skin assessment/braeden scale Flashcards
what is the purpose of the skin?
protection
sensory
vitamin D synthesis
fluid balance
natural flora
whenever you inspect the body what specific things are you looking for?
bony prominences
visual and tactile assessments
rashes or lesions
hair distribution
skin color
blanch test
in pediatric patients what bony prominence are you most likely to notice skin breakdown?
the back of the head
in geriatric patients what bony prominence are you most likely to notice skin breakdown?
sacral/coccyx area
what patients are at higher risk for skin breakdown?
older patients
bed bound
diabetics
critically ill
during a skin assessment what do you want to focus on?
level of sensation
movement
continence
what are the time intervals you would want to perform skin assessments on your patients?
high risk patients
every 4 hours or more
already compromised skin
every 1-2 hours
non risk patients
on admission
once by each shift
what are the six aspects of skin integrity that we rate on the bradan scale?
sensory perception
moisture
activity
nutrition
mobility
friction and sheer
within sensory perception if the patient can not communicate their discomfort always and has a sensory impairment in 1-2 limbs what rate is this?
slightly limited
if there is sensory impairment over half of the body and painful stimuli what grade of sensory perception would that be?
very limited
when linens get changed at minimum once per shift what moisture level would this be categorized as?
very moist
if a patient can never get out of bed what are they categorized as?
bedfast
a patient that is categorized as chairfast is limited to what activity?
ambulation is severely limited to non-existent
cant bear their own weight must be assisted
patients who walk short distances with or without assistance are categorized as what?
walks occasionally
categorized as walks frequently patients can either do one option or the other what are those options?
walk outside the room at least 2 times a day or inside the room during the day at least once every 2 hours
how do you describe adequate nutrition?
eats over 1/2 of the meals
usually takes a supplement
tube feeding or TPN probably meets nutritional needs
even if ordered by physician only consuming clear liquids for 5 consecutive days is classified as what type of nutrition?
very poor nutrition
a potential problem with friction and sheer is classified by…
minimum assitance and is able to move feebly
skin probably slides against sheets
a problem of friction and sheer is described by?
moderate to minimum assistance in moving
frequently slides down in bed or chair
spasticity, contractures leads to almost constant friction
what classifies a low risk patient according to the braden scale?
15-18
regular turning schedule
enables as much activity as possible
protects heels
manage moisture and friction/sheer
what classifies a patient as moderate risk based off the braden scale?
13-14
regular turning schedule
enable as much activity as possible
protect heels
manage moisture, friction and sheer
position patient at 30 degree lateral incline using wedges or pillows
what classifies a patient as high risk based off the braden scale?
12 or less
regular turning schedule
enable as much activity as possible
manage moisture, friction and sheer
protect heels
position patient at 30 degree lateral incline using wedges or pillows
make small shifts in position frequently
pressure redistribution surface
what are some tissue integrity interventions you can implement?
frequent repositioning
sitting in chair for 2-hour intervals
keeping HOB at 30 degrees but no higher
keeping a written schedule of turning and positioning
what is the interval protocol?
cleanse
hydrate (protect the skin)
alleviate pressure
nourish
treat
what are the four wound stages?
stage 1
nonblanchable redness
stage 2
partial-thickness
stage 3
full-thickness skin loss
stage 4
full-thickness tissue loss
unstageable/unclassified
full-thickness skin or tissue loss-depth unknown
the inflammatory response is the sequential response to cell injury based off what?
neutralizes and dilutes inflammatory agent
removes necrotic materials
establishes an environment suitable for healing and repair
does inflammation always equal infection?
no inflammation is always present with infection, but infection is not always present with inflammation
what conditions does the inflammatory response occur with?
surgical wounds, other skin injuries
allergies
autoimmune diseases
skin infections
what does the intensity of the response depend on?
extent and severity of the injury
reactive capacity of the injured person
what occurs in a vascular response to inflammation?
increased capillary permeability
fluid moves into tissue spaces
initially serous fluid that eventually contains albumin pulls more fluid from vessels into tissue
what results from a vascular response?
redness
heat
swelling at site of injury and surrounding area
what occurs within the body during a cellular response to inflammation?
neutrophils and monocytes move through capillary wall and accumulate at site of injury
bone marrow releases more neutrophils in response to infection
elevated white blood cell count
local response to inflammation involves?
redness
heat
pain
swelling
loss of function
systemic response to inflammation involves?
increased WBC count
malaise
nausea and anorexia
increased pulse and respiratory rate
fever
likely due to complement activity and release of cytokines
types of inflammation
acute
healing in 2-3 weeks
nuetrophils predominant cell type at site
subacute
same features but last longer
chronic
may last for years
predominant cell types are lymphocytes and macrophages
may result from changes in the immune system
what is the final phase of the inflammatory process?
healing
regeneration
repair
what are the 3 phases included in the primary intention of healing?
INITIAL PHASE
3-5 days, acute inflammatory response
GRANULATION PHASE
fibroblasts secrete collagen, the wound is pink and vascular
risk for dehiscence and resistant to infection
MATURATION PHASE AND SCAR FORMATION
begins 7 days after injury, continues for months/years
wound becomes stronger and mature scar forms
how does secondary intention healing occuring?
ulceration and infection have large amounts of exudate and wide
irregular wound margins with extensive tissue loss
edges cannot be approximated
healing process is same as primary, inflammation may be greater
wound may need to be debrided
tertiary intention occurs by what?
delayed primary intention due to delayed suturing of wound
occurs when a contaminated wound is left open to heal from inside out
regeneration occurs in partial thickness wounds and heals the wound by?
inflammatory process occurs
epithelial proliferation and migration
reestablishment of epidermal layers
repair occurs within full-thickness wounds and heals the wound by?
hemostasis
inflammatory phase
proliferative phase
maturation
due to the injury extending into the dermis they heal by scar formation
what factors influence wound healing?
nutrition
tissue perfusion
infection
age
decreased function of macrophages leads to delayed inflammatory response in older adults
what are some complications that can occur during wound healing?
hemorrhage
hematoma
infection
dehiscence
evisceration
what are precautions to take for a redden rectal area?
cleanse
dry thoroughly
moisture barrier daily & PRN
what precautions do you take for redden skin between skin folds?
cleanse
dry thoroughly
place inner dry or dry AG textile in skin folds
what precautions do you take for redden heels?
position pressure off of heels
elevate on pillows
sage boot
reduce friction
what precautions do you take for a redden coccyx or sacral area?
change position every 1-2 hours
HOB 30 degrees unless contraindicated
avoid excess moisture
frequent peri care
wrinkle free linen
how do you classify a skin tear?
wound caused by shear, friction, or blunt force
can be partial or full thickness
common in older adults and critically ill
how often should you assess the skin integrity of a patient?
every shift and on admission; unless already compromised skin integrity
what are the purpose of dressings?
protects from microorganisms
aids in hemostasis
promotes healing by absorbing drainage or debriding a wound
supports wound site
promotes thermal insulation
provides a moist environment
what are types of dressings?
gauze
transparent film
hydrocolloid
hydrogel
foam
composite
what are important comfort measures to take whenever changing a patients dressing?
administer analgesic medications 30 to 60 minutes before
carefully remove tape
gently clean around wound edges
turn and position patient dressings
carefully manipulate dressings and draisn to minimize stress on sensitive tissues
date and time dressings
turn and position patient dressings
document
what is the enemy of wound healing and why?
dryness
antimicrobial and antibacterial solutions can damage new epithelium and delay healing
what must you do to contaminated wounds?
they must be converted to clean wound before healing can occur
debridement may be necessary
dressings are available that can absorb exudate and clean the wound
whats the most common type of drain found to remove excess fluids?
jackson-pratt
