Skin Integrity Flashcards
1
Q
What are the Risk Factors for impaired tissue Integrity?
A
- young (usually get irritation due to immature skin)
- OLD ( higher risk for skin tears & issue trauma due to decreased collagen stores, thinner skin, & decreased elasticity)
- Sun exposure –> sunburnts
- Skin tears, pressure injuries, cellulitis (serious bacterial skin infection)
2
Q
What are the Assessment findings related to skin integrity?
A
- Medical history (identify risk factors)
- Assessing skin (if present, assess history):
- Abrasians –> scrape
- Edema
- Moisture
- Rashes
- Skin texture/temp - Head to toe assessment
- Bony prominences for erytheme (Redness of skin due to dilation of blood) & other tissue discoloration
- Temp. changes:
– Inflammation areas w/ increased skin temp., decreased blood flow with decreased skin temp)
- Obesity –> assess skin folds for pressure ulcers
- Medical devices - increase frequency of monitoring when condition worsens
3
Q
What are the 2 types of Wounds?
A
- ACUTE (Intentional: surgical incision & laceration vs Unintentional: skin tear & moisture-associated damage)
A) Traumatic (lacerations & skin tears) also burns, punctures, gun-shot wound- lacerations –> tears in the skin caused by blunt/sharp objects; may have an irregular or jagged shape
- skin tears –> from mechanical force like removing tape from client’s skin
B) Surgical (clean, clean-contaminated, contaminated, dirty) - clean & clean-contaminated: minimal bacteria & are @ the completion of the procedure
- contaminated & dirty: have higher bacteria
C) Moisture-associated skin damage (dermatitis due to exposure to urine, feces, & wound exudateS)
- CHRONIC (disruption of healing process vs. chronic condition origin)
- Risk factors: smoking, malnourished, immunosuppressed, immobilized, infection
- venous (due to poorly functional veins), arterial (poor perfusion or ischemia), & neurophatic wounds (non-healing, usually on diabetic ppl because they have lower sensation = cannot feel the wound)
4
Q
How do you do your Wound assessment?
A
- Monitor exudate for changes in color, amount, and ODOR OF exudate (indicate healing or infection)
- Exudate: serous, serosanguineous, sanguineous, or purulent
- If you have wound that’s going from sanguineous to serous, (color lightens), that means it’s a sign of healing!!
- Size & shape: tracing vs length (head to toe) & width (R-to-L)
- Depth & tunneling –> insert a sterile cotton tip under the wound edges until resistance is felt. We’re Looking for the extend of the skin intact & missing skin tissue underneath the surface
- Exudate: serous, serosanguineous, sanguineous, or purulent
5
Q
How is Pressure Injury developed?
A
- Pressure (body weight, gravity)
- Shearing (bed position) –> patient’s sliding off the bed. Skin and the bone are sliding the opposite direction!!
- Friction (changing positions
6
Q
What are the risk factors contributing to pressure injury development?
A
- Immobility
- Malnutrition !!
- Reduced perfusion –> get blood supply to the tissue so that it can heal. low perfusion means inadequate supply of blood circulation, which result in low oxygen levels in tissues)
- Altered sensation –> usually DIABETIC can’t feel (decreased sensation) SOO they won’t be able to feel their wounds
- Decreased level of consiousness
- Exposure to moisture (fever), tearing, cuts, bruises, & friction
7
Q
What are the common locations of pressure injury formation?
A
boney prominences
shoulder, elbow, sacrum, back, heels, hips, ankles, shoulders
8
Q
What are the stages of pressure injuries?
A
- STAGE 1: Non-blanchable erythema
- Wound/skin have not broken yet.
- If you put a pressure on the redness, and it doesn’t turn white, then it means it’s non blanch able! - STAGE 2: Partial-thickness skin loss
- Skin tear or ruptured blisters where the FIRST layer is disrupted - STAGE 3: Full-thickness skin loss
- Visible adipose/fat tissue - STAGE 4: Full-thickness skin and tissue loss
- Visible DEEP materials like muscles & bones
A. Unstageable – obscured skin and tissue loss (slough or eschar)
- When it has slough (yellow material) and eschar (black tissue)!! you won’t be able to stage this wound until you can flush out the slough or remove the eschar
B. Deep Tissue Pressure injury – skin may be intact (deep red/purple)
- Tissue is intact and color is deep red, maroon, purple color!!! DON’T MISTAKE THIS WITH STAGE 1
C. Device-related Pressure injury – skin breakdown around devices!!
D. Mucosal Membrane Pressure Injury
- Medical device that lead to injury to a mucous membrane caused by the pressure related to the insertion/placement
9
Q
What should you document for pressure injuries?
A
- During routine shift assessment & with dressing changes
- Monitor for healing or worsening
- Document: location, stage & size; Exudate, tissue, description
10
Q
What are the 3 types of wound care?
A
- Surgical debridement –> surgically removing dead tissue & other debris that can cause infection
- Irrigation –> removes surface materials & decreases bacterial levels in the wound w/ some type of LIQUID
- Biological debridement –> using ENZYMATIC agents to the wounds to clean it
11
Q
What are the 2 factors that indicate injury??
A
Pressure & time!!
12
Q
How do you Assess for risk of pressure injury forming?
A
- If they have reduced skin perfusion
- Using Braden scale
- Minimum score = 6 (HIGHER risk)
- Max score = 23 (LOWER risk)
13
Q
If a wound is dry, what should you do? How about If it’s a wet wound?
A
If it’s a dry wound = MOIST it
If it’s a wet wound = DRY it
14
Q
What are the 5 wound dressing types??
A
- Clean vs. sterile dressings
- Sterile dressings are applied AFTER surgery. After 48 hrs, you use a clean dressings! - Dry vs Wet dressings:
A) Open dressings:- EX: gauze bandages. After being moistened with sodium chloride, gauze dressings are applied. As the gauze dries, it clings t tissue inside the wound. When gauze is removed, the tissues that clung will also be removed along w/ the gauze. this helps w/ the debridement process
B) Semi-open dressings: - Has 3 layers
C) Semi- Occlusive dressings:
1. Films –>used when wound is dry to cover SUPERFICIAL wounds that have MINIMAL exudate. It allows moisture to evaporate while still maintaining a moist wound bed, & allow oxygen to enter the wound
2. Hydrocolloid –> Used for abrasions, superficial burns, pressure injuries, & post-op wounds
3. Alginate –> moderate to highly exudative wounds. Requires less frequent change & is high absorbent. Need a 2nd dry dressing to go on top of it to cover it
4. Hydrofiber –> provide high absorbency for moderate to highly exudate wounds
5. FOAM –> mild to moderate exudate but require frequent changes
6. Polymeric membranes –> mildly exudative wounds
7. Hydrogels –> used in dry wounds, provide moisture to or draw moisture away from the wound
- EX: gauze bandages. After being moistened with sodium chloride, gauze dressings are applied. As the gauze dries, it clings t tissue inside the wound. When gauze is removed, the tissues that clung will also be removed along w/ the gauze. this helps w/ the debridement process
15
Q
What are used for wound closures?
A
- Sutures & staples
- Sutures –> can be absorbable (have to be removed after a period of time) & absorbable (absorbed in the skin)
- Staples –> NOT used for face or neck wounds. staples Can increase scarring & hard to remove. healing is faster - Skin adhesive –> have a decreased infection rate, minor wounds & cuts with straight edges, do not put over joints, keep it away from touch for 24 hrs & keep it dry for 5 days
- Negative pressure wound therapy
- Primary vs Delayed primary closures
- Primary closure:- Edges of surgical wounds & traumatic wounds that have clear edges (good for sutures, staples and skin adhesive)
- Delayed primary closure: - Leave open to avoid swelling and close later
- Chest & abdominal wounds without infections
- Edges of surgical wounds & traumatic wounds that have clear edges (good for sutures, staples and skin adhesive)
