Notes Ch: 48 - Skin Integrity and Wound Care Flashcards
What is a pressure ulcer?
A local injury to the skin over a bony prominence due to pressure and other factors
How does pressure result in an ulcer forming?
- If pressure over a capillary exceeds normal capillary pressure and the vessel is occluded (obstructed) for a prolnted time, tissue ischemia (shortage of blood supply/O2) occurs which can cause tissue death.
What is “blanching”/
Normal red tones of skin are abscent when area is pressed and released.
What is “non-blanching”?
When an reddish area is pressed and released and no blanching occurs. Indicitve of an ulser/pressure issue.
What is debridement?
The removal of damaged tissue or foreign objects from a wound leaving granulated tissue.
What is granulated tissue?
- New connective tissue and microscopic blood vessels that form on the surfaces of a wound during the healing process.
- Typically grows from the base of a wound and is able to fill wounds of almost any size.
What are the 6 risk factors for pressure ulcer development?
- Impaired sensory perception - unable to feel pressure or pain
- Alterations in LOC - Confused and unable to verbalize
- Impaired mobility - unable to change position independently
- Shear (sliding of skin)
- Friction (dragging of skin)
- Moisture
How many stages are there in the classification of pressure ulcers?
4 only
Describe a Stage 1 pressure ulcer.
Intact skin with non-blanchable redness
Describe a Stage 2 pressure ulcer.
Partial-thickness skin loss involving epidermis, dermis, or both
Describe a Stage 3 pressure ulcer.
Full-thickness tissue loss with visible fat
Describe a Stage 4 pressure ulcer.
Full-thickness tissue loss with exposed bone, muscle, or tendon
What is the term for an ulcer that defies clear indentification of the 4 stages of pressure ulcer classification?
Non-stageable
Define unstabeable ulcer.
Pressure ulcer with full-thickness tissue loss in which the depth is obscured by slough and/or eschar in the wound bed.
What are the colors of slough?
- yellow
- tan
- gray
- green
- brown
What are the colors of eschar?
- tan
- brown
- black
Define a suspected deep tissue injury
A purple or marron localized area of discolored intact skin or blood-filled blister caused by damage to underlying tissue from pressure and/or shear.
Wound healing occurs by _____ or _____ intention.
Primary, secondary
When checking on wound healing, what are the items we are assessing?
REEDA
- Redness
- Ekymosis
- Edema
- Drainage
- Approximation
Define the primary intention healing process
- This occurs when the would edges are approximated
- ex. surgical incision is sewn up and winds up with minimal to no scarring
Define the secondary intention healing process
Secondary intention occurs when the would heals with non-approximated edges and leaves a scar
A surgical incision heals by _____ intention.
primary
A burn, pressure ulcer, or severe laceration heals by _____ intention.
secondary
Describe tertiary intention.
- occurs when the wound is left open for several days
- while open, it is observed for signs of infection
- closure is delayed until infection is resolved
What are the 4 types of wound drainage?
- Serous
- Sanguineous
- Serosanguineous
- Purulent
Describe Serous wound drainage.
- This type of drainage is plasma that’s thin, clear and watery
- During the inflammatory stage, a small amount of this bloody leakage is natural.
- When this type of exudate occurs during other wound healing stages, it may be an indicator that the wound bed has undergone trauma, such as during dressing changes, which can hinder healing.
Describe Sanguineous wound drainage.
Drainage that is fresh blood and prevalent among deep wounds of full and partial thickness
Describe Serosanguineous wound drainage
- Leakage is thin and watery, and it’s pink in color (it can also be a darker red).
- The pink tinge is the effect of red blood cells in the fluid, which is a sign that there is damage to the capillaries.
- Such damage generally occurs during wound dressing changes and can disrupt the healing process.
Describe Purulent wound drainage.
- Wound appears milky
- It’s generally gray, green or yellow
- Most commonly thick in consistency, though some purulent exudate can be thin.
- This may be a sign that the wound has an infection
The first dressing change is done by…
the doctor
If the doctor is delayed for the first dressing change and the current dressing is soaked, what action is the nurse permitted to take?
Reinforce with a new bandage on top of the old.
What are five types of complications?
- Hemorrhage
- Hematoma
- Infection
- Dehiscence
- Evisceration
Define “hemorrhage”
An escape of blood from a ruptured blood vessel, especially when profuse.
Define “hematoma”
- a solid swelling of clotted blood within the tissues.
- bruising
Define “infection”
- a localized defect or excavation of the skin or underlying soft tissue
- pathogenic organisms have invaded into viable tissue surrounding the wound.
- Infection of the wound triggers the body’s immune response, causing inflammation and tissue damage
- slows the healing process.
Define “Dehiscence”
- splitting of the wound
- healing would edges become non-approximated
- surgical wound reoopens
Define “Evisceration”
- Occurs when an abdominal wound opens and interal organs prodrude
What are the factors to address with an evisceration?
- Emergent
- Cover with sterile gauge
- Rush back to OR
- At risk for sepsis
The Braden Scale is used for…
predicting pressure ulcer risk
What are the six categories used in the Braden Scale Score?
- Sensory perception
- Moisture
- Activity
- Mobiility
- Nutrition
- Friction and shear
A Braden Scale Score of 23 indicates what level of risk for developing a pressure ulcer?
No Risk
A Braden Scale Score of 15-18 indicates what level of risk for developing a pressure ulcer?
At risk
A Braden Scale Score of 13-14 indicates what level of risk for developing a pressure ulcer?
Moderate Risk
A Braden Scale Score of 10-12 indicates what level of risk for developing a pressure ulcer?
High Risk
A Braden Scale Score of ≤ 9 indicates what level of risk for developing a pressure ulcer?
Very High Risk
How do we check for overall tissue perfusion?
- At the periferal pulse
- If pulse week, perfusion will be low
- If pulse strong, perfusion will be high
On the Braden Scale, the higher the number the _____ the risk.
lower
What are four other factors (not on the Braden Scale) that can influence pressure ulcer formation?
- Tissue perfusion
- Infection
- Age
- Psychsocial impact of wounds
What is the Jackson-Pratt Drainage Device?
A closed-suction medical device that is commonly used as a post-operative drain for collecting bodily fluids from surgical sites.
What are the nursing responsibilities regarding the JP Drainage Device?
- Measure output
- Assess T.A.C.O
- Check tubing to make sure its not kinked or dislodged
- If its coming apart call MD
What are the three types of Implementation?
- Independent
- Dependent
- Collaborative
What is the female external catheter called?
Purewick
What is the male exteral catheter called?
Condom catheter or Texas catheter
How does the Nurse know what kind of dressing to use on a wound?
The doctor will indicate
What are five types of wound dressings?
- Dry/Moist
- Film Dressing
- Hydrocolloid
- Hydrogel
- Vacuum assisted closure (VAC)
Describe a film dressing.
What stage ulcer is it used for?
- transparent to permit viewing of wound without opening it
- adheres to undamaged skin
- does not require secondary dressing
- traps moisture over wound
- Used for stage I and II ulcers
Describe a hydrocolloid dressing.
What stage ulcer is it used for?
- Wafer dressing
- protects wound from surface contamination
- Used for Stage II and III ulcers
Describe a hydrogel dressing.
What stage ulcer is it used for?
- gel-based wound care dressing
- protects and provides a moist wound-healing environment
- helps remove dead tissue from the wound bed during the healing process.
- used for stage III and IV ulcers
How does a VAC work?
- uses a negative pressure to support healing
What are the Nurse responsibilities when a VAC is in use?
- Tell patient not to pull on it
- Checked tubing to make sure its not dislodged
- Beeping is a leak, call surgical team
