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NUR 118 Lecture > NUR 118 - Lecture 2 - Wounds/Skin Integrity > Flashcards

NUR 118 - Lecture 2 - Wounds/Skin Integrity Flashcards

1
Q

What are the 12 factors that affect skin integrity?

A

Age
Impaired Mobility
Nutrition
Hydration (Over/Under)
Impaired Circulation
Medications
Moisture
Infection
Fever
Lifestyle
Diminished Sensation
Diminished Condition

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2
Q

Explain the following factors affect on skin integrity: Age, impaired mobility, nutrition,

A

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

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3
Q

Explain the following factors affect on skin integrity: Hydration, diminished sensation, diminished cognition

A

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

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4
Q

Explain how these factors affect skin integrity: Impaired circulation, medications, moisture

A

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

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5
Q

Explain how these factors affect skin integrity: Fever, infection, lifestyle

A

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

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6
Q

Classification of wounds: Skin integrity

A

Open - break in skin or mucus membrane
Closed - no break in skin (bruise, edema, hematoma)

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7
Q

Classification of wounds: length of time for healing

A

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)

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8
Q

Classification of wounds: level of contamination

A

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

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9
Q

Classification of wounds: Depth of wound

A

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​

​

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10
Q

List and describe types of wound drainage

A

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 ​

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11
Q

List and describe TYPES (not phases) of wound healing

A

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

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12
Q

List and describe the 3 PHASES (not types) of wound healing

A

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

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13
Q

Complications of wound healing

A

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

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14
Q

Define pressure injury

A

“Localized injury to the skin & underlying tissue, usually over a bony prominence”

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15
Q

Intrinsic factors in the development of pressure injuries (internal, patient health status)

A

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

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16
Q

Extrinsic (external) factors in the development of pressure injuries

A

Friction
Shearing - pt sliding down, epidermis and dermis separate
Moisture
Compression

17
Q

Things to remember when staging pressure injuries

A

-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”​

18
Q

Describe a Stage 1 Pressure Ulcer

A

Erythema (reddened skin), intact and non-blanchable (does not blanch when pressed)

19
Q

Describe a Stage 2 Pressure Ulcer

A

Resembles a blister, dermis exposed, partial thickness skin loss.

20
Q

Describe a Stage 3 Pressure Ulcer

A

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.

21
Q

Describe a Stage 4 Pressure Ulcer

A

Full-thickness skin and tissue loss, exposed muscles, tendons, cartilage and bone. Slough and/or escar may be present. Undermining or tunneling may occur.

22
Q

Describe slough

A

Soft, moist necrotic tissue, white, yellow, tan​
- Debride

23
Q

Describe Eschar

A

Necrotic tissue, dry, thick, leathery, black, brown, gray​
-Debride, may be removed to see underneath if suspected infection

24
Q

Describe granulation tissue

A

Pink to red moist tissue, blood vessels, connective tissue, fibroblasts
-Cleanse and protect

25
Q

Describe “Clean, non-granulating tissue”

A

No granulation tissue, bed is pink, shiny, smooth​
-Cleanse and protect

26
Q

Describe epithelial tissue

A

Regenerating epidermis
-Cleanse and Protect

27
Q

List interventions to prevent pressure injuries

A
  • t&p q2h
  • Assess skin
  • Manage moisture
  • Monitor labs (skin:albumin, infection:leukocyte)
  • Nutrition
  • Hydration
  • Pressure limiting devices
28
Q

Heat therapy: indications and effects

A

When: For chronic issues

Indications:
- Joint stiffness
- Contractures
-Low Back pain

Effects:
Vasodilation
Increased inflammation
Increased cellular metabolism

29
Q

Cold therapy: Indications and effects

A

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

30
Q

What to ensure when administering heat/cold therapy?

A

Requires prescription
VS pre & post treatment
Assess site
Assess pt’s perception of temp changes (sensation)
Inspect skin every 15 mins

31
Q

Braden scale: Use? And 6 Categories
What is the best and worst score?

A

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

32
Q

In prone position, what is at risk for breakdown?

A

Ear
Breast
Genitalia

33
Q

Identify the following

  1. Pink to red moist tissue, connective tissue, blood vessels in wound bed
  2. Dry thick necrotic tissue, black, brown or grey
  3. Soft moist necrotic tissue white, yellow, tan
  4. Wound bed is pink, shiny and smooth
A
  1. Granulation tissue
  2. Eschar
  3. Slough
  4. Clean, non-granulating
34
Q

What interventions to manage moisture?

A

Barrier cream

35
Q

Interventions to prevent sheering injuries include:

A

Keep HOB at or below 30 degrees
Use foot boards
Elevate foot of bed

36
Q

What is the type of wound healing for extensive tissue loss?

A

Secondary intention

37
Q

A nurse identifies reactive hyperemia over a client’s bony prominence. What is the cause of this response?

A

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

NUR 118 Lecture (14 decks)

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