N200 Midterm Chapter 48 Skin and Wound Care Flashcards
What are 5 factors affecting skin integrity?
- Genetics and heredity: some people have thicker skin.
- Age: decrease in SQ fat, decreasing collagen, muscle atrophy
- Chronic illnesses and their treatments: cancer pts will have skin integrity issues.
- Medications: steroids cause tissue damage and bleeding under surface of skin (in elderly)
- Poor nutrition: metabolism, protein, fat. Reference: dying with a stage IV pressure ulcer.
What are 7 risk factors for pressure ulcers?
- Advanced age
- Chronic mental conditions: ex if young in mental institute, may want to sit all day in same position. contact/pressure areas susceptible to skin breakdown.
- Poor lifting and transferring techniques; poor nursing lifting;
- Incorrect positioning: increased risk for skin ulcers: ex. leaning on arm rail. if on prednisone (steroid) increases risk.
- Hard support surfaces: when put in chair, put pillow on seat of chair if they going to be there a while.
- Incorrect application of pressure-relieving devices: ex. don’t use donut in right spot.
- tissue breakdown from urine and fecal incontinence
____ is caused by pulling pt, dragging feet can cause skin breakdown via sheering affect.
SHEARING:
prednisone (steroid) increases or decreases risk of pressure ulcer?
increases
The Braden Scale is used for predicting pressure sore risk, what are the 6 assessments? what is indicated for a low vs high result?
- Sensory perception
- Moisture
- Activity
- Mobility
- Nutrition
- Friction and Shear
Low score = higher risk for sore
High score = lower risk for sore
With the Norton pressure ulcer scale, what 5 assessments are used? what is indicated with a low score vs. high score?
- physical condition
- mental state
- activity
- mobility
- incontinence
low= higher risk
high= lower risk
a _____ is localized injury to the skin and other underlying tissue, usually over a body prominence, as a result of pressure or pressure in combination with shear and/or friction.
pressure ulcer
What are 3 pressure-related factors that contribute to pressure ulcer development?
- pressure intensity
- pressure duration
- tissue tolerance
What are the 6 stages of pressure ulcer classification.
Stage I: Nonblanchable Redness of Intact Skin
Stage II: Partial-thickness Skin Loss or Blister
Stage III: Full-thickness Skin Loss (Fat Visible)
Stage IV: Full-thickness Tissue Loss (Muscle/Bone Visible)
Unstageable/Unclassified: Full-thickness Skin or Tissue Loss—Depth Unknown
Suspected Deep-Tissue Injury—Depth Unknown
______ tissue is red, moist tissue composed of new blood vessels, the presence of which indicates progression toward healing.
Granulation
What are the 3 types of Healing process?
Primary, Secondary and Tertiary Intention
With Primary Intention:
- Wound is open or closed?
- Has or doesn’t have a surgical incision? (ie cause)
- Healing occurs by _____; heals quickly with minimal ____ formation.
- closed
- has sutures or staples
- epithelialization, scare
With Secondary Intention:
- Wound edges are or are not approximated
- caused by:_____ and surgical wounds that have tissue loss
- heals by _______ formation, wound contraction, and epithelialization.
- are not approximated
- Pressure ulcers
- granulation tissue
With Tertiary Intention:
- Wound left open for several days, then wound edges are or are not approximated
- Caused by _____ and require observation for signs of inflammation
- Is closure of wound is immediate or delayed?
- are approximated
- contamination
- delayed until risk of infection is resolved
If skin edges are _____ , or closed, and the risk of infection is low.
approximated
Severe scaring occurs in _____ intention.
Secondary
With pressure ulcer staging, what is indicated at stage I, stage II, stage III and stage IV?
I nonblanching Redness of intact skin.
II Partial-thickness Skin Loss or Blister
III Full-thickness Skin Loss (Fat Visible)
IV Full-thickness Tissue Loss
Black or brown necrotic tissue is _____
eschar
What are common sites of decubitus ulcers?
Areas with little fat or muscle over bony prominences.
What type of Intention?
- Wound that is closed
- Surgical incision, wound that is sutured or stapled
- Healing occurs by epithelialization; heals quickly with minimal scar formation.
Primary Intention
What type of Intention?
Wound edges are not approximated (not together)
Pressure ulcers, surgical wounds that have tissue loss Ex skin cancer removal.
Wound heals by granulation tissue formation starts to heal on own, wound contraction, and epithelialization.
Secondary Intention
What type of intention?
Wound left open for several days, then wound edges are approximated (healing on edge but not center yet)
Wounds that are contaminated and require observation for signs of inflammation
Closure of wound is delayed until risk of infection is resolved
Tertiary Intention
What phase of wound healing?
histamine release causes vasodilation, exudate of serum and WBC goes into damaged tissue; in clean wound, inflammatory phase body establishes clean area, don’t want to ice, want body to naturally clear out (phagocytosis). if too long give steroids
Inflammatory Phase:
What phase of wound healing?
3-24 days in, granulation of tissue wound retracts in and starts closing on its own, resurfacing happens, new stuff forming is collagen (gives scar its color, lack of pigmentation in skin).
Proliferative Phase:
What phase of wound healing?
can take up to a year depending on depth of wound.
Maturation Phase (Remodeling):
What are 4 types of complication in wound healing?
Hemorrhage
Infection
Dehiscence
Evisceration
What Occurs when a wound fails to heal properly? (the layers of the skin and tissue separate)
Dehiscence
What is Total separation of the wound layers with protrusion of visceral organs?
Evisceration
What nursing measures would you take for dehiscence?
splinting…supporting the surgical are from separation. get gauze apply NSS, call Dr. and document findings
what nursing measure would you take for evisceration?
Place sterile towels soaked in NSS, this reduces chances for bacteria contamination and drying of the tissues
What is the difference b/w eccymosis and a hematoma?
hematoma is pooling of blood vs ecchymosis is bruising
What are the four phases involved in the healing proces of a full thickness wound?
hemostasis
inflammatory
proliferative
remodeling.
Part of the nursing process includes the nursing history, what aspects shoube included for a skin ulcer assesssment?
Review of systems Skin diseases Previous bruising General skin condition Skin lesions Usual healing of sores
While performing a skin assessment, what is the key inspection and palpation focus?
Skin color distribution Skin turgor Presence of edema Characteristics of any skin lesions Particular attention paid to areas that are most likely to break down: ischium, back of head, scapula
When performing ______ of pressure sites, inspect pressure areas for discoloration and capillary refill or blanche response.
-Inspect pressure areas for abrasions and excoriations
-Palpate the surface temperature over the pressure area sites
-Palpate bony prominences and dependent body areas for the presence of edema: ears, shoulder, elbow, hip , heel, knee, ankle
WOCN recommends a 30 degree lateral position which should prevent positioning directly over the bony prominence.
assessment
What 5 factors affect wound healing?
Age Nutritional status Lifestyle Medications Tissue Perfusion
What lab tests are important when assessing skin/wound healing?
- Leukocyte count (WBC)
- Hemoglobin level (oxygenation) <12 is bad!
- Blood coagulation studies: platelet/ clotting factors. represents homeostasis
- Serum protein analysis: are you healing?
Pre-Albumin level: whats absorbed, digested and metabolized. if low pre-albumin, need nutritional support. - Results of wound culture and sensitivities
What nutritional factors prevent pressure ulcers?
Fluid intake
Protein, vitamins, zinc (helps with collagen production and protein synthesis.
Dietary consult: min of 1500 calories per day
Weight/lab data monitoring
To prevent pressure ulcers, what skin hygiene is important?
Mild cleansing agents Avoid hot water Moisturizing lotions/skin protection Reduce irritants massage promotes circulation
To prevent skin ulcers, what 4 factors should be considered?
nutrition
maintain skin hygien
avoid skin trauma
provide supportive devices
All are examples of \_\_\_\_\_ to prevent skin ulcers? Smooth, firm surfaces Semi-Fowler’s position: sitting up position Frequent weight shifts Exercise and ambulation Lifting devices Reposition q 2 hours Turning schedule
Avoiding skin trauma
All are examples of \_\_\_\_ to prevent skin ulcers? Mattresses Beds Wedges, pillows Miscellaneous devices: ex gel pad
Provide supportive devices
What are effective skin ulcer treatments?
Minimize direct pressure Schedule and record position changes Provide devices to reduce pressure areas Clean and dress the ulcer using surgical asepsis Never use alcohol or hydrogen peroxide Obtain C&S, if infected Teach the client Provide ROM exercise PROM: passive ROM
With the following wound colors, what should be performed?
- Red
- Yellow
- Black
- protect
- clean
- debride
All are examples of? Transparent film Impregnated nonadherent Hydrocolloids Clear absorbent acrylic Hydrogel Polyurethane foam Alginate
Wound dressing
Should alcohol or hydrogen peroxide be used to clean wounds?
NO
What are the WOCN Dressing Recommendations?
- Use a dressing that will continuously provide a moist environment.
- Wet-to-dry dressings are only for debridement and are not continuously moist saline dressings.
- Perform wound care using topical dressings as determined by a thorough assessment.
- No specific studies have proven an optimal dressing type for pressure ulcers
- Choose a dressing that keeps the surrounding intact (periulcer) skin dry while keeping the ulcer bed moist.
- Choose a dressing that controls exudate but does not desiccate the ulcer bed.
- Consider caregiver time, ease of use, availability, and cost when selecting a dressing.
- Eliminate wound dead space by loosely filling all cavities with dressing material.
What are the nursing diagnosis/goals of care for wound managment? (5)
- Risk for Impaired Skin Integrity (Maintain Skin Integrity Avoid or reduce risk factors)
- Impaired Skin Integrity (Progressive wound healing
Regain intact skin) - Impaired Tissue Integrity (Assess and treat existing wound, Prevention of pressure ulcers)
- Risk for Infection
- Pain
What is the purpose of wound dressings?
Protects a wound from microorganism contamination
•Aids in hemostasis
•Promotes healing by absorbing drainage and debriding a wound
•Supports or splints the wound site
•Protects patients from seeing the wound (if perceived as unpleasant)
•Promotes thermal insulation of the wound surface
•Provides a moist environment
The type of dressing is usually based on the _____ of the pressure ulcer, the type of ____ in the wound, and the ___ of the dressing.
stage
tissue
function
What are the physiological effects of heat?
Vasdilation Increases capillary permeability Increases cellular metabolism Increases inflammation Produces sedative effect
What are the indications for use of heat?
Muscle spasms Inflammation Pain Contracture Joint stiffness
How is dry heat applied?
Hot water bottle
Aquathermia pad
Disposable heat pack
Electric pad
How is moist heat applied?
Compress
Hot pack
Soak
Sitz bath
What are the physiologic effects of cold?
Vasoconstriction Decreases capillary permeability Decreases cellular metabolism Slows bacterial growth Decreases inflammation Local anesthetic effect
What are the indicatinos for us of cold?
Muscle spasms
Inflammation
Pain
Traumatic injury
How is Dry cold applied?
Cold pack
Ice bag
Ice glove
Ice collar
How is moist cold applied?
Compress
Cooling sponge bath
True or False:
You must provide a barrier between the application of cold and the skin
True
When repositioning an immobile patient, the nurse notices redness over a bony prominence. What is indicated when a reddened area blanches on fingertip touch?
A. A local skin infection requiring antibiotics.
B. Sensitive skin that requires special bed linen.
C. A stage III pressure ulcer needing the appropriate dressing.
D. Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode.
D. Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode.
Which type of pressure ulcer is noted to have intact skin and may include changes in one or more of the following: skin temperature (warmth or coolness), tissue consistency (firm or soft), and/or pain? A. Stage I B. Stage II C. Stage III D. Stage IV
A. Stage I
hen obtaining a wound culture to determine the presence of a wound infection, from where should the specimen be taken?
A. Necrotic tissue
B. Wound drainage
C. Drainage on the dressing
D. Wound after it has first been cleaned with normal saline
D. Wound after it has first been cleaned with normal saline
Drainage that has been present on the wound surface can contain bacteria from the skin, and the culture may not contain the true causative organisms of a wound infection. By cleaning the area before obtaining the culture, the skin flora is removed.
After surgery the patient with a closed abdominal wound reports a sudden “pop” after coughing. When the nurse examines the surgical wound site, the sutures are open, and pieces of small bowel are noted at the bottom of the now-opened wound. Which corrective intervention should the nurse do first?
A. Allow the area to be exposed to air until all drainage has stopped
B. Place several cold packs over the area, protecting the skin around the wound
C. Cover the area with sterile, saline-soaked towels and immediately notify the surgical team; this is likely to indicate a wound evisceration
D. Cover the area with sterile gauze, place a tight binder over it, and ask the patient to remain in bed for 30 minutes because this is a minor opening in the surgical wound and should reseal quickly
C. Cover the area with sterile, saline-soaked towels and immediately notify the surgical team; this is likely to indicate a wound evisceration
Which of the following describes a hydrocolloid dressing?
A. A seaweed derivative that is highly absorptive
B. Premoistened gauze placed over a granulating wound
C. A debriding enzyme that is used to remove necrotic tissue
D. A dressing that forms a gel that interacts with the wound surface
D. A dressing that forms a gel that interacts with the wound surface
A hydrocolloid dressing is made of materials that are adhesive and can form a gel over the open area of the wound. Since moisture enhances wound healing, the gel that forms places the wound in the proper environment for healing.
- Which of the following is an indication for a binder to be placed around a surgical patient with a new abdominal wound?
A. Collection of wound drainage
B. Reduction of abdominal swelling
C. Reduction of stress on the abdominal incision
D. Stimulation of peristalsis (return of bowel function) from direct pressure
C. Reduction of stress on the abdominal incision
A binder placed over the abdomen can provide protection to the abdominal incision by offering support and decreasing stress from coughing and movement.
When is an application of a warm compress indicated? (Select all that apply.)
A. To relieve edema
B. For a patient who is shivering
C. To improve blood flow to an injured part
D. To protect bony prominences from pressure ulcers
Rationale
When is an application of a warm compress indicated? (Select all that apply.)
A. To relieve edema
C. To improve blood flow to an injured part
Warm compresses can improve circulation by dilating blood vessels, and they reduce edema. The moisture of the compress conducts heat.
On assessing your patient's sacral pressure ulcer, you note that the tissue over the sacrum is dark, hard, and adherent to the wound edge. What is the correct stage for this patient's pressure ulcer? A. Stage II B. Stage IV C. Unstageable D. Suspected deep tissue damage Rationale
C. Unstageable
To determine the stage of a pressure ulcer you examine the depth of the tissue involvement. Since the pressure ulcer assessed was covered with necrotic tissue, the depth could not be determined. Thus this pressure ulcer cannot be staged.
