Skin Integrity and Wound Care Flashcards
Alterations in skin integrity can have a tremendous impact on
physical and psychological well-being
the skin weight more than
6lbs
skin is involded in
thermoregulation
how is skin involved in thermoregulation
through its ability to dilate and constrict blood vessels, allowing for heat to be released or retained by the body
The skin is involved in the production of vitamin
D
Intact skin serves as an effective barrier to
environmental hazards
what is the skin’s normal PH?
acidic
why is the skin acidic?
provides a protective mechanism against pathogens
skin is composed of three main layers:
epidermis
dermis
subcutaneous
The epidermis can be subdivided into five more layers:
stratum corneum
stratum lucidum
stratum granulosum
stratum spinosum
stratum germinativum or Basale
The outermost of the epidermal layers is the
stratum corneum
The innermost layer of epidermal
stratum germinativum
the dermis is between
epidermis and subcutaneous layer
who is thicker dermis or empidermis
dermis
subcutaneous layer delivers
blood supply to the dermis, provides insulation, and has a cushioning effect
subcutaneous layer size depends on
body location and person’s weight, sex, and age.
Factors Affecting Skin Integrity
Wounds
Vascular disease
Diabetes
malnutrition
nonsteroidal antiinflammatory drugs
anticoagulants
excessive moisture
external forces
aging
diabetes also affect
the skins PH level
Medical adhesive-related skin injuries (MARSIs) occur when
superficial layers of skin are removed by medical adhesive
MARSI not only affects skin integrity but also causes
pain, increases risk of infection, potentially increases wound size, and delays healing
Wounds are also classified on the basis of
wound depth
superficial, or partial thickness, versus deep, or full thickness are
wound calssification
An open wound is
an actual break in the skin’s surface
closed wound is
bruising
superficial wound involves which skin layer
only the epidermis
partial-thickness wound involves which skin layer
epidermis and the dermis
full-thickness wound involves which skin layer
dermis to the subcutaneous layer and may extend farther, to the muscle, bone, or other underlying structures
wounds can be classified as
clean
clean contaminated
contaminated
infected
colonized
clean wound is
no infection and the risk of the development of an infection is low
clean contaminated wound is
no infection but high risk for infection
Contaminated wounds are a
result from a break in sterile technique during surgery higher
higher risk of infection than clean contaminated wound
An infected wound shows
clinical signs of infection,
including redness,
warmth,
increased drainage that may or may not be purulent (contain pus),
and has a bacterial count higher than 10^5 per gram
colonized wound happen when
one or more organisms are present on the surface of the wound when a swab culture is obtained,
but there is no overt sign of an infection in the tissue below the surface
acute wound is
A wound that progresses through the phases of wound healing in a rapid, uncomplicated manner
approximated wounds are
surgical incisions or traumatic wounds
they heal by primary intention
chronic wounds are
wounds that take longer time to heal
chronic wounds heal by
secondary intention
When a wound heals by secondary intention
new tissue must fill in from the bottom and sides of the wound until the wound bed is filled with new tissue
When a delay occurs between injury and closure, the wound healing is described as
tertiary intention.
Phases of Wound Healing
inflammatory phase
proliferative phase
maturation phase
inflammatory phase lasts
3 days
During the inflammatory phase, there is an increase in
pain,
redness,
warmth
swelling
at the end of inflammatory phase
wound bed is clean and ready to begin the actual repair process
proliferative phase of healing are
repair of the defect
filling in the wound bed with new tissue
resurfacing the wound with skin
granulation tissue formation
Proliferative Phase lasts
several weeks
The proliferative phase involves the development of
new blood vessels (angiogenesis)
The key cells in proliferative phase of wound healing are
fibroblasts
fibroblasts produce
growth factors, synthesize the collagen and proteins
Granulation tissue is
the new tissue created to fill the wound
Granulation tissue color is
beefy red
Finally, in proliferative phase, epithelial cells
proliferate and migrate laterally from the edges of the wound, across the moist granulation tissue, until the wound has been resurfaced
Factors Affecting Wound Healing
Oxygenation and Tissue Perfusion
Diabetes
Nutrition
Age
Infection
Dehiscence is
connection with surgical incisions, is the partial or complete separation of the tissue layers during the healing process
Evisceration is
total separation of the tissue layers, allowing the protrusion of visceral organs through the incision
coughing, vomiting, or straining puts additional stress on
healing tissue increasing the risk of dehiscence and evisceration
what indicated a healing wound
1-cm-wide ridge, or area of induration, can be palpated next to the incision line (healing ridge)
what does it mean if healing ridge is not felt
the wound is at increased risk for dehiscence and evisceration
A fistula is
abnormal connection between two internal organs or between an internal organ and, through the skin, the outside of the body
Fistulas usually are the result of
specific disease process, such as that in certain cancers and Crohn disease, treatment modalities (such as radiation), or any of the factors implicated in poor wound healing
Fistulas predispose the affected person to
fluid and electrolyte loss
nutritional deficits
alterations in skin integrity
Burns can be
superficial
Partial-thickness
Full-thickness
three evidence-based practice steps is key to pressure injury prevention
- Determine each patient’s risk level through assessment with a reliable tool.
- Reduce pressure on bony prominences using nursing interventions discussed in the Intervention and Evaluation section of this chapter.
- Improve pressure tolerance of the patient’s skin by ensuring that the patient is well nourished, and that the skin is dry, intact, padded, and perfused
pressure injury more closely reflects
the underlying etiology of the wound
pressure injury is
damage to the skin in an area that may include soft-tissue damage and is usually found over bony prominences
The primary cause of pressure injuries is
pressure
The terms capillary closing pressure and critical closing pressure refer to
minimum pressure required to collapse a capillary
capillary closing pressure is difficult to achieve, it generally is accepted to be __ to __ mm hg
12 to 32 mm Hg
pain is felt when
tissue ischemia occurs
subcutaneous and muscle tissues are more susceptible to
pressure injury
low levels of pressure over long periods of time can
be as damaging to the skin and underlying tissue as high levels of pressure over a short period of time
Patients who have medical devices (such as oxygen tubing, a nasogastric [NG] tube, oxygen sensor probes, a continuous positive airway pressure [CPAP] mask, or trach ties) are at risk for
medical device–related pressure injuries
Nurses caring for patients with medical devices followed a protocol described by the acronym CARE which stands for
- Choose a size-appropriate device
- Assess the skin under the medical device
- Reposition and Reapply the device, using padding if necessary
- Empowered to evaluate daily discontinuation
Friction is
rubbing together of two surfaces
The real danger of friction comes from the relationship between friction and gravity and the resultant phenomenon of
shear
Sensory Loss or Immobility patients are at risk for
spinal cord injury or advanced multiple sclerosis
Moisture-associated skin damage (MASD) is
general term for inflammation or skin erosion caused by prolonged exposure to a source of moisture
Moisture-associated skin damage (MASD) is caused by
urine, stool, sweat, wound drainage, saliva, or mucus
maceration iss
a condition in which excessive moisture causes a softening of the skin
incontinence-associated dermatitis (IAD) is
skin irratation and breakdown
deficiencies in vitamins A, C, and E and the minerals zinc and copper; and protein-calorie malnutrition, weakens
the ability of the tissue to withstand the forces of pressure and shear and to combat infectious agents
Classification of Pressure Injuries
Stage 1 Pressure Injury: Nonblanchable Erythema of Intact Skin
Stage 2 Pressure Injury: Partial-Thickness Skin Loss With Exposed Dermis
Stage 3 Pressure Injury: Full-Thickness Skin Loss
Stage 4 Pressure Injury: Full-Thickness Skin and Tissue Loss
Unstageable Pressure Injury: Obscured Full-Thickness Skin and Tissue Loss
Deep-Tissue Pressure Injury: Persistent Nonblanchable Deep-Red, Maroon, or Purple Discoloration
A stage 1 pressure injury is characterized by
intact, nonblistered skin with nonblanchable erythema, or persistent redness, in the area that has been exposed to pressure
stage 2 pressure injury is
shallow and superficial, with a red-pink wound bed, Intact or ruptured blisters
Undermining is
an area of tissue loss present under intact skin, usually along the edges of the wound, forming a “lip” around the wound
A tunnel or sinus tract is
similar to an undermining but is a narrower passageway extending outward from the edge of the wound.
Stage 4 Pressure Injury: Full-Thickness Skin and Tissue Loss involves exposure of
muscle, bone, or connective tissue
in stage 4 pressure injury the bone is
palpable
unstageable pressure injury is
full-thickness wound in which the amount of necrotic tissue, or eschar, in the wound bed makes it impossible to assess the depth of the wound or the involvement of underlying structures
Suspected deep-tissue pressure injury injuries can
progress rapidly, exposing deeper layers of tissue even if treated quickly and appropriately
Patients with disabilities that cause difficulty with mobility or sensory perception are at risk for
development of pressure injuries
Obesity is a risk factor for
poor wound healing
thorough skin assessment by the nurse should occur on every patient upon
admission,
every shift
with transfer of the patient to another unit facility
when the patient is discharged
assessment of the skin includes
skin’s temperature, overall color and local variations in that color, presence of excessive moisture or dryness, odor, texture, turgor, and integrity
General Skin Assessment Questions
- How would you describe your overall skin condition?
- Have you ever had problems with your skin? What kind of problems? Location? When?
- Describe your usual skin care regimen.
- Describe your usual diet. Have you experienced any recent unintended weight loss?
- Are you ever incontinent of urine or stool?
- Have you been told that you have diabetes or problems with your circulation?
- Do you smoke?
- Do you drink alcohol or use illicit drugs?
- Have you noticed any numbness or tingling in your feet?
- Has it seemed to take a long time for a wound to heal in the past?
Focused Wound Assessment
- How long has this wound been present? What do you think caused this wound? Have you ever had a wound like this before?
- What are you doing for this wound at home? What are you using to clean the wound? What have you put on it?
- Have you noticed any changes in the appearance of the wound or the skin around it?
- How much wound drainage is there? Has the amount, color, or odor of the drainage changed? How often do you need to change the bandage at home?
- Do you live alone? Do you have anyone who helps you at home?
- Is the cost of caring for this wound difficult for you to manage?
Two available tools for risk assessment of presure injurys are
Braden Scale
Norton Scale
With both the Braden and Norton scales, the lower the score, the
greater the overall risk
Braden and Norton scales
usually under or over predict risk assessment
over predict
A focused wound assessment includes an evaluation of
location
size, and color
presence of drainage
condition of the wound edges
characteristics of the wound bed
patient’s response to the wound or wound treatment
Undermining is often seen when
the wound is a result of pressure and shear forces
During wound assessment, note whether drainage is present if it is note
amount of drainage
color
consistency
odor
Serous drainage is
clear, watery fluid from plasma
Serosanguineous drainage is
pink to pale red and contains a mix of serous fluid and red (bloody fluid)
Sanguineous drainage is
bleeding and is bright red
Increases in the amount of drainage and the presence of purulence or a foul odor can indicate
infection or the presence of a fistula
Common organisms causing wound infections include
Staphylococcus aureus and Streptococcus pyogenes
wounds heal from the ______ _______
edges inward
A lack of epithelial tissue is an indication that
something is preventing the wound from healing
The surrounding tissue is inspected for
maceration
signs of infection
tissue breakdown
the development of new wounds
maceration looks
pale, soft, or wrinkled skin
signs of infection of wound
redness, warmth, induration
Wounds are usually classified as what color
Red Yellow Black (RYB)
The wound bed should be
beefy red and shiny or moist in appearance.
Yellow wound bed is
a type of slough tissue
necrotic tissue looks
black
The wound will need debridement if
yellow and/or black tissue are present
inflammation and infection in the wound, can cause
intense pain
Treatments used in the care of wounds can be additional sources of
pain and anxiety
what is used to asses open wound
Wound Characteristic Instrument
what are the two pressure injuries assessment tool
Pressure Sore Status Tool (PSST) and the Pressure Ulcer Scale for Healing (PUSH)
The PSST assigns a numerical score based on __ wound attributes
13
the PUSH tool’s score is based on
wound size, wound bed tissue type, and fluid amount
Implementation of consistent use of the Braden Scale along with prevention strategies resulted in a __% reduction in pressure injuries
25%
how often should you turn a patient
every 2 hours
The head of the bed of an at-risk patient should be elevated no more than __ degrees
30
When side-lying, patients should be positioned at __ degrees
30
The skin over the heels is
at a particularly high risk for breakdown
All support surfaces work to reduce pressure by
redistributing or “spreading out” the body’s weight over a greater surface area
Wound care depends on
the type of wound
amount of drainage
presence of infection
resources available
antiseptic solutions are
harmful to the cells needed for wound healing
what is the good temperature that is good for irrigation solutions
room temperature or warmer
Debridement is
the removal of necrotic tissue/ devitalized tissue
The removal of necrotic tissue is
necessary for wound healing and for the wound to be assessed adequately for viable tissue and staged in the case of pressure injuries
debridement is not usually recommended if
necrotic tissue is dry and stable, with no evidence of infection
Sharp debridement is
the use of a sharp instrument (scalpel, curette, or scissors)
Caution is used in patients with bleeding disorders, and the procedure can be painful. Thus ________ __ ____________
premedication is recomended
Mechanical debridement is
nonselective form of debridement in that it not only removes the necrotic tissue but also can remove or disturb exposed viable tissue that may be in the wound
The main forms of mechanical debridement are
/damp-to-dry dressings and whirlpools
Enzymatic debridement is
achieved through the application of topical agents containing enzymes that work by breaking down the fibrin, collagen, or elastin present in devitalized tissue
Enzymatic debridement is used for
nonviable tissue
Occlusive dressings are used for
autolytic debridement
Autolytic debridement is based on
the principle that wounds have an innate ability to clean themselves of debris and necrotic tissue through the action of the body’s own enzymes and phagocytic cells
Biologic debridement involves
the use of sterile, medicinal larvae from green bottle flies (maggots), which secrete proteolytic enzymes that break down necrotic tissue, digest bacteria, and stimulate the formation of granulation tissue
No single dressing type is ideal for all wounds
A. TRUE
B. FALSE
A. TRUE
Gauze is used for
Packing in all types of wounds.
Transparent film, adhesive-backed polyurethane is used for
Wounds that have minimal or no drainage
Hydrocolloids, occlusive, adhesive dressings composed of gelling agents and carboxymethyl-cellulose is used for
clean, uninfected wounds with small to moderate amounts of drainage.
Foams is used for
Wounds producing moderate to heavy amounts of exudates.
Alginates, made from brown seaweed fiber is used for
Highly exudative wounds.
Use on bleeding wounds
Gels are used for
Wounds that have minimal or no drainage
The placement of drains in or around surgical sites is thought to reduce the chance of
infection by preventing excess blood, serum, or pus from collecting in the surgical area
with a drain assess for
The amount, color, consistency, and odor
The skin around the drain is assessed for
signs of infection
damage from the drainage
Drainage from the small intestine, gallbladder, stomach, and pancreas is
damaging to the skin
Effective strategies to prevent chemical damage to the skin from drainage include
the use of barrier ointments designed for incontinence
Closed drainage systems include
Jackson-Pratt (JP) drains and Hemovac drains
Jackson-Pratt (JP) drains and Hemovac drains, are
soft drains attached to a bulblike (JP) or springlike (Hemovac) suction device
Closed drainage systems allow for
more accurate assessment of the drainage and prevent bacteria on the dressing
Penrose drain is
an open drain that is a flexible piece of tubing, usually is not sutured into place
Negative-Pressure Wound Therapy or vacuum-assisted closure (VAC) is for
remove excess wound fluid, stabilize the wound edges, and stimulate granulation tissue
Negative-Pressure Wound Therapy or vacuum-assisted closure (VAC) reduce
bacteria
The combination dressing usually is changed every
3 days but can be changed more frequently, depending on the wound assessment
Suture and Staple Care used to
bring the edges of a wound together in order to speed wound healing and reduce scar formation
The combination dressing usually is used for
acute and chronic wounds
The timing of suture or staple removal
7 to 14 days after insertion
Bandages and Binders are
placed over wound dressings to secure a dressing or splint
When a bandage is applied to an extremity, the nurse assesses ___ ____ __ __ __________ within 30 minutes of application
the five Ps of circulation
what are the 5 P’s of circulation?
pain
pallor
pulselessness
paresthesia
paralysis
The therapeutic application of heat or cold requires _______ order
doctor order
hydrocolloid dressings are
dressing that forms a gel
if an area becomes lighter on fingertip touch it indicated
blanching hyperemia
serous fluid looks
clear and watery
when there is less drainage than expacted when using collecting device it means
there is a blockage
stuture are
tied and knotted individually
if patent has lower limb injjury you should
elevate the patient legs for 30 minutes
gnasc tool is used to assess
stage 1 pressue injury in patient with dark skin tone
bates-jensen tool is used to assess
wund status
stab wounds are what type of injury
open, full thinkness
purulent drainage is usually ______ and indicates ________ infection
think, bacterial
