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NUR120 > Skin Integrity and Pressure Injury > Flashcards

Skin Integrity and Pressure Injury Flashcards

1
Q

What are vitamin C, zinc, and copper good for? What does a deficiency in these cause?

A
  • these elements aid in formation and maintenance of collagen
  • a deficiency causes delayed healing
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2
Q

What are the layers of the skin?

A
  • 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
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3
Q

What factors put clients at risk for pressure injury? (9)

A 
impaired mobility
friction and shear
moisture
incontinence
poor nutrition and hydration
perfusion (circulation)
age (infants and elderly)
skin condition
altered level of conciousness
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4
Q

How does getting enough protein affect the skin?

A

protein maintains the skin, repairs minor defects, and preserves intravascular volume which prevents edema

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5
Q

How does impaired venous circulation affect the skin?

A

Results in engorged tissues with metabolic waste buildup which increases likelihood of edema, ulcers, and breakdown.
Delays wound healing.

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6
Q

How does impaired arterial circulation affect the skin?

A

It restricts activity and causes pain. Muscles atrophy and the thin tissue becomes more prone to ischemia and necrosis.
Delays wound healing.

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7
Q

What sources of moisture lead to skin breakdown?

A

incontinence and fever

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8
Q

How does fever affect the oxygenation of the skin?

A

It increases the metabolic rate which means body needs more oxygen which can be hard to meet if there are circulatory problems

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9
Q

What is the difference between an open wound and a closed wound? What are some examples of each?

A

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

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10
Q

What is the difference between an acute wound and a chronic wound?

A

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)

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11
Q

What is a clean wound?

A
  • open or closed wound with minimal inflammation

- little risk of infection

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12
Q

What is a clean-contaminated wound?

A
  • surgical incisions that enter the GI, respiratory, or GU tracts
  • increases risk of infection there is no infection present
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13
Q

What is a contaminated wound?

A
  • open, traumatic, surgical wounds where there was a break in asepsis
  • high risk of infection
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14
Q

When is a wound considered infected? Are there any exceptions?

A
  • 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
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15
Q

What layer of the skin classifies it as a superficial wound? Examples?

A
  • epidermal

ex: friction, shear, burns

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16
Q

What layer of the skin classifies it as a partial-thickness wound?

A

extend through epidermis, not through dermis

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17
Q

What layer of the skin classifies it as a full-thickness wound?

A

through subcutaneous and beyond

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18
Q

What types of wounds heal by regeneration? Scar formation?

A
  • superficial and partial-thickness wounds

- no scar formation

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19
Q

What are the characteristic of a wound that heals via primary intention? Scar formation? Example?

A
  • minimal to no tissue loss and edges that are well approximated.
  • little scarring expected
    ex: clean surgical incisions
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20
Q

What are the two scenarios where a wound heals via secondary intention? Scar formation?

A
  • extensive tissue loss prevents edges from approximating
  • wound is intentionally left open because it is infected
  • most scar tissue out of the three
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21
Q

Where does healing begin in secondary intention?

A

inner layer to the surface

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22
Q

When do we see granulation tissue?

A

secondary intention- granulation tissue has an abundant blood supply

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23
Q

What are some examples of wounds that heal via secondary intention?

A

Pressure injuries and infected wounds

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24
Q

What is another name for tertiary intention?

A

delayed primary closure

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25
Q

How is healing via tertiary intention used? Scar formation?

A

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

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26
Q

What happens in the inflammatory phase of wound healing? When does the inflammatory phase take place?

A
  • 1-5 days
  • hemostasis (vessels constrict to limit blood loss, platelets aggregate)
  • inflammation (brings WBCs to the scene, macrophages engulf bacteria, scab formation)
27
Q

What happens in the proliferative phase of wound healing?

A
  • days 5-21
  • granulation as vessels start forming to supply area with blood
  • fibroblasts start making collagen for strength
28
Q

What happens in the maturation phase of wound healing?

A
  • after 2-3 weeks and 3-6 months

- old collagen is broken down and remodeled into an organized structure (scar tissue)

29
Q

What are some types of wound closures? Where/why would each be used?

A

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

30
Q

***What does serous exudate look like? What kind of wound would it be expected from?

A
  • straw colored

- typically from clean wounds

31
Q

***What does sanguineous drainage look like? What kind of wound would it be expected from?

A
  • bloody

- usually from deep wounds or highly vascular areas

32
Q

***What does serosanguineous drainage look like? What kind of wound would it be expected from?

A
  • bloody and serous drainage

- usually from new wounds

33
Q

***What does purulent drainage look like? What kind of would would it be expected from?

A
  • thick, usually yellow, smelly drainage (pus)

- usually from infected wounds

34
Q

***What does purosanguineous drainage look like? What can it mean?

A
  • red-tinged pus

- small vessels around an infected wound have ruptured

35
Q

What do we expect to see when there is hemorrhage of a wound?

A

in first 24-48 hours

  • the body part affect gets swollen
  • pain
  • decreased blood pressure
  • elevated pulse
36
Q

What is dehiscence? When does is usually occur? What are risk factors for it?

A
  • 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
37
Q

What is evisceration? What do you do if it happens?

A
  • total separation of the wound with internal viscera protruding
  • Call surgeon, cover the wound with sterile saline soaked towels
38
Q

What is a fistula and why does it occur?

A
  • 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)

39
Q

***What are the six risk factors related to skin integrity that the Braden scale focuses on? What does it NOT include?

A 
sensory perception
moisture
activity
mobility
nutrition
friction/sheer
**does NOT include cognition
40
Q

What labs are appropriate for assessing wounds?

A

WBC count, Serum protein/albumin/prealbumin, ESR, coagulation studies, INR, wound cultures, tissue biopsies

41
Q

When are wound cultures indicated?

A
  • signs of infection
  • suddenly elevated glucose levels
  • pain in a neuropathic extremity
  • lack of healing for 2 weeks of a clean wound
42
Q

What are some nursing diagnosis for skin?

A

risk for impaired skin integrity
impaired skin integrity
impaired tissue integrity
risk for impaired tissue integrity

43
Q

How do we irrigate a wound?

A

ideal irrigation pressure is 4-15 psi. More than 15 psi has a risk of driving bacteria deeper

44
Q

What are some ways to debride a wound?

A

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

45
Q

What are some common drainage devices?

A

Hemovac, Jackson-Pratt drain, Vac dressing, Penrose drain

46
Q

What is negative pressure wound therapy?

A

applies suction to the wound surface. pack the wound with foam or gauze and seal, the pump collects the drainage

47
Q

What is a transparent dressing good for?

A
  • air and water vapor can be exchanged but not bacteria

- good for wounds with little to no drainage, IV sites

48
Q

What are gauze dressings good for?

A

packing large wounds, cavities, tracts, heavily draining wounds

49
Q

What are hydrocolloids good for?

A
  • 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)
50
Q

What are hydrogels good for?

A
  • they have a high water content that is soothing

- good for softening slough or eschar in necrotic wounds

51
Q

What is ischemia?

A

skin problem from a pressure injury

52
Q

What are common pressure points for a client lying supine?

A

occiput, scapulae, elbows, arms, sacrum, and heels

53
Q

***What classifies a pressure injury as stage 1?

A

localized area of intact skin with nonblanchable redness

54
Q

***What classifies a pressure injury as stage 3?

A
  • full thickness loss of tissue makes a crater
  • adipose is visible
  • no bone or tendon visible
55
Q

What medications put clients at risk for skin integrity?

A
  • anti-hypertensives
  • NSAIDS
  • chemotherapy
  • antibiotics
  • some herbal products like lavender and tea tree oil
56
Q

What interventions are there when there is wound dehiscence?

A

if abdominal: maintain bedrest with HOB at 20 degrees with knees flexed
apply a binder if indicated
notify the provider

57
Q

***What classifies a pressure injury as stage 2?

A
  • partial-thickness loss of dermis
  • open but shallow with a red-pink wound bed
  • no slough
  • sometimes is a blister
58
Q

***What classifies a pressure injury as stage 4?

A
  • full-thickness loss of tissue (necrosis and damage to muscle, bone or support structures)
  • bone/tendon is visible
  • slough or eschar is present
59
Q

What things do you document when doing a focused assessment of a wound? (9)

A 
Location
Type of wound
Size
Undermining/tunneling
Periwound
Extent and type of tissue at wound base
Drainage
Wound/tissue pain
Nutritional status
60
Q

What are Montgomery straps?

A
  • straps that decrease the irritation and pulling of the area around the wound
  • good to use if dressing changes are frequent
61
Q

What are the common binders?

A
  • sling
  • t-binder (perineal)
  • abdominal binder
62
Q

How should we use heat therapy?

A
  • used to relieve stiffness and discomfort (musculoskeletal)
  • can be moist or dry
  • 105-115 degrees is usually recommended
63
Q

How should we use cold therapy?

A
  • use for edema, inflammation, pain, reduce oxygen requirements, control bleeding, treat fever
  • use ice for no more than 15 minutes

NUR120 (17 decks)

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