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IM1 Exam 4 > Skin Integrity 1 > Flashcards

Skin Integrity 1 Flashcards

1
Q

skin is the _____ organ

A

largest organ

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2
Q

skin is a __________ barrier

A

protective

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3
Q

it is the ________ responsibility to assess and monitor skin integrity

A

nurse’s

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4
Q

skin’s purpose

A
  • protection
  • sensory
  • vitamin D synthesis
  • fluid balance
  • natural flora: things on skin fight bacteria
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5
Q

assessment of the skin

A

inspect entire body
- especially bony prominences: places w/o fat where bone will rub against mattress, skin will break down easily (peds most likely place is back of head)
- visual and tactile: looking and feeling
- assess any rashes or lesions
- note hair distribution
- skin color
- blanch test: hold fingers on skin and see if skin turns white from being red or stays red (non-blanch)

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6
Q

skin assessment

A
  • identify the patient’s risk
  • identify signs and symptoms of impaired skin integrity or poor wound healing
  • examine skin for actual impairment
  • focus on: level of sensation, movement, and continence (can they feel your hand on their skin? are they up and moving frequently or limited?)
  • assess skin on intiation of care (admission), then at least once/shift
  • high-risk patients: assess every 4 hours or more often
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7
Q

skin assessment details

A
  • visual and tactile inspection of ALL the skin
  • palpate areas of redness to determine if skin is blanchable, paying attention to bony prominences, medical devices, areas with adhesive tapes
  • turn the patient to inspect the skin, assess when patient returns to bed from chair, when bathing, etc.
    (would take off oxygen not for long but do need to check for skin breakdown,
    do take off SCDs and socks to look at those areas,
    if they’re hard to turn, can assess skin during hygiene, or when moving them to barton chair,
    if pressure ulcer is created during hospital stay, hospital has to pay for their stay bc insurance won’t pay for it)
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8
Q

Braden scale assesses _____

A

risk of skin breakdown

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9
Q

braden scale scoring

A

high risk = low number
low risk = high number

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10
Q

sensory perception category

A
  1. completely limited
    - unresponsive
    - limited ability to feel pain over most of the body
    (comatose, sternal rub gets no response)
  2. very limited
    - painful stimuli
    - cannot communicate discomfort
    - sensory impairment over half the body
    (respond to painful stimuli like sternal rub)
  3. slightly limited
    - verbal commands
    - cannot always communicate discomfort
    - sensory impairment: 1-2 extremities
  4. no impairment
    - verbal commands
    - no sensory deficit
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11
Q

moisture category

A
  1. constantly moist
    - perspiration, urine, etc.
    - always
  2. very moist
    - often but not always
    - linen changed at least once per shift
  3. occasionally moist
    - extra linen changed every day
  4. rarely moist
    - usually dry
    (independent, gets up to go to bathroom, don’t have to change sheets)
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12
Q

activity category

A
  1. bedfast
    - never OOB (out of bed)
  2. chairfast
    - ambulation severely limited to non-existent
    - cannot bear own weight: assisted to chair (by several ppl)
  3. walks occasionally
    - short distances daily with or w/o assistance
    - majority of time in bed or chair
    (walks to chair, gets up for PT but not alone)
  4. walks frequently
    - outside room 2x per day
    - inside room every 2 hours during waking hours
    (walks to nurse’s station with no help, easily, or if don’t want to walk around in gown, they move around in their room)
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13
Q

mobility category

A
  1. completely immobile
    - makes no change in body or extremity position
    (can’t turn)
  2. very limited
    - occasional slight changes in position
    - unable to make frequent/significant changes
    independently
    (need help to turn over or adjust)
  3. slightly limited
    - frequent slight changes independently
    (can turn by themselves)
  4. no limitations
    - major and frequent changes w/o assistance
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14
Q

nutrition category

A
  1. very poor
    - never eats complete meal, very little protein
    - NPO, clear liquids, IV greater than 5 days
    (could be bc of doctor’s order, upcoming surgery, if more than 5 days considered in very poor nutrition no matter what they normally eat outside of the hospital)
  2. probably inadequate
    - rarely eats complete meal, very little protein
    - occasionally takes dietary supplement
    - receives less than optimum liquid diet or tube feeding
    (supplement = protein shake)
  3. adequate
    - eats over 1/2 of most meals, adequate protein
    - usually takes a supplement
    - tube feeding or TPN probably meets nutritional need
  4. excellent
    - eats most of meal, never refuses, plenty of protein
    - occasionally eats between meals
    - does not require supplements
    (asking about a coke, extra food)
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15
Q

friction and shear category

A
  1. problem
    - moderate to max assistance in moving
    - frequently slides down in bed or chair
    - spasticity, contractures or agitation leads to almost constant friction
    (need help to slide back up all the time)
  2. potential problem
    - moves feebly, requires minimum assistance
    - skin probably slides against sheets
    - relatively good position in chair or bed with occasional sliding
    (slides sometimes)
  3. no apparent problem
    - moves in bed and chair indepently
    - sufficient muscle strength to lift up completely during move
    - good position in bed or chair
    (still have to assess and lay eyes on them and document patient sitting on edge of bed, up going to the bathroom)
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16
Q

low risk (15-18 pts)

A
  • regular turning schedule
  • enable as much activity as possible
  • protect heels
  • manage moisture, friction and shear
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17
Q

moderate risk (13-14 pts)

A
  • regular turning schedule
  • enable as much activity as possible
  • protect heels
  • manage moisture, friction and shear
  • position patient at 30 degrees lateral incline using wedges or pillows
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18
Q

high risk (12 or less pts)

A
  • regular turning schedule
  • enable as much activity as possible
  • protect heels
  • manage moisture, friction and shear
  • position patient at 30 degree lateral incline using wedges or pillows
  • make small shifts in position frequently
  • pressure redistribution schedule (make small shifts like moving wedge pillow)
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19
Q

tissue integrity interventions

A
  • frequent repositioning**
  • sitting in chair for 2-hour intervals: if not contraindicated, longer than 2 hours may cause increased pressure to sacral tissue
  • keeping HOB at 30 degrees: no higher than 30 degrees
  • keeping a written schedule of turning and positioning: EMR
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20
Q

wound staging

A

stage 1: nonblanchable redness
stage 2: partial thickness
stage 3: full-thickness skin loss
stage 4: full-thickness tissue loss
unstageable/unclassified full-tissue skin or tissue loss - depth unknown
suspected deep-tissue injury - depth unknown

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21
Q

early intervention protocol C.H.A.N.T.

A

what to do when you see redness on patient and do blanch test that stays red (non-blanchable)
C - cleanse
H - hydrate (and protect) skin: have a moisture barrier to keep moisture or what is causing skin breakdown from sitting right up against the skin, ex: diaper cream
A - alleviate pressure
N - nourish: supplement like protein shake, or if have NG tube can have supplement added
T - treat: treat wound with antibiotics, keep wound from continuing to get worse

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22
Q

early intervention protocol details

A

red/ excoriated peri/rectal area
- cleanse
- dry thoroughly
- moisture barrier daily and prn

redness/excoriation between skin folds
- cleanse
- dry thoroughly
- place inner dry (doctor’s order to place on skin folds to wick away moisture) or dry AG textile in skin folds

red heels
- position pressure off of heels
- elevate on pillows
- sage boot
- reduce friction

red sacral/coccyx area
- change position every 1-3 hours
- HOB less than 30 degrees unless contraindicated
- avoid excess moisture
- frequent peri care
- wrinkle free linen

23
Q

nursing priorities for skin

A
  • assessing and monitoring skin integrity
  • identifying risks for skin problems
  • identifying present skin problems
  • planning, implementing and evaluating interventions to maintain skin integrity: evaluating = is what we are doing working
24
Q

inflammatory response

A
  • sequential response to cell injury
    – neutralizes and dilutes inflammatory agent
    – removes necrotic materials
    – establishes an environment suitable for healing and repair
  • inflammation doesn’t equal infection
    – inflammation is always present w/infection, but infection is not always present with inflammation
  • inflammatory response occurs with multiple conditions
    – surgical wounds, other skin injuries
    – allergies
    – autoimmune diseases
    – skin infections
25
Q

wounds

A
  • wound: any disruption of the integrity and function of tissues in the body
  • wound assessment and classification is important to wound healing
  • tissue trauma causes an inflammatory response in the first 24 hours (see inflammatory response as a warning that there is tissue trauma)
26
Q

inflammatory response

A
  • mechanism is the same regardless of the injuring agent
  • intensity of the response depends on:
    – extent and severity of the injury
    – reactive capacity of the injured person
27
Q

vascular response

A

whole point of this is to prevent spread of bacteria
- increased capillary permeability, fluid moves into tissue spaces (fluid moves into tissue spaces = swelling)
- initially serous fluid, but eventually contains albumin, pulling more fluid from vessels into tissue
- result:** redness, heat, and swelling at site of injury and surrounding area
- fibrinogen is activated to fibrin, which strengthens the blood clot, prevents the spread of bacteria

28
Q

cellular response

A
  • neutrophils and monocytes move through capillary wall and accumulate at site of injury
  • bone marrow releases more neutrophils in respnse to infection, WBC elevated
  • complement system - major mediator of inflammatory response
  • exudate
    – fluid and leukocytes
    – nature and quantity of exudate
    — type and severity of injury
    — tissues involved
    (see inflammation and order CBCs blood work to see it occurring on this level)
29
Q

clinical manifestations - local response

A

local response to inflammation
- redness
- heat
- pain
- swelling
- loss of function
ex: no fever or high WBC count, but you take dressing off after wrist surgery and see redness, heat, pain, swelling, can become systemic if not treated

30
Q

clinical manifestations - systemic response

A

systemic response to inflammation
- increased WBC count
- malaise
- nausea and anorexia
- increased pulse and resp. rate (bc of fever (and pain))
- fever
causes are poorly understood, but likely due to complement activation and release of cytokines

31
Q

types of inflammation

A

acute:
- healing in 2-3 weeks, no residual damage
- neutrophils predominant cell type at site
(something happened in their life, could be trauma, but fine in 2-3 weeks)
subacute:
- same features, but lasts longer
(maybe have something else going on so aren’t healthy enough to fight off in 2-3 weeks)
chronic:
- may last for years
- injurious agent persists or repeats injury to site
- predominant cell types are lymphoctyes and macrophages
- may result from changes in immune system
(ex: psoriasis, psoriatic arthritis, eczema)

32
Q

nursing and interprofessional management

A

health promotion:
- prevention of injury
- adequate nutrition
- early recognition of injury/inflammation
- immediate treatment

33
Q

nursing and interprofessional management

A
  • observation/recognition:
    – classic manifestations of inflammation may be masked for immunosuppressed patient, early symptom may be general malaise
  • vital signs:
    – important to note, especially if infection is present, temp., pulse and resp. rates may increase
  • fever management:
    – antipyretics may not be necessary, as mild-moderate fever usually does little harm. however very young or very old, uncomfortable, or those with significant medical problems may benefit
    – fever greater than 104F can be damaging to body cells. intervention is necessary.
34
Q

wound healing

A
  • final phase of inflammatory process is healing
  • healing includes 2 major components;
    – regeneration: replacement of lost cells and tissues with cells of the same type
    – repair: healing as a result of lost cells being replaced by connective tissue, results in scar formation
    — more common, more complex
    — occurs by primary, secondary, or tertiary intention
35
Q

healing by primary intention

A

(patient cut open in surgery, had a wound that was sown back together and it healed, ex: c-section)
includes 3 phases
- initial phase: 3-5 days
- granulation phase: fibroblasts secrete collagen, wound pink and vascular, risk for dehiscence, resistant to infection (starts to heal)
- maturation phase and scar formation: begins 7 days after injury, continues for months/years, fibroblasts disappear, wound becomes stronger, mature scar forms (scar forming)

36
Q

healing by secondary intention

A

(any wound caused by trauma, healing takes longer bc edges can’t be approximated, may need more surgeries)
- wounds from trauma, 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, but inflammatory reaction may be greater, wound may need to be debrided before healing can take place

37
Q

healing by tertiary intention

A

(should’ve been primary but went wrong, ex: c-section happened and patient forgot nurse’s tips so later when she finally went to hospital, there was a huge infection, so cut her open, removed infection, packed it and heal from inside)
- delayed primary intention due to delayed suturing of wound
- occurs when a contaminated wound is left open and sutured closed after infection is controlled

38
Q

wound healing - partial-thickness wounds (regeneration)

A
  • 3 components in healing process
  • inflammatory response
  • epithelial proliferation and migration
  • reestablishment of epidermal layers
39
Q

wound healing - full-thickness wounds (repair)

A

(more phases than partial) (more skin you lose, longer it takes wound to heal)
- 4 phases in healing process
- hemostasis
- inflammatory phase
- proliferative phase
- maturation
- full-thickness wounds extend into dermis, they heal by scar formation

40
Q

factors that influence wound healing

A

(good nutrition, good oxygen, lack of infection and younger age = good wound healing)
NOIA
- nutrition: protein, vitamins (esp. A and C), trace minerals of zinc and copper + adequate calories
- tissue perfusion: oxygen fuels cellular functions
- infection: prolongs the inflammatory stage, delays collagen synthesis, prevents epithelialization, increases cytokine production
- age: decreased function of macrophages leads to delayed inflammatory response in older adults

41
Q

complications of wound healing

A
  • hemorrhage: bleeding
  • hematoma: collection of blood that shows under skin, like a swollen bruise
  • infection: will slow wound healing
  • dehiscence: when a wound breaks open, stitches come off or open
  • evisceration: wound comes open and insides are on the outside (ex: c-section and uterus comes out of the wound)
42
Q

wound identification and classification

A

classified by cause and depth:
- surgical or non-surgical; acute or chronic
- superficial, partial thickness, full thickness
skin tear: wound caused by shear, friction, and/or blunt force
- can be partial or full thickness
- common in older adults and those critically/chronically ill

43
Q

wound assessment

A
  • assess skin on admission and every shift
  • include: location, size, condition of surrounding tissue, and wound base
  • any drainage - consistency, color, odor
  • determine if there are factors that could delay healing
44
Q

nursing and interprofessional management

A

management of wounds, including types of dressings, depends on type, extent, and character of wound and the phase of healing
clean wounds:
- may need cleansing and some type of wound closure (adhesive strips, sutures, staples)
- various dressings available to keep wound clean and slightly moist
- surgical wounds may be covered with sterile dressing, removed in 2-3 days
- dryness is enemy of wound healing. antimicrobial and antibactericidal solutions can damage new epithelium and delay healing, should not use in a clean granulating wound
- surgical wounds may have a drain placed to help remove excess fluid
- Jackson-Pratt drain is common

45
Q

nursing and interprofessional management

A

contaminated wounds:
- must be converted (opened up) to clean wound before healing can occur
- debridement (removal of dead tissue and debris) may be necessary (medicate pt)
- dressings are available that can absorb exudate and clean the wound

46
Q

purposes of dressings

A
  • 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
47
Q

types of dressings

A
  • gauze
  • transparent film
  • hydrocolloid
  • hydrogel
  • foam
  • composite
48
Q

nursing and introprofessional management

A

changing dressings: know type of dressing, placement of drain, and equipment needed
prepare the patient for dressing change:
- review previous wound assessment
- evaluate pain, and if indicated, administer analgesics
- describe procedure
- gather all supplies
- recognize normal signs of healing
- answer questions about the procedure or wound
(prepare patient for how it’s going to feel and what is going to happen with changing dressing)

49
Q

dressing change comfort measures

A
  • administer analgesic (painkiller) medication 30-60 minutes before
  • carefully remove tape
  • gently clean wound edges
  • carefully manipulate dressings and drains to minimize stress on sensitive tissues
  • turn and position patient carefully
  • date and time dressings that you put on
  • document!!!
50
Q

cleaning skin and drain sites

A

basic skin cleaning
- clean from least contaminated to the surrrounding skin
- use gentle friction
- when irrigating, allow the solution to flow from the least to most contaminated area
- pictures of cotton ball on end of tweezers used to clean wounds with stitches

51
Q

suture and staples

A
  • cleaning skin and drain sites with irrigation
  • suture removal: review policy before removing, how many was it = document, clip near skin, opposite of knot
  • staple removal - know how many put on and removed
    – review policy (NII) and orders prior to removing staples
  • steri-strips: don’t pull or create tension, teach to allow them to fall off naturally, (even if dangling) (about 10 days), may shower
52
Q

antibiotics for surgical prophylaxis

A
  • prophylactic doses of antibiotics can decrease the incidence of infection in certain kinds of surgery
  • will observe prophylactic use of antibiotics for cardiac surgery, peripheral vascular surgery, orthopedic surgery, GI surgery, and OB/GYN surgeries. For contaminated surgeries (compound fractures, perforated abdominal organs, animal bites), antibiotics are treatment, not prophylaxis, as infection rates of these surgeries is 100%.
  • prophylactic antibiotics should be given prior to surgery, and may be re-dosed if the surgery is unusually long
  • an additional dose of antibiotics after surgery may be given in some instances, but is usually unnecessary.
53
Q

antibiotics for surgical prophylaxis

A

cephalosporins are widely used, especially 1st and 2nd generation.
- most effective against cells undergoing active growth and division, one of most widely used antibacterial drugs.
- 1st generation: Cefezolin, Cephalexin
- 2nd generation: Cefotetan
- 3rd generation: ceftriaxone (also used for active infections, penetrates CSF)

54
Q

important points

A
  • surgical site infection prevention: may be given prophylactic antibiotics
  • patient may be distressed about appearance, fear of scars or permanent disfigurement
  • caregiver’s facial expressions can cause further alarm and mistrust (learn nurse face, don’t freak them out)
  • teach patient and family healing process and normal changes to wound as it heals, as well as home care of wound, infection prevention (hand washing), s/s to report, adequate nutrition (teach them what it should look like, what infection looks like)

IM1 Exam 4 (2 decks)

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