Skin Flashcards
What does the skin do?
Regulates body temperature
Protects the body
Infection control
Decubitus ulcers
Are bedsores
They cut off blood supply and tissue dies
Malleolus
Ankle
Impaired sensory perception (cannot feel pressure)
Neuropathy
Spinal cord injury
Stroke
Patients that have these impairments, or at higher risk for decubitus ulcers (bedsores)
What are some examples of patients with impaired nutrition?
Impaired nutrition also put the patient at risk for bedsores
Lack of proteins
Patience with feeding tubes
Financially unable to afford good food
Patient that cannot swallow
Friction and shear
Body goes one way to skin goes the other way
What does moisture, fecal, or urinary incontinence do to patient’s
They cost breakdown of skin & massuration when the skin is moist for long periods of time, —-prolong moisture
What is the Braden scale?
The Braden scale is a number that measures the likelihood for the cutest ulcers
^ the higher, the number, the lower the risk
The lower, the number, the higher, the risk
Stage one pressure ulcer
The skin is intact
Redness
Non-blanchable
Stage two pressure ulcer
Partial Dash thickness, loss involving the epidermis, dermis, or both
A stage two pressure ulcer resembles a popped blister/superficial
It can be pink in color
Stage three pressure ulcer
Full thickness, tissue loss with visible fat(adipose)
Is bright red with drainage
Stage four pressure ulcer
Full thickness, tissue, loss with exposed muscle, tendon, bone
Unstageable pressure ulcer
Full thickness, loss, but the actual depth of the ulcer is obscured by sloth or eschar
Deep tissue injury(DTI)
Localized area of discolor, intact, skin, or blood filled blister caused by damage of underlying soft tissue from pressure or sheer
This can usually be caused by things that are left under the patient
Eschar
Can be black or brown when this is present, the wound is unstageable once the eschar leaves, the wound can be staged
Slough
Green or yellow in color
What labs do we look at with wounds?
Albumin
Protein
White blood count
Primary intention
A closed wound that heals quickly on its own
Staples, stitches
Secondary intention
Balloon is left open in order to heal from inside out
Tertiary intention
The wound is left open until risk of infection has passed usually within a 24 to 48 hour window. Then the wound is sealed.
Factors that influence wound healing
Nutrition
Tissue perfusion (blood circulation)
Infection
Age
Psychosocial impact of wounds: how it makes the patient feel, may give a different body image, may cause pain
Dehiscence
Separation of splitting open of layers of surgical wound
This can be due to pressure, straining
I can occur 3 to 12 days after procedure
Obese, patient or most at risk due to deeper adipose tissue
Evisceration
Extrusion of viscera or intestine through a surgical wound (guts spilling out)
When assessing wounds remember taco
T= type of drainage
A= amount of drainage(in centimeters)
C= color
O= odor
What are the two types of drains?
Hemovac or Jackson, Pratt
What are five types of exudates
Serous
Clear, Amber, yellow, thin, watery
Serosanguinous
Pink, thin, watery
Sanguineous
Bright red
Purulent
Thick, yellowish green
Bad odor
Hemorrhage
Read, thick
What are the two types of debridement for wounds?
Chemical and mechanical
Chemical : use of ointment or gel that softens or get rid of dead tissue
Mechanical: can be wet to dry dressings, scrubbing, scraping the tissue can also remove healthy tissue
Both types of debridement remove dead tissue
Santiel ointment on wound
Is meant to eat dead tissue and will also eat away healthy tissue
Hydrocolloid dressing
Is moldable
Impermeable to liquids and bacteria
Absorbs wound fluids
Swells and forms a gel that covers the one bed
Maintains moisture and protects newly formed tissue from dressing changes
Can be worn for 3 to 7 days
Hydrogel dressing
Maintains a moist healing environment
Provides up to 72 hour where time
For partial and full thickness wound
Transparent dressing
Allows visualization of site
Impermeable to liquids and bacteria
Do not use in wounds with excess of moisture
Can be worn for 3-7 days
Are usually placed on IVs
How to clean wounds
Start in the middle of the wound and work your way out in a circular motion
Normally, saline or sterile water is used
Exudate
Drainage
Heat intervention
Increase circulation, improves blood flow, prevents, redness, prevents, localized tenderness, must place barrier to prevent heat burn
Cold intervention
Decreases swelling/pain
Promotes coagulation
Caution should be used in length of application to avoid tissue ischemia
Requirement on MD order
Site, type, frequency, duration
Example
Apply cold pack two left knee x 20 minutes three times a day.
Safety key points do
Do:
Explain the patient what they may feel during application (this may feel warm/cold)
Protect skin (towel, pillowcase)
Instruct patient to report changes in sensation
Check the patient frequently
Safety key points do not
-Do not allow patient to adjust temperature settings
-Do not place patient in a position that does not allow them to move away from temperature source
-Do not leave patient unattended if they are unable to since change, or move away from source
