skin integrity and wound care

Question 1

Promoting healthy skin

Answer 1

• Self assessment
• Bathing
• Nutrition
• Hydration
• Sunscreen
• Moisturizing
• Perfusion
• Mobility

Question 2

Skin care strategies for infants

Answer 2

• gentle bathing
• avoid alcohol based products
• no direct adhesives
• limit topical agents
• maintain adequate nutrition

Question 3

Skin care strategies for adults

Answer 3

• complete bath every other day
• tepid water temperature
• pat dry
• no tight or rubbing clothes
• maintain adequate nutrition
• avoid caffeine & alcohol

Question 4

Cultural Considerations

Answer 4

• Darker skinned individuals may be subject to drier hair, scalps, and skin
• Use of skin moisturizers, hair oils and different cleansers may be necessary
• Some products contain shea butter, olive oil, petrolatum and more
• caution products that are oil or alcohol based may also increase damage to skin

Question 5

Types of impaired skin integrity

Answer 5

Disorders (inflammatory, papulosquamous, vesiculobullous, vascular), lesions, insect bites, infections, tumors (begin, malignant), burns, pressure ulcer, surgery & trauma

Question 6

Wound classifications

Answer 6

• Acute wound- occurred suddenly, trauma, heal in orderly sequence of events
• Chronic wound- caused by chronic condition & don’t heal in orderly manner
• Partial thickness wound- involves partial loss of skin layers, not deeper tissues, superficial & painful due to exposed nerve endings, scarped knee, heals quickly
• Full thickness wound- involves total loss of epidermis & dermis, plus extends into subcutaneous & occasional muscle, heals by complex process of scar formation

Question 7

Normal wound healing

Answer 7

Intentions; primary, secondary, tertiary
Regeneration
Scarring

Question 8

Phases of wound healing

Answer 8

1. Inflammatory (control bleeding, establish clean wound bed, clot dissolution releases growth factors, release vasoactive substances, 1-5 days)
2. Proliferative (rebuilding phase, days 6-21, granulation- tissue fills the wound with vessels & connective tissue, epithelialization, contraction- wound edges pull together to reduce the size of the wound opening)
3. Remodeling (final phase pf fun thickness repair 3 weeks up to 2 full years, replacing connective tissue- strength is acquired within 3 months- but tissue is never as strong as original tissue 80% optimal, fill thickness repair, keloid scar- tissue extending beyond boundaries of the original wound heal)

Question 9

Factors affecting wound healing

Answer 9

tissue perfusion, nutritional status, diabetes mellitus, corticosteroids, age

Question 10

Factors affecting wound healing (tissue perfusion & nutritional status & Nutritional Status & Corticosteroids)

Answer 10

• Tissue perfusion: fibroblast proliferation, collagen synthesis, leukocyte activity, phagopcytosis, reepithelialization
• Nutritional status: connective tissue needs- proteins, vitamins, minerals
• Diabetes mellitus: leukocytosis, growth factor, collagen synthesis, tensile strength
• Corticosteroids: inhibits repair, 20-40 mg/day

Question 11

Factors affecting healing- older adult

Answer 11

• Reduced macrophage functioning
• Delayed inflammatory response
• Delayed collagen synthesis
• Slower epithelialization
• Increased incidence of chronic illnesses that compromise circulation & tissue oxygenation

Question 12

Wound healing complications

Answer 12

• infection
• hemorrhage
• dehiscence
• evisceration
• fistula

Question 13

S/S of infection

Answer 13

Drainage (purulent, increasing in quantity), pain, redness & swelling, elevated temperature, increased WBC

Question 14

Hemorrhage

Answer 14

1st 48-hours (occurs most in this period); check wound frequently 
Excessive bleeding (pressure with sterile dressing, sterile packing, fluid replacement, surgical repair)

Question 15

Dehiscence & Evisceration

Answer 15

Dehiscence (disrupted wound layers, increased serousanguinous drainage, “something given way”)
Evisceratin (protrusion of viscera)

Question 16

Fistula development

Answer 16

Abnormal passage- internal organ to skin, one organ to another

Question 17

Wound assessment

Answer 17

Location- where on the body
Dimensions & depth- length, width, depth, tunneling
Stage- what layers of tissue are involved
Status of wound bed- presence of eschar (dry brownish or black tissue), slough
Exudate- fluid how much, what does it look like,
Status of wound edges- open, proliferative, closed
Status of surrounding skin- redness, warmth, is it inflamed
Pain- intense pain is associated with wound care, treat aggressively

Question 18

Types of dressings

Answer 18

Xeroform; gauze; tegasorb; tegaderm; bioclusive transport dressing; montgomery straps; ABD binder

Question 19

Wound drainage

Answer 19

• Serous; clear/ watery plasma
• Purulent; thick, yellow, green, tan, brown
• Serousanguinous; pale, red, watery, mixture of clear and red fluid
• Sanguinous; bright red, indicates active bleeding

Question 20

Wound management

Answer 20

Abrasions- non adherent, absorptive dressing
Lacerations- clean (closed primarily), contaminated (open to heal)
Surgical incisions- closed by sutures or staples, heal quickly
Skin tears- viable flap (cleanse wound & roll flap back into place & secure with adhesive strips), no flap (cleanse & apply non adherent, adsorptive dressing)

Question 21

Wound care facts

Answer 21

Wound care should be performed:

• From an area that is the least contaminated to the most contaminated area
• With a new gauze pad for each wipe
• This means that you should start from top to bottom, inner to outer, using a new pad for each wipe

Question 22

Wound irrigation

Answer 22

steady flow of a solution across an open wound surfaceto achieve wound hydration, to remove deeper debris, and to assist with the visual examination

Question 23

Wound culture

Answer 23

a test to find germs (such as bacteria or a fungus) that can cause an infection. A sample of skin, tissue, or fluid is added to a substance that promotes the growth of germs. If no germs grow, the culture is negative. If germs that can cause an infection grow, the culture is positive

Question 24

Pressure Ulcers stage 1

Answer 24

• pressure-related skin alteration
• changes may include: skin temperature, tissue consistency, sensation, color
• intact skin
• non-blanchable
• affects epidermis
• redness
• warm skin
• softer than normal

Question 25

Pressure Ulcers stage 2

Answer 25

- partial thickness skin loss: epidermis, dermis - presents clinically as: abrasion, blister, shallow crater - open epidermis & may include the dermal layer - looks like blister - blanchabe

Question 26

Pressure Ulcers stage 3

Answer 26

- full thickness skin loss: subcutaneous tissue, fascia - clinically presents as: deep crater, undermining - down to the fascia w/ tunneling

Question 27

Pressure Ulcers stage 4

Answer 27

- full thickness skin loss: tissue necrosis, muscle, bone, supporting structures, sinus tracts - through to the bone, may be necrotic- big infection risk - looks like holes

Question 28

Pressure ulcers

Answer 28

Etiology- shearing & friction: layers slide against one another, pressure: reduces or eliminates blood flow (prolonged, high intensity) Location- over bony protection Results in subcutaneous compressions- blood vessel compression, ulcer development, tunneling extension up under top layer

Question 29

Pressure ulcer risk factors

Answer 29

Altered LOC, immobility, maceration, pain, malnourished, debilitation, impaired sensory perception, shear & friction

Question 30

Pressure ulcer risk assessment

Answer 30

Physical assessment Wound & ostomy care nurse- guidelines Standard-risk assessment tools- Braden scale for predicting pressure sore risk, Norton scale for prediction of pressure ulcer risk

Question 31

Barden Scale

Answer 31

``` 19-23= no risk 15-18= low risk 13-14= mod. Risk 10-25= high risk < or equal to= very high risk ```

Question 32

Norton Scale

Answer 32

< 14 is at risk - Assesses client risk factors for pressure ulcer formation - Clients are scored 1-4 points for: physical condition, mental condition, activity, mobility, incontinence - Higher the score, the better the patient is and the lower their risk factor is for developing a pressure ulcer

Question 33

Pressure ulcer assessment

Answer 33

- location - stage & tissue involvement - drainage - measurements: size, depth, undermining & tunnels

Question 34

Consequences of pressure ulcer

Answer 34

Pain (provide analgesics prior to dressing changes) Anxiety (over change in body image) Economics (increases cost of care & length of hospitalization) Quality of care (used as a quality or lack of quality indictor for facilities) Use of resources (increase in nursing, costs, & support service care)

Question 35

Prevent pressure ulcer

Answer 35

Identify high-risk clients, identify contributing factors, ongoing assessment, hygiene & skin care, repositioning with support, reduce shear & friction, control moisture, nutrition & fluid support

Question 36

Independent nursing interventions for pressure ulcer care

Answer 36

Skin care, teaching, pressure relief, reduction of shear & friction, don’t massage over bony prominences, nutrition & hydration

Question 37

Dependent & independent nursing interventions

Answer 37

Cleaning of wound bed, dressing type & frequency per order, pressure relief specialized mattresses, surgical procedures debridement/reconstruction/skin flaps, controlling infection with antibiotics, nutrition & fluid support enteral or parenteral

Question 38

Lower extremity ulcer

Answer 38

Arterial (caused by arterial insufficiency, results in ischemic tissue, heals by improving tissue perfusion, lifestyle changes, baby aspirin & avoiding the cold) Venous (cause by venous insufficiency, one-way vale damage, dark red ulcer bed, edema, ulceration, exudate, DVT’s, treatment is compression wraps) Neuropathic ulcer (found in pt w/ diabetes or neurological damage; treatment is keep blood glucose normal, foot care, & routine exams)

Question 39

Nursing process for wound management

Answer 39

Assessment, nursing diagnosis, goal & outcomes, establish plan, implement plan, evaluation

Question 40

Wound care plan

Answer 40

Nursing diagnosis- impaired skin integrity R/T immobility and poor nutrition AEB: 4cm reddened area on patient’s left hip Goal (opposite of diagnosis)- skin integrity will improve by time of discharge from facility Outcomes- patient will exhibit improved or healed left hip, patient will have minimal complications, patient will verbalized precipitating factors and appropriate skin care measures

Question 41

Nursing interventions & rationales

Answer 41

Assess: Inspect skin q-shift, document findings. Provides evidence of effectiveness of skin care regimen and signs of further complications. Do: Provide wound care as prescribed and report adverse response. Maintain or modify treatment plan. Turn/reposition patient every two hours. Provides uniform pressure over bony prominences and promotes uniform blood flow to tissues. Teach: Explain wound and skin care to client and caregiver. Promotes compliance with treatment regimen. Evaluate (review the outcomes): the outcomes): what worked? Changes? Patient will exhibit improved or healed left hip wound. Patient will have minimal complications. Patient will verbalize precipitating factors as well as appropriate skin care measures.