skin integrity and wound care Flashcards
epidermis
top layer of skin
dermis
inner layer of skin
collagen
dermal - epidermal junction
separates dermis and epidermis
intact skin protects patient from what
chemical and mechanical injury
critically think when assessing skin
when toileting, dressing, showering, changing brief lift up folds pendulous breasts pannus turn patient and assess backside
identifying abnormals within skin characteristics
if skin is reddened, showing signs of breakdown notify provided and intervene appropriately to prevent further issues
what is a wound
interruption of the integrity of the skin
types of wounds
surgical incisions nonsurgical cut/laceration skin tears ulcer pressure ulcer arterial wound/ulcer venous wound/ulcer diabetic wound/ulcer
assessing wounds
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
colors of wound
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
drainage and exudate type
sanguineous
serosanguineous
serous
purulent
skin around wound
irritation from adhesive?
increased warmth tender to touch inflammation?
old dressing when removed
any drainage: amount, color, odor on dressing
absent drainage
no drainage or exudate present
scant amount of exudate present
the wound is moist, even though no measurable amount of exudate appears on dressing
small or minimal amount of exudate
exudate covers less than 25% of the dressing
moderate amount of drainage
wound tissues are wet and drainage involves 25-75% of the dressing
large amount of drainage
wound tissue is filled with fluid and exudate covers more than 75% of dressing
copious amount of drainage
wound dressing is filled with fluid and dressing is saturated with exudate
factors that influence healing process
nutrition tissue perfusion infection age stress albumin and total protein labs for nutrition and healing of wounds
age affecting wound healing
children and healthy adults heal more rapidly
circulation and oxygenation
adequate blood flow is essential
nutritional status
healing requires adequate nutrition
wound condition
specific condition of wound affects healing
health status
corticosteroid drugs and postoperative radiation therapy delay healing
skin tears
occur when layers of the skin separate or peel back
what causes skin tears
skin bumping into a hard object
wound dressing changes and adhesive removal
aggressively washing or drying the skin
skin tear prevention
be careful with thin delicate skin
place sleeves on individuals prone to skin tears
decrease use of adhesive
carefully remove adhesive
care of skin tears
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
wound dressings can be very complex
many facilities have wound care nurses
review orders in detail to understand what needs to be done
if unsure ask for help
leave dressing on unless
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
assess old dressing,
remove
drainage noted to old dressing?
amount, color, odor?
assess wound characteristics
clean wound per orders with
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
risk of adhesive use on skin
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
pressure injuries
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
types of pressure injuries
pressure ulcer, decubitus ulcer, bed sore
may be present as intact skin, blister, or open ulcer. may be painful
patients at risk for pressure injuries
decreased mobility
decreased sensory perception
fecal or urinary incontinence
poor nutrition
pressure intensity
pressure applied over a capillary occluding the vessel
causes tissue ischemia
when a patient has reduced sensation and cannot respond to discomfort of ischemia,
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
to assess area of pressure injury
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
pressure duration
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
tissue tolerance
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
risk factors for pressure ulcer development
impaired sensory perception alterations in level of consciousness impaired mobility shear friction moisture
