hypodermis - Fatty base layer
What are the six function of skin?
–> Barrier and Protection
–> Immunity
–> Temperature regulation
–> Insulation, fat and water storage
–> Sensory perception
–> Vit D synthesis
–> Sociosexual communication and display
Which individuals are at higher risk for skin breakdown
Older adults + very young population, immunosuppressed, oncology patients, those with diabetes
What are important things to note when document changes in skin?
- New onset or existing
- Location
- Colour, shape, size
- Borders, texture, arrangement, elevation or depressed
- Temperature/altered sensation
What kind of lights are best to accurately inspect dark skin tones?
Natural or halogen light, not fluorescent
–> Inspect and palpate
What products are best for cleansing skin?
A gentle/balance pH product and moisturizer or barrier products as needed
What do we need to avoid to protect skin integrity? Which areas should we pay extra attention to
Very hot water, rubbing & friction.
Frequently check bony prominences, folds, creases, contact points.
What is the decision algorithm for skin tears? (7 steps)
- Stop and control bleeding
- Assess and classify (measure, photograph and document)
- Cleanse
- Approximate edges/recover skin integrity
- Determine goals of treatment
- Select product for dressing
- Document and report
What are the kinds of skin tears?
Type 1 - No skin Loss
–> Flap can be repositions to cover the wound bed
Type 2 - Partial Flap Loss
–> Flap cannot be repositioned to cover the wound bed
Type 3 - Total flap loss
–> Wound bed is completely exposed
What differentiates a chronic or acute wound?
Acute: Healing as expected
Chronic/Persistent: Doesn’t match expected trajectory for the type of wound
What are the steps in the cycle of woundcare?
- Assess
- Set goals
- Assemble the team
- Establish and Implement a Plan of Care
- Evaluate outcomes
Looks a lot like the nursing process
When assessing a wound, what should you assess other than the wound itself?
Risk and causative factors that may impact skin integrity for wound healing
–> Pt, environment, systems
What is the MEASURE tool for wound assessment?
Measure - Length. width, depth, area
Exudate - Color, amount, consistency
Appearance - Tissue type and percentage
Suffering - Pain on valid scale and odour
Undermining - Presence or Absence of undermining and tunelling
Re-evaluate - Onset and ongoing every 1-4 weeks
Edge - Condition of edge and peri-wound area
What unit should you measure a wound size in?
Cm
What is fibrous exudate?
Cloudy, thin, watery.
What is haemopurulent exudate?
Dark red, viscous, sticky
What is granulation tissue?
Granulation tissue: red or bright pink, healthy tissue.
What is hypergranulation tissue?
Hypergranulation: excessive growth of granulation tissue “proud flesh”, raised red.
–> Can occur with high moisture
What is slough?
Slough: yellow stringy tissue – none or loosely adherent.
What is fibrin?
Fibrin: yellow stringy tissue – firmly adherent. May be confused with slough.
What is eschar?
Eschar: soft or firm, black or tan necrotic (devitalized) tissue.
What is epithelialization?
Epithelization: hypopigmented, ie pearly white
–> Often seen on wounds that are contracting and decreasing in width
What can cause odour in a wound?
Infection, dead tissue (necrotic, slough), certain dressing products.
Odour might be present before cleansing wound, but should not be after wound care. Perform wound care before complete odour assessment
What is meant by saying a wound has indistinct edges?
Unable to distinguish wound outline