NUR 118 - Lecture 2 - Wounds/Skin Integrity Flashcards
What are the 12 factors that affect skin integrity?
Age
Impaired Mobility
Nutrition
Hydration (Over/Under)
Impaired Circulation
Medications
Moisture
Infection
Fever
Lifestyle
Diminished Sensation
Diminished Condition
Explain the following factors affect on skin integrity: Age, impaired mobility, nutrition,
Age: Decreased Sebaceous, sweat glands = dry skin; Subcutaneous layer thins; epidermis-dermis bond weakens = tears
Impaired mobility: Weight of body leads to pressure = breakdown
Nutrition: Protein required to keep IntraVASCULAR volume (albumin); Ascorbic acid, zinc copper = wound healing
Explain the following factors affect on skin integrity: Hydration, diminished sensation, diminished cognition
Hydration (over/under): Edema vs dehydrated, edema = build up of serous fluid in tissue (skin too tight); dry, dehydrated skin
Diminished Sensation: May not be able to feel heat/cold/pain
Diminished Cognition: Unaware of reposition, can feel pain but may not realize need to fix it
Explain how these factors affect skin integrity: Impaired circulation, medications, moisture
Impaired circulation:
- Arterial: impairs oxygen and nutrient flow to wound
- Venous - Impairs venous return = edema, stasis, blood clots
Medications: Steroids = infection, anticoagulants = bleeding
Moisture: Maceration (softening of skin), Incontinence = when someone can’t hold urine/feces
Explain how these factors affect skin integrity: Fever, infection, lifestyle
Fever: Sweating = maceration (fingers pruning), increase metabolic rate
Infection: Increase metabolic demand, skin vulnerable to breakdown, impedes healing
Lifestyle: tanning, diet, bathing (too much or too little), smoking
Classification of wounds: Skin integrity
Open - break in skin or mucus membrane
Closed - no break in skin (bruise, edema, hematoma)
Classification of wounds: length of time for healing
Acute - Short, no complications; 3 phases = inflammation, proliferation, maturation
NOT NECESSARILY DEPENDENT ON TIME (i.e. over/under 6 months)
Chronic - Longer to heal d/t (due to) interrupted healing (ex: infection, trauma, edema)
Classification of wounds: level of contamination
Clean: No infection, limited inflammation = low infection risk
ex: hand surgery
Clean contaminated: Surgical incisions within GI, GU or Respiratory system = increased infection risk
Contaminated: Open wounds, pressure ulcers; surgeries with break in asepsis
Infected: Bacteria >100k per gram of tissue, signs and symptoms of infection
Classification of wounds: Depth of wound
Superficial: 1 layer = AT epidermis; friction, sheer, burn
Partial thickness: 2 layers = through epidermis, NOT DERMIS
Full thickness: 3+ layers = epidermis to dermis to sub q to bone
Penetrating - FULL THICKNESS TO INTERNAL ORGANS
List and describe types of wound drainage
Serous: WATERY - SERUM - CLEAR TO STRAW COLORED = CLEAN WOUNDS
Sanguineous: BLOOD - BRIGHT RED TO DARK RED/BROWN = FRESH BLEEDING
- Initial bleeding
Serosanguineous : COMBO OF BLOOD & SEROUS = NEW WOUNDS
This is following the initial blood gushing
Purulent : THICK - ODOROUS - WHITE - YELLOW - GREY = INFECTION
Purosanguinous: RED TINGED PUS & BLOOD = INFECTION / NEW WOUND
List and describe TYPES (not phases) of wound healing
Regeneration/epithelial - epidermis & dermis regeneration
Primary intention: clean, approximated = SURGICAL wound
Secondary intention: not approximated, heals inside out by filling with granulation tissue = PRESSURE ULCER
Tertiary intention: Delayed closure to allow edema/infection to diminish, then sutured afterwards
List and describe the 3 PHASES (not types) of wound healing
1) Inflammatory - Cleansing
- 1-5 days
- Hemostasis - Vessels constrict, platelets aggregate to slow bleeding
Inflammation - erythema, WBCs mobilize, scab formation
2) Proliferative/Granulation/Healing
- 5 to 21 days, higher risk of infection here
- Cells grow to fill in from base of wound (from inside out)
3) Maturation/Epithelialization/Remodeling
- 12 to 21 days & up to 3-6 months
- Collagen fibers broken down, reorganized into organized structure = increased strength of wound
Complications of wound healing
Hemorrhage - Blood loss
Infection
Dehiscence - Sutures came undone
- Raise head of bed 20 degrees, pull in knees, place binder
Evisceration - Organ came out
- Raise head of bed 20 degrees, pull in knees & prepare pt for surgery, cover with sterile drape + sterile saline
Fistula formation - Creation of abnormal passageway in GI/GU tracts
Define pressure injury
“Localized injury to the skin & underlying tissue, usually over a bony prominence”
Intrinsic factors in the development of pressure injuries (internal, patient health status)
Age - Thinner subq, epidermis-dermis bond weakens
Poor nutrition - Low protein = weakened intravascular
Immobility - Weight of patient = breakdown
Edema
Impaired sensation - Patient can’t feel breakdown or pain/heat/cold
Impaired cognition - May feel pain, but won’t realize attention is needed
Fever
Extrinsic (external) factors in the development of pressure injuries
Friction
Shearing - pt sliding down, epidermis and dermis separate
Moisture
Compression
Things to remember when staging pressure injuries
-Staged by: the degree of tissue involvement
-Only wounds caused by pressure are staged
-Healing ulcers are not “reverse” staged
- A stage 4 does not become stage 3, it remains known as a “stage 4: healing”
Describe a Stage 1 Pressure Ulcer
Erythema (reddened skin), intact and non-blanchable (does not blanch when pressed)
Describe a Stage 2 Pressure Ulcer
Resembles a blister, dermis exposed, partial thickness skin loss.
Describe a Stage 3 Pressure Ulcer
Full-thickness skin loss with crater, adipose tissue visible, slough and/or eschar (dead tissue-black, brown or tan) may be present.
Bone/tendon not visible.
Describe a Stage 4 Pressure Ulcer
Full-thickness skin and tissue loss, exposed muscles, tendons, cartilage and bone. Slough and/or escar may be present. Undermining or tunneling may occur.
Describe slough
Soft, moist necrotic tissue, white, yellow, tan
- Debride
Describe Eschar
Necrotic tissue, dry, thick, leathery, black, brown, gray
-Debride, may be removed to see underneath if suspected infection
Describe granulation tissue
Pink to red moist tissue, blood vessels, connective tissue, fibroblasts
-Cleanse and protect
Describe “Clean, non-granulating tissue”
No granulation tissue, bed is pink, shiny, smooth
-Cleanse and protect
Describe epithelial tissue
Regenerating epidermis
-Cleanse and Protect
List interventions to prevent pressure injuries
- t&p q2h
- Assess skin
- Manage moisture
- Monitor labs (skin:albumin, infection:leukocyte)
- Nutrition
- Hydration
- Pressure limiting devices
Heat therapy: indications and effects
When: For chronic issues
Indications:
- Joint stiffness
- Contractures
-Low Back pain
Effects:
Vasodilation
Increased inflammation
Increased cellular metabolism
Cold therapy: Indications and effects
When: For acute issues
Indications:
Fractures
Post injury swelling
Bleeding
Sprains, strains
Effects:
Vasoconstriction
Slowed bacterial growth
Local anesthetic effect
Decreased inflammation/edema
Decreased cellular metabolism
What to ensure when administering heat/cold therapy?
Requires prescription
VS pre & post treatment
Assess site
Assess pt’s perception of temp changes (sensation)
Inspect skin every 15 mins
Braden scale: Use? And 6 Categories
What is the best and worst score?
Use: to identify clients who are at heightened risk for alteration in skin integrity
Sensory perception
Moisture
Mobility
Activity
Friction & Shear
Nutrition
6 is the worst score (highest risk), 23 is best (no risk)
SEVERE RISK: Total score less than/equal to 9
HIGH RISK: Total score 10-12
MODERATE RISK: Total score 13-14
MILD RISK: Total score 15-18
In prone position, what is at risk for breakdown?
Ear
Breast
Genitalia
Identify the following
- Pink to red moist tissue, connective tissue, blood vessels in wound bed
- Dry thick necrotic tissue, black, brown or grey
- Soft moist necrotic tissue white, yellow, tan
- Wound bed is pink, shiny and smooth
- Granulation tissue
- Eschar
- Slough
- Clean, non-granulating
What interventions to manage moisture?
Barrier cream
Interventions to prevent sheering injuries include:
Keep HOB at or below 30 degrees
Use foot boards
Elevate foot of bed
What is the type of wound healing for extensive tissue loss?
Secondary intention
A nurse identifies reactive hyperemia over a client’s bony prominence. What is the cause of this response?
Turning a client who was in one position for several hours
Rationale:
-Compressed skin appears pale d/t lack of circulation
-When pressure is relieved, extra blood flows to area to compensate == bright red flush
Hyperemia - Excess of blood in vessels
