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Unit 14 > Skin Integrity > Flashcards

Skin Integrity Flashcards

1
Q

Who are at risk for developing impaired skin integrity?

A

Older Adults
Decreased Mobility
Bariatric

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2
Q

Older Adults skin changes

A

Thinning skin- Decreased collagen (decreased elasticity)
Decreased Hydration
SQ Tissue
Blood Supply

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3
Q

Older Adults Problems that is caused due to skin changes

A

Skin tears
PI
Dry flaky skin
Skin infections

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4
Q

Decreased Mobility Skin changes

A

Reduced blood circulation
Incontinence
Loss of collagen
Muscles Atrophy
Impaired Sensation

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5
Q

Decreased Mobility Problems due to skin changes

A

Skin tears
PI
Skin infections
Incontinence associated dermatitis

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6
Q

Bariatric Skin changes

A

Decreased moisture
Dry skin
Maceration
Elevation in temp
Decreased blood and lymph flow

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7
Q

Bariatric Problems due to skin changes

A

Skin tear
PI
Diabetic ulcer
Moisture lesions
Skin-fold rashes

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8
Q

What are components of the comprehensive skin assessment?

A

Medical history
Risk factors (think about the Braden risk assessment)
Assessing skin for open areas
Redness
Abrasions
Edema
Moisture
Rashes
Texture
Temperature

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9
Q

Erythema

A

redness due to dilation of blood vessels

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10
Q

Blanchable erythema

A

temporarily becomes pale when pressure is applied, then turns red when pressure is released

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11
Q

Nonblancahble erythema

A

redness does not go away when pressure is applied, indicating structural damage to blood vessels

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12
Q

Temperature changes

A

Heat indicates inflammation
Coolness with decreased blood flow

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13
Q

Where are common areas of skin breakdown?

A
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14
Q

What are some Acute wounds?

A

Traumatic
Surgical
Moisture associated skin damage

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15
Q

Lacerations

A

tears in skin (blunt or sharp objects)

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16
Q

Skin Tear

A

Caused by mechanical forces (removing tape)
Seen in older adults

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17
Q

Surgical Wounds

A

created intentionally during surgery

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18
Q

Clean, Clean-contaminated

A

minimal bacteria and will be closed after surgery

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19
Q

Contaminated, dirty wounds:

A

Higher bacterial load
May be left open at first

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20
Q

How should a surgical wound look?

A

Intact, well- approximated edges

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21
Q

Day 1-4

A

Red

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22
Q

Day 5-14

A

Pink

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23
Q

Day 15- 1 year

A

Pale

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24
Q

What should the surgical would look by Day 4?

A

Epithelial Closure

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25
Q

What should the surgical would look by Day 5?

A

Edema and exudate should decrease

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26
Q

What should the surgical would look by Day 9-14?

A

Staples, sutures usually removed

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27
Q

What kind of moisture causes skin damage?

A

Urine
Feces
Stoma Effluent
Wound Exudate
Excessive sweating
Deep skin folds
Predisposes patient to PI

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28
Q

What is Chronic wounds?

A

Develops over time

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29
Q

What conditions predispose patients to develop chronic wounds?

A

Disruption of wound healing process in acute wounds
Decreased blood flow (venous insufficiency, peripheral artery disease, DM)

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30
Q

Who is more prone to experiencing Chronic wounds?

A

Those with chronic illnesses
Malnourished
Smokers
Immobilized
Infected wounds have a higher risk for developing chronic wounds

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31
Q

What causes Arterial Wound?

A

Blocked arteries-unable to deliver nutrients
DM
Age
Smoking
HTN
Hyperlipidemia
Kidney failure
Atherosclerosis
Vasculitis

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32
Q

Description of Arterial Wound

A

“Punched out” ankle, feet, heels, toes
Red, yellow, black sores.
Deep. Leg pain at night.
No bleeding.
Cool to the touch

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33
Q

Arterial Wound Nursing Interventions

A

Need to restore perfusion- angioplasty.
Keep wound, clean, dry

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34
Q

Venous Wound Causes

A

Damage to veins- blood has difficulty returning to heart
Varicose veins
HTN
Injuries
Obesity
DVT
HF
Pregnancy

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35
Q

Description of Venous Wound

A

Shallow, irregular margins.
Below knee, inner ankle.
Inflammation, swelling, itchy, hardened skin, scabbing, darkened brownish stained skin, exudate.

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36
Q

Venous Wound Nursing Intervention

A

Keep free of infection. Debridement.
Compression therapy to prevent.

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37
Q

Neuropathic Wound Causes

A

Diabetes, neurological condition.
Neuropathy (decreased sensation)

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38
Q

Neuropathic Wound Description

A

Well defined, punched out.
Soles of the feet.
Surrounding skin is calloused.
Undermining and pockets of infection with risks of osteomyelitis. Painless

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39
Q

Neuropathic Wound Nursing Interventions

A

Infection prevention
Debridement
Keep wound moist
Reduce pressure on area
Therapeutic shoes

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40
Q

What causes pressure injuries?

A

Localized injury to skin or underlying tissue due to pressure and shear (force exerted parallel to surface of the skin- sitting at an incline)

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41
Q

What are risk factors for pressure injury development?

A

Immobility
Malnutrition
Reduced perfusion
Altered sensation
Decreased LOC
Friction
Moisture

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42
Q

What areas on the body are most susceptible to pressure injury development?

A

Bony prominences
Skin folds
Medical devices

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43
Q

Describe the pressure injury risk assessment- what is assessed?

A

Mobility
Nutrition
Skin perfusion
Sensory

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44
Q

Stage 1

A

Non-blanchable erythema

45
Q

Stage 2

A

Partial thickness skin loss- pink or red viable tissue/moist. Or ruptured serum filled blister

46
Q

Stage 3

A

Full thickness skin loss with visible adipose tissue.
Granulation tissue will form on surface.
Edges may be rolled under (epibole), undermining and tunneling may exist.
Necrosis may exist

47
Q

Stage 4

A

Full thickness skin loss with fascia
Muscle, tendons, ligaments, cartilage and/or bone seen.
Edges are rolled, undermining and tunneling may exist.
Necrosis may exist

48
Q

Unstageable Injury

A

Obscured full thickness- unable to see depth or extent of damage. Covered with slough or eschar

49
Q

Deep Tissue Injury

A

Localized, non-blanchable, deep red, maroon, purple discoloration.

50
Q

Device Related Tissue Injury

A

Assumes shape of device

51
Q

Mucosal Membrane Tissue Injury

A

Respiratory equipment, feeding tubes, drainage tubes.
Can’t be staged

52
Q

Patients with Darker Skin Injury Assessment

A

Harder to stage.
Assess for changes in skin color, temperature, moisture, texture (hardened), pain, shiny

53
Q

Maceration

A

Irritation caused by moisture

54
Q

Slough

A

Yellow, Stringy nonviable tissue

55
Q

Eschar

A

Hard Nonviable brown/ black tissue

56
Q

Granulation Tissue

A

New Connective Tissue
Pinkish- Reddish color

57
Q

Dermatitis

A

Red irritation after skin is exposed to irritants

58
Q

Skin Tear

A

Loss of top layer of skin caused by mechanical forces

59
Q

Skin frailty

A

At-Risk, Vulnerable skin (chronic disease and old age risk)

60
Q

Skin frailty

A

At-Risk, Vulnerable skin (chronic disease and old age risk)

61
Q

Cellulitis

A

Infection of superficial layer of skin

62
Q

What are the different wound drainage?

A

Serous
Serosanguinous
Sanguineous
Purulent

63
Q

Serous Wound Drainage

A

Plasma. Clear to yellowish

64
Q

Serosanguinous Wound Drainage

A

Serum with some blood
Light pink or red tinge

65
Q

Sanguineous Wound Drainage

A

Fresh blood- bright pink/red

66
Q

Purulent Wound Drainage

A

Infection

67
Q

How are wounds measured?

A

Tracing circumference and measuring with see-through film
Length (head to toe) and width (lateral) with ruler and depth with Qtip against ruler

68
Q

What is tunneling and how is it measured?

A

Narrow channel in any direction from base of the wound. Insert sterile cotton tip applicator until resistance is met, measure with ruler.

69
Q

What is undermining and how is it measured?

A

Under skin at the edge of the wound. Use clock (example 9 o’clock to 12 o’clock)

70
Q

Wound Color Indication: Pink

A

Epithelial Tissue.
Need to be protected

71
Q

Wound Color Indication: Pinkish- Red

A

Healing.
Need to protect
Keep moist (helps with granulation)
Fill dead space

72
Q

Wound Color Indication: Yellow

A

Slough
Might be stuck in inflammatory stage.
May indicate infection.
Need to clean wound, loosen and debride devitalized tissue, loosely fill dead space and keep separated from healthy skin.
Absorb fluid and exudate.

73
Q

Wound Color Indication: Black

A

Debridement
Monitor for impaired circulation in surrounding area.

74
Q

What happens if there is hard necrotic tissue, covering the patients heels?

A

Might be left in place because it is acting as a protective barrier.

75
Q

SIgns of inflammation

A

Pain
Redness
Swelling

76
Q

Montgomery Straps

A

Adhesive straps that are affixed to skin to provide method for securing dressing w/o having to replace tape every time.

77
Q

Wound Cleansing

A

The use of fluids to gently remove loosely adherent contaminants and devitalized material from the wound surface.

78
Q

When do you use Wound Cleansing?

A

Most wounds should be cleansed initially and at each dressing change.

79
Q

What do you use for Wound Cleansing?

A

Biofilm- microbes that adhere to wound bed- not always able to see

80
Q

Surgical Debridement

A

Surgically remove dead tissue to prevent infection

81
Q

When do you use Surgical Debridement?

A

Chronic wounds

82
Q

Irrigation Wound Care

A

Removes surface material to decrease bacteria.
Most often use 0.9% NS.
Remember principles of hygiene and infection control- irrigate from least to most contaminated

83
Q

When is Irrigation used?

A

The goal of wound irrigation is to remove foreign material, decrease bacterial contamination of the wound, and to remove cellular debris or exudate from the surface of the wound.

84
Q

Biologic Debridement

A

Enzymatic agents (collagenase- targets necrotic tissue) larvae- liquify necrotic tissue

85
Q

When is Biologic Debridement used?

A

Patients who are unable to undergo surgery

86
Q

What is the ideal environment for wound healing?

A

Moist when healing

87
Q

What factors are considered when selecting dressing?

A

Acute v. chronic
Drainage
Stage of healing
Surrounding tissue

88
Q

When are sterile dressings used?

A

After surgery, usually kept on for 24-48 hours

89
Q

Sutures Closure

A

Keep wounds secure and intact

90
Q

Suture Closure Complications

A

Nonabsorbable sutures can cause more pain and suture sinus

91
Q

Staples Closure

A

Keep wounds secure and intact.
Can be put in place quickly.
And wounds heal faster.

92
Q

Staples Closure Complications

A

Scarring and difficulty removing

93
Q

Skin Adhesive Closure

A

Time saving.
Protective waterproof barrier to cover wound.

94
Q

Skin Adhesive Complications

A

Glue must stay in place for 5-7 days in order to close the wound

95
Q

Negative Pressure Wound Therapy

A

Assist in healing and closing of wound
Reducing edema
Increases granulation

96
Q

Negative Pressure Wound Therapy Complications

A

Bleeding
Retained foam
Pain
Granulation tissue growing into foam dressing

97
Q

What is the purpose of wound drains?

A

Decrease accumulation of fluid, air, collect wound drainage

98
Q

Passive Drains

A

Rely on gravity

99
Q

Active Drains

A

Use negative pressure

100
Q

Open Drains

A

Remove fluids to air

101
Q

Closed Drains

A

Remove fluids to closed containment system

102
Q

When are drains usually removed?

A

When drainage is 30-100 mL/24 hours

103
Q

What are complications of early drain removal?

A

Hematoma and Seroma

104
Q

How do nurses monitor drainage output?

A

Monitor amount
Type
Consistency
Odor
Surrounding skin

105
Q

What findings would be a cause for concern?

A

Report significant change in output
Blood clots
Infection
Accidental removal

106
Q

How do nurses prevent skin breakdown?

A

Identify at risk patients
Repositioning (patients need to be on a turn schedule and be re-positioned a minimum of every 2 hours- sometimes more frequently)
Use proper transfer devices to reduce friction
Position appropriately to reduce shearing forces
Early mobilization
Keep skin clean and dry
Support surfaces
Protect bony prominences
Skin and mucosa under devices
Proper hygiene
Hydration
Nutrition (protein, omega 3, vitamin A and C, zinc)
Promote circulation

107
Q

What factor might impair wound healing?

A

Diabetes
Infection
Foreign body in wound
Medications
Malnutrition
Tissue necrosis
Hypoxia
Multiple wounds

108
Q

Describe the process for obtaining a wound culture. When would one be indicated?

A

Any signs of infection-
Purulent drainage
Odor
Pain
Erythema
Edema

Unit 14 (1 decks)

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