Skin integrity and wound care

Question 1

Intentional wound

Answer 1

Result of planned invasive therapy or treatment
Wound edges are clean, bleeding controlled
Contamination unlikely-sterile environment

Question 2

Unintentional wound

Answer 2

Accidental from unexpected trauma
Contamination likely
Wound edges are usually jagged
Bleeding is uncontrolled

Question 3

Acute wounds

Answer 3

Usually heal within days to weeks
Wound edges are well approximated
Risk of infection less
Move through healing process w/o difficulty

Question 4

Chronic wounds

Answer 4

Healing is impeded
Wound edges not often approximated
Risk of infection is increased
Remain in inflammatory phase

Question 5

Primary intention

Answer 5

Well approximated wound edges

Intentional wounds such as surgical incisions

Question 6

Secondary intention

Answer 6

• Wound edges are not well approximated
• Large open wounds: burns, major trauma, pressure ulcers
• Primary intention wounds that have become infected
• Take a longer time to heal and form more scar tissue
• Connective tissue healing and repair follow same course as primary-> just take longer

Question 7

Tertiary intention

Answer 7

Wounds that are left open for several days to allow edema or infection to resolve, or fluid to drain and then are closed

Question 8

Hemostasis (1st)

Answer 8

Immediately after initial injury
Blood vessels initially constrict
Platelet activation and mobilization
Blood vessels then dilate and increase capillary permeability
Exudate is formed-> swelling, pain
Increased perfusion results in heat and redness
Platelets perform chemotaxis

Question 9

Inflammatory phase (2nd)

Answer 9

Second phase: lasts about 4-6 days
WBC and macrophages arrive at wound
Macrophages ingest cellular debris, release growth factors–> new blood vessel & epithelial growth
Growth factors attract fibroblasts
Patient has generalized body response: fever, leukocytosis, malaise

Question 10

Proliferation phase (3rd)

Answer 10

Fibroblastic, regenerative, or connective tissue phase
Lasts several weeks
New tissue is built in wound space via fibroblasts–> synthesize and secrete collagen and growth factors
Capillaries grow across wound
Fibroblasts form fibrin
Thin layer of epithelial cells form across wound and blood flow is reinstated
Granulation tissue is formed-> forms foundation for scar tissue to develop
Collagen is deposited over weeks-years
Systemic symptoms disappear

Question 11

Maturation phase (4th)

Answer 11

Remodeling- begins 3 weeks after initial injury
Continues for months-years
Collagen is remodeled–> making wound stronger
Collagen continued to be deposited-> compress blood vessels so that scar does not sweat, grow hair, or tan
Wounds that heal by secondary intention take longer to remodel and form a scar

Question 12

Scaar

Answer 12

Avascular collagen tissue

Does not sweat, grow hair, or tan

Question 13

Granulation tissue

Answer 13

Forms foundation for scar to develop

New tissue that is formed in proliferation phase

Question 14

Local factors that can prolong wound healing

Answer 14

• Pressure
• Desiccation: dried out
• Maceration: over hydrated
• Trauma
• Edema
• Infection
• Excessive bleeding
• Necrosis
• Biofilm

Question 15

Systemic factors that can prolong wound healing

Answer 15

• Age
• Circulation and oxygen
• Nutritional status
• Medication and health status
• Immunosuppression

Question 16

Moist wounds

Answer 16

Experienced enhanced epidermal migration which supports epithelialization

Question 17

Epithelialization

Answer 17

epithelial cells migrate to wound bed

Question 18

Wound complications: overview

Answer 18

• Hemorrhage
• Infection
• Dehiscence
• Evisceration
• Fistula formation

Question 19

Dehiscence

Answer 19

Partial or total separation of wound layers as a result of excessive stress on wounds that are not healed

• Muscle intact
• Patient reports “giving away of wound.”
• Increase in fluid flow fro wound b/n postoperative days 4 & 5 may signal impending dehiscence

Question 20

Evisceration

Answer 20

Most serious complication of dehiscence
Wound completely separates-> protrusion of viscera
-Muscle not intact

Question 21

Actions to take in dehiscence

Answer 21

• Cover the wound with strike towels moistened with sterile 0.9% NaCl and notify physician
• Wound is managed like any open wound
• Medical emergency
• Place patient in semi-fowlers & cover as described
• Do not leave patient alone

Question 22

Pressure ulcer definition

Answer 22

Wound with a localized area of injury to the skin and/or underlying tissue

Question 23

How do most pressure ulcers develop?

Answer 23

• When soft tissue is compressed between a bony prominence and an external surface for a prolonged period of time
• Or when soft tissue undergoes pressure in combination with shear and/or friction

Question 24

Most pressure ulcers occur in?

Answer 24

Older adults

Question 25

Risk factors for pressure ulcers?

Answer 25

- Age - Chronic illness - Poor nutritional status - Immobility - Fecal and urinary incontinence - Altered level of consciences - Spinal cord injuries - TBI patients - Neuromuscular disorders

Question 26

Where do most pressure ulcers develop?

Answer 26

Coccyx and sacrum

Question 27

Other areas common for pressure ulcer development?

Answer 27

Trochanter and heal

Question 28

Major predisposing factor for pressure ulcer development?

Answer 28

External pressure applied over an area which results in occluded blood capillaries and poor circulation to tissues -Insufficient blow circulation deprives tissues of oxygen, nutrients--> leads to ischemia, hypoxia, edema, inflammation, necrosis

Question 29

How quickly can a pressure ulcer develop?

Answer 29

1-2 hours if patient hasn't been repositioned

Question 30

Friction

Answer 30

Occurs when two surfaces rub against each other - Injury resembles abrasion - A patient who lies on wrinkled sheets - Skin over elbows when patient tries to lift themselves up - When a patient is pulled or slid over sheets while being moved in bed or transferred onto a stretcher

Question 31

Shear

Answer 31

Results when one layer of tissue slides over another layer Separates the skin from underlying tissue -Blood vessels and capillaries are stretched and torn -Patients who are pulled rather than lifted -A patient sitting up in bed whose skin sticks to sheets and then they slide down

Question 32

First indication of pressure ulcer development?

Answer 32

Blanching of skin-> skin becomes pale and white

Question 33

Suspected deep tissue injury

Answer 33

Purple or maroon localized area discoloration skin intact Blood-filled blister May present as mushy, firm, boggy, warmer, or cooler area as compared to adjacent tissue

Question 34

Stage 1 pressure ulcer

Answer 34

Area of intact skin w/nonblanchable redness of a localized area over a bony prominence Area may be painful, firm, soft, warm, or cool

Question 35

Stage 2 pressure ulcer

Answer 35

Partial-thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed - No slough or bruising - Shiny or dry shallow ulcer - May present as intact or open serum-filled blister - Can describe: excoriation, take burns, skin tears

Question 36

Stage 3 pressure ulcer

Answer 36

Full thickness tissue loss, subQ may be visible - Slough may be present but does not obscure depth of tissue loss - Bone, muscle, tendon are NOT visible - May have tunneling - Can be shallow or deep depending on location

Question 37

Stage 4 pressure ulcer

Answer 37

Full thickness tissue loss, exposing bone, tendons, muscle - Slough and eschar may be present - Osteomyelitis is a possible complication

Question 38

Unstageable

Answer 38

Full thickness tissue loss Base is covered by slough and eschar Stable eschar on heels should not be removed

Question 39

Eschar color

Answer 39

tan, brown, black

Question 40

Slough

Answer 40

yellow, tan, gray, green, brown

Question 41

Braden assessment

Answer 41

For pressure ulcer risk | Lower number= Higher risk

Question 42

RYB wound classification

Answer 42

Red=Protect Yellow= Cleanse Back= Debride

Question 43

Serous drainage

Answer 43

clear, serous watery fluid | Normal

Question 44

Sanguineous drainage

Answer 44

Large number of rbc's and looks like blood Chunky Abnormal

Question 45

Serosanguineous drainage

Answer 45

mixture of serum and rbc's light pink to blood tinged Normal

Question 46

Purulent drainage

Answer 46

wbc's liquified dead tissue debris and bacteria Yellow and thick Abnormal

Question 47

Impaired Skin Integrity

Answer 47

r/t any condition that alters the epidermis and/or dermis - surgical incision - Traumatic wound - Moisture - Immobility Defining characteristics - Presence of intentional or unintentional wound - Presence of pressure ulcer

Question 48

Risk for Infection

Answer 48

r/t any condition that interferes with normal inflammatory process or provides an entry for infectious agents ``` Defining characteristics Risk factors -Disruption of skin integrity -Immunosuppression -Extremes of age -Malnutrition -Presence of drains, tubes, catheters ```