Skin Integrity and Pressure Injury Flashcards
What are vitamin C, zinc, and copper good for? What does a deficiency in these cause?
- these elements aid in formation and maintenance of collagen
- a deficiency causes delayed healing
What are the layers of the skin?
- epidermis- composed of stratum corneum (dead cells) and stratum germinativum (new cells)
- dermis- blood vessels, sweat glands, sebaceous glands, ceruminous glands, follicles, sensory receptors, elastin, collagen
- subcutaneous layer- connective and adipose tissue
What factors put clients at risk for pressure injury? (9)
impaired mobility friction and shear moisture incontinence poor nutrition and hydration perfusion (circulation) age (infants and elderly) skin condition altered level of conciousness
How does getting enough protein affect the skin?
protein maintains the skin, repairs minor defects, and preserves intravascular volume which prevents edema
How does impaired venous circulation affect the skin?
Results in engorged tissues with metabolic waste buildup which increases likelihood of edema, ulcers, and breakdown.
Delays wound healing.
How does impaired arterial circulation affect the skin?
It restricts activity and causes pain. Muscles atrophy and the thin tissue becomes more prone to ischemia and necrosis.
Delays wound healing.
What sources of moisture lead to skin breakdown?
incontinence and fever
How does fever affect the oxygenation of the skin?
It increases the metabolic rate which means body needs more oxygen which can be hard to meet if there are circulatory problems
What is the difference between an open wound and a closed wound? What are some examples of each?
Open- break in the skin of mucous membranes.
ex: abrasion, laceration, puncture, surgical incisions
Closed- no breaks in the skin
ex: contusion, tissue swelling from fractures
What is the difference between an acute wound and a chronic wound?
Acute- expected to be of short duration, moves through the three phases of wound healing
Chronic- wounds that exceed the expected length of recovery (diabetic foot ulcers, pressure injuries, arterial ulcers, venous stasis ulcers)
What is a clean wound?
- open or closed wound with minimal inflammation
- little risk of infection
What is a clean-contaminated wound?
- surgical incisions that enter the GI, respiratory, or GU tracts
- increases risk of infection there is no infection present
What is a contaminated wound?
- open, traumatic, surgical wounds where there was a break in asepsis
- high risk of infection
When is a wound considered infected? Are there any exceptions?
- bacteria count in the wound tissue is above 100,000 organisms per gram of tissue
- beta-hemolytic streptococci is the exception, if it is present the wound is infected
What layer of the skin classifies it as a superficial wound? Examples?
- epidermal
ex: friction, shear, burns
What layer of the skin classifies it as a partial-thickness wound?
extend through epidermis, not through dermis
What layer of the skin classifies it as a full-thickness wound?
through subcutaneous and beyond
What types of wounds heal by regeneration? Scar formation?
- superficial and partial-thickness wounds
- no scar formation
What are the characteristic of a wound that heals via primary intention? Scar formation? Example?
- minimal to no tissue loss and edges that are well approximated.
- little scarring expected
ex: clean surgical incisions
What are the two scenarios where a wound heals via secondary intention? Scar formation?
- extensive tissue loss prevents edges from approximating
- wound is intentionally left open because it is infected
- most scar tissue out of the three
Where does healing begin in secondary intention?
inner layer to the surface
When do we see granulation tissue?
secondary intention- granulation tissue has an abundant blood supply
What are some examples of wounds that heal via secondary intention?
Pressure injuries and infected wounds
What is another name for tertiary intention?
delayed primary closure
How is healing via tertiary intention used? Scar formation?
a clean-contaminated or contaminated wound is allowed to heal via secondary intention, then when there is no edema, infection, or foreign matter the edges of granulation tissue are brought together
*more scar tissue than primary, less than secondary
What happens in the inflammatory phase of wound healing? When does the inflammatory phase take place?
- 1-5 days
- hemostasis (vessels constrict to limit blood loss, platelets aggregate)
- inflammation (brings WBCs to the scene, macrophages engulf bacteria, scab formation)
What happens in the proliferative phase of wound healing?
- days 5-21
- granulation as vessels start forming to supply area with blood
- fibroblasts start making collagen for strength
What happens in the maturation phase of wound healing?
- after 2-3 weeks and 3-6 months
- old collagen is broken down and remodeled into an organized structure (scar tissue)
What are some types of wound closures? Where/why would each be used?
steri strips- superficial wounds, support to a wound that was sutured or stapled
sutures- absorbent can be used in deep tissue
surgical staples- arms, legs, abdomen, back, scalp, bowel
surgical glue- good for clean, low-tension wounds
***What does serous exudate look like? What kind of wound would it be expected from?
- straw colored
- typically from clean wounds
***What does sanguineous drainage look like? What kind of wound would it be expected from?
- bloody
- usually from deep wounds or highly vascular areas
***What does serosanguineous drainage look like? What kind of wound would it be expected from?
- bloody and serous drainage
- usually from new wounds
***What does purulent drainage look like? What kind of would would it be expected from?
- thick, usually yellow, smelly drainage (pus)
- usually from infected wounds
***What does purosanguineous drainage look like? What can it mean?
- red-tinged pus
- small vessels around an infected wound have ruptured
What do we expect to see when there is hemorrhage of a wound?
in first 24-48 hours
- the body part affect gets swollen
- pain
- decreased blood pressure
- elevated pulse
What is dehiscence? When does is usually occur? What are risk factors for it?
- separation of one or more layers of a wound usually during the inflammatory phase of healing before collagen is laid down
- Risk factors are poor nutrition, infection, obesity, increased tension such as coughing
What is evisceration? What do you do if it happens?
- total separation of the wound with internal viscera protruding
- Call surgeon, cover the wound with sterile saline soaked towels
What is a fistula and why does it occur?
- abnormal passage connecting two body cavities
- usually occurs when there is infection or debris left in a wound which forms an abscess (GI and GU)
***What are the six risk factors related to skin integrity that the Braden scale focuses on? What does it NOT include?
sensory perception moisture activity mobility nutrition friction/sheer **does NOT include cognition
What labs are appropriate for assessing wounds?
WBC count, Serum protein/albumin/prealbumin, ESR, coagulation studies, INR, wound cultures, tissue biopsies
When are wound cultures indicated?
- signs of infection
- suddenly elevated glucose levels
- pain in a neuropathic extremity
- lack of healing for 2 weeks of a clean wound
What are some nursing diagnosis for skin?
risk for impaired skin integrity
impaired skin integrity
impaired tissue integrity
risk for impaired tissue integrity
How do we irrigate a wound?
ideal irrigation pressure is 4-15 psi. More than 15 psi has a risk of driving bacteria deeper
What are some ways to debride a wound?
Debridement: we remove senescent cells (alive but not functioning)
Mechanical- lavage, wet-to-dry dressing, whirlpool
Enzymatic- clean the wound, apply cream, apply moisture retaining dressing
Autolysis- moisture retaining dressing, changed q 72 hours
Maggot biotherapy
Sharp debriding
What are some common drainage devices?
Hemovac, Jackson-Pratt drain, Vac dressing, Penrose drain
What is negative pressure wound therapy?
applies suction to the wound surface. pack the wound with foam or gauze and seal, the pump collects the drainage
What is a transparent dressing good for?
- air and water vapor can be exchanged but not bacteria
- good for wounds with little to no drainage, IV sites
What are gauze dressings good for?
packing large wounds, cavities, tracts, heavily draining wounds
What are hydrocolloids good for?
- the hydrophilic particles interact with exudate to form a gel that keeps wound moist
- good for wounds with minimal drainage (partial-thickness, stage 2 pressure injury)
What are hydrogels good for?
- they have a high water content that is soothing
- good for softening slough or eschar in necrotic wounds
What is ischemia?
skin problem from a pressure injury
What are common pressure points for a client lying supine?
occiput, scapulae, elbows, arms, sacrum, and heels
***What classifies a pressure injury as stage 1?
localized area of intact skin with nonblanchable redness
***What classifies a pressure injury as stage 3?
- full thickness loss of tissue makes a crater
- adipose is visible
- no bone or tendon visible
What medications put clients at risk for skin integrity?
- anti-hypertensives
- NSAIDS
- chemotherapy
- antibiotics
- some herbal products like lavender and tea tree oil
What interventions are there when there is wound dehiscence?
if abdominal: maintain bedrest with HOB at 20 degrees with knees flexed
apply a binder if indicated
notify the provider
***What classifies a pressure injury as stage 2?
- partial-thickness loss of dermis
- open but shallow with a red-pink wound bed
- no slough
- sometimes is a blister
***What classifies a pressure injury as stage 4?
- full-thickness loss of tissue (necrosis and damage to muscle, bone or support structures)
- bone/tendon is visible
- slough or eschar is present
What things do you document when doing a focused assessment of a wound? (9)
Location Type of wound Size Undermining/tunneling Periwound Extent and type of tissue at wound base Drainage Wound/tissue pain Nutritional status
What are Montgomery straps?
- straps that decrease the irritation and pulling of the area around the wound
- good to use if dressing changes are frequent
What are the common binders?
- sling
- t-binder (perineal)
- abdominal binder
How should we use heat therapy?
- used to relieve stiffness and discomfort (musculoskeletal)
- can be moist or dry
- 105-115 degrees is usually recommended
How should we use cold therapy?
- use for edema, inflammation, pain, reduce oxygen requirements, control bleeding, treat fever
- use ice for no more than 15 minutes
