Skin Integrity Flashcards
clean wounds
closed, intact, not infected
clean-contaminated wounds
surgical wounds - no infection
contaminated wounds
open, accidental or surgical - involves major break in sterile technique
dirty & infected wounds
show evidence of infection
partial thickness wounds
dermis & epidermis healing by regeneration (on its own)
full thickness wounds
all 3 layers of tissue - possible muscle & bone - requires tissue repair
etiology of pressure wounds
ischemia
reactive hyperemia
blanchable bright red flush to skin when pressure removed - results from vasodilation
pressure ulcer risk factors
friction & shearing Immobility Inadequate nutrition Incontinence - can cause maceration Decreased mental status Diminished sensation Excessive body heat Advanced age Chronic medical conditions
stages of pressure ulcers
Stage 1—Nonblanchable erythema
Stage 2—Partial-thickness skin loss - to dermis - open or closed ulcer
Stage 3—Full-thickness skin loss - SQ visible
Stage 4—Full-thickness skin loss c necrosis - muscle, tendon, ligament, bone visible
epibole
edges of ulcer roll under & damage to skin extends beneath roll
slough and eschar prevent us from…
assessing depth
staging injury
Deep tissue pressure injury
Purple or black intact skin - blackish blistered area - heavy or spongy at palpation
prevention of pressure ulcers
Assess pt’s risk factors q shift - Braden Scale
Keep skin dry & clean
Use barrier creams
Wrinkle-free linens
Turn q 2 hrs
Watch friction & shear
Special air beds & devices for pts c high risk
components of braden scale
sensory perception moisture activitiy mobility nutrition friction & shear
braden scale explain scores
the higher the score, the less risk for an ulcer
Primary intention healing
tissue surfaces approximate - minimal/no tissue loss - minimal granulation tissue & scarring
secondary intention healing
extensive tissue loss - no approximation - repair time longer - scarring greater - susceptibility to infection
tertiary intention healing
leave wound open for 3-5 days until edema/drainage is gone - closed with sutures, staples, adhesives
phases of healing
inflammation
proliferative
maturation
dehisence
rupture of sutured wound - partial or total - usually involves abdominal wound c layers beneath skin also separating
evisceration
what do you do?
4-5 days post op - protrusion of internal organ through incision - emergency situation - organ is exposed - immediately put on sterile wet dressing, then call physician
risk factors for dehisence, evisceration
obesity, poor nutrition, multiple trauma, failure of suturing, excessive coughing, vomiting, dehydration
assess pressure ulcers for…
location related to bony prominence, undermining or sinus tracts, stage, color of wound bed, location of necrosis or eschar, condition of margins, integrity of surrounding skin, signs of infection
minimal drainage
stains dressing - give size of stain
moderate drainage
saturates dressing but does not leak out - notify physician
maximal drainage
overflow dressing - emergency
support wound healing
Clean & dress injury using surgical asepsis Do not use alcohol or hydrogen peroxide Obtain C&S if infected Teach pt to move often Provide active or passive ROM exercise RYB color code (color of wound)
RYB
red - protect
yellow - cleanse
black - debride
4 types of debriding
Sharp - scissors, scalpel to debride wound
Mechanical - scrubbing
Chemical - enzymes, etc
Autolytic - hydrocolloid dressing
off loading
devices to prevent ulcers
masd
moisture associated skin damage
function of wound drains
prevent abscess
penrose drain
little tube - drains surgical wounds
jackson pratt drain
bulb - squeeze before closing lid - slowly opens and pulls drainage into it
hemovac drain
same concept as JP drain, but holds more drainage
wound irrigation pressure
4-15 psi
type of dressing depends on…
Depends on location, size, type of wound, amount of exudate, whether it requires debridement, is infected, frequency of change, cost, difficulty of application
3 types of dressings & what they are used for
Transparent - ulcerations, burns
Hydrocolloid - pressure injuries
Secure - ensure dressing covers entire wound & doesn’t become dislodged
bandage turns & description
Circular - anchor bandages & terminate them - not applied directly to wound
Spiral - part of body uniform in circumference
Recurrent - cover distal parts of body
Figure 8 - elbow, knee, ankle - allow some movement
applying arm sling
80º angle arm - thumb facing upward or inward toward body
heat causes _______ after 20-30 mins
vasodilation
heat increases…
cold decreases…
vasodilation
cap permeability
inflammation
cellular metabolism
heat no longer than ___ mins
30
heat indications
muscle spasm
inflammation
pain
joint stiffness
heat has no effect on
traumatic injuries
do not use heat…
First 24 hours after traumatic injury Active hemorrhage Noninflammatory edema Skin disorder that causes blister Longer than 30 mins
maximum cold vasoconstriction
60º
lewis hunting effect
alternation of vasodilation & vasoconstriction with cold <60º
cold slows _______
mild _______ effect
bacterial growth
anesthetic
cold indications
muscle spasm
inflammation
pain
traumatic injury
cold has no effect on
contracture
joint stiffness
do not use cold….
Open wounds
Impaired circulation
Allergy or hypersensitivity to cold
rebound phenomenon
occurs at maximum therapeutic effect of hot or cold applications is achieved and the opposite effect begins - Lewis Hunting
to know about heat/cold devices
cover them
do not use heat beneath pt
