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NSG 1135 > skin integrity and wound care > Flashcards

skin integrity and wound care Flashcards

1
Q

epidermis

A

top layer of skin

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2
Q

dermis

A

inner layer of skin

collagen

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3
Q

dermal - epidermal junction

A

separates dermis and epidermis

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4
Q

intact skin protects patient from what

A

chemical and mechanical injury

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5
Q

critically think when assessing skin

A 
when toileting, dressing, showering, changing brief
lift up folds
pendulous breasts
pannus
turn patient and assess backside
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6
Q

identifying abnormals within skin characteristics

A

if skin is reddened, showing signs of breakdown notify provided and intervene appropriately to prevent further issues

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7
Q

what is a wound

A

interruption of the integrity of the skin

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8
Q

types of wounds

A 
surgical incisions
nonsurgical
cut/laceration
skin tears
ulcer
pressure ulcer
arterial wound/ulcer
venous wound/ulcer
diabetic wound/ulcer
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9
Q

assessing wounds

A 
what kind, how did it occur?
location
color
size
drainage
odor
pain
skin around wound
old dressing when removed
drainage/exudate amount on old dressing
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10
Q

colors of wound

A

beefy red- indicates tissue and skin healing, appropriate blood supply
pink - no active s/s of infection, blood supply isn’t ideal
yellow- slough or infection
black- dead tissue no blood supply

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11
Q

drainage and exudate type

A

sanguineous
serosanguineous
serous
purulent

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12
Q

skin around wound

A

irritation from adhesive?

increased warmth tender to touch inflammation?

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13
Q

old dressing when removed

A

any drainage: amount, color, odor on dressing

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14
Q

absent drainage

A

no drainage or exudate present

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15
Q

scant amount of exudate present

A

the wound is moist, even though no measurable amount of exudate appears on dressing

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16
Q

small or minimal amount of exudate

A

exudate covers less than 25% of the dressing

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17
Q

moderate amount of drainage

A

wound tissues are wet and drainage involves 25-75% of the dressing

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18
Q

large amount of drainage

A

wound tissue is filled with fluid and exudate covers more than 75% of dressing

19
Q

copious amount of drainage

A

wound dressing is filled with fluid and dressing is saturated with exudate

20
Q

factors that influence healing process

A 
nutrition
tissue perfusion
infection
age
stress
albumin and total protein labs for nutrition and healing of wounds
21
Q

age affecting wound healing

A

children and healthy adults heal more rapidly

22
Q

circulation and oxygenation

A

adequate blood flow is essential

23
Q

nutritional status

A

healing requires adequate nutrition

24
Q

wound condition

A

specific condition of wound affects healing

25
Q

health status

A

corticosteroid drugs and postoperative radiation therapy delay healing

26
Q

skin tears

A

occur when layers of the skin separate or peel back

27
Q

what causes skin tears

A

skin bumping into a hard object
wound dressing changes and adhesive removal
aggressively washing or drying the skin

28
Q

skin tear prevention

A

be careful with thin delicate skin
place sleeves on individuals prone to skin tears
decrease use of adhesive
carefully remove adhesive

29
Q

care of skin tears

A

control the bleeding
apply saline or warm water and clean area while gently attempting to replace the torn skin back into the original position
pat dry with clean gauze
measure size of skin tear
add steri strips across site carefully
cover skin with nonadhesive dressing
use stockinette instead of adhesive dressing or tape if available
document skin tear location, size, cleansing and dressing, how the patient tolerated
also document how skin tear developed if info is available

30
Q

wound dressings can be very complex

A

many facilities have wound care nurses
review orders in detail to understand what needs to be done
if unsure ask for help

31
Q

leave dressing on unless

A

visibly soiled or orders indicate dressing needs changed
may only need to change outer dressing
some wounds may be left open to air and will require a cleaning only

32
Q

assess old dressing,

A

remove
drainage noted to old dressing?
amount, color, odor?
assess wound characteristics

33
Q

clean wound per orders with

A

saline most likely
pat dry with gauze
apply topical ointments or special medicated dressings - indicated with orders
apply top dressing securely - initial date time
document

34
Q

risk of adhesive use on skin

A

can cause further damage, especially on chronic wounds and thin fragile skin
be cautious when removing adhesive and how much adhesive you’re using while applying dressing

35
Q

pressure injuries

A

impaired skin integrity related to unrelieved prolonged pressure
localized damage to the skin and underlying soft tissue
usually over a bony prominence or secondary to a foreign object creating pressure on the skin

36
Q

types of pressure injuries

A

pressure ulcer, decubitus ulcer, bed sore

may be present as intact skin, blister, or open ulcer. may be painful

37
Q

patients at risk for pressure injuries

A

decreased mobility
decreased sensory perception
fecal or urinary incontinence
poor nutrition

38
Q

pressure intensity

A

pressure applied over a capillary occluding the vessel

causes tissue ischemia

39
Q

when a patient has reduced sensation and cannot respond to discomfort of ischemia,

A

tissue death will occur
after a period of tissue ischemia, when patient is repositioned, area should be assessed
if blood flow has returned to the area, it will turn erythematic in color due to vasodilation

40
Q

to assess area of pressure injury

A

press finger to area
if area blanches (turns lighter in color) and erythema returns when finger is removed, this is balled blanch able
if the eythematic area does not blanch when pressure is applied, this is called non-blanchable - deep tissue damage is probable

41
Q

pressure duration

A

both low pressure over a prolonged period and high intensity pressure over a short period can cause tissue damage
pressure occludes blood flow, nutrients, and contributes to cell death

42
Q

tissue tolerance

A

how well can the tissue endure pressure
depends on integrity of the tissue and supporting structures
what factors are present? shear, friction, moisture will make the skin more susceptible to damage from pressure applied
how well can underlying vessels redistribute pressure?
poor nutrition aging hydration status and low BP can decrease tolerance of tissue to pressure

43
Q

risk factors for pressure ulcer development

A 
impaired sensory perception
alterations in level of consciousness
impaired mobility 
shear
friction
moisture

NSG 1135 (3 decks)

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