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Fundamentals of Nursing > Skin integrity and wound care > Flashcards

Skin integrity and wound care Flashcards

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1
Q

Intentional wound

A

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

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2
Q

Unintentional wound

A

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

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3
Q

Acute wounds

A

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

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4
Q

Chronic wounds

A

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

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5
Q

Primary intention

A

Well approximated wound edges

Intentional wounds such as surgical incisions

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6
Q

Secondary intention

A
  • 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
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7
Q

Tertiary intention

A

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

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8
Q

Hemostasis (1st)

A

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

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9
Q

Inflammatory phase (2nd)

A

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

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10
Q

Proliferation phase (3rd)

A

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

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11
Q

Maturation phase (4th)

A

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

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12
Q

Scaar

A

Avascular collagen tissue

Does not sweat, grow hair, or tan

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13
Q

Granulation tissue

A

Forms foundation for scar to develop

New tissue that is formed in proliferation phase

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14
Q

Local factors that can prolong wound healing

A
  • Pressure
  • Desiccation: dried out
  • Maceration: over hydrated
  • Trauma
  • Edema
  • Infection
  • Excessive bleeding
  • Necrosis
  • Biofilm
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15
Q

Systemic factors that can prolong wound healing

A
  • Age
  • Circulation and oxygen
  • Nutritional status
  • Medication and health status
  • Immunosuppression
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16
Q

Moist wounds

A

Experienced enhanced epidermal migration which supports epithelialization

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17
Q

Epithelialization

A

epithelial cells migrate to wound bed

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18
Q

Wound complications: overview

A
  • Hemorrhage
  • Infection
  • Dehiscence
  • Evisceration
  • Fistula formation
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19
Q

Dehiscence

A

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
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20
Q

Evisceration

A

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

21
Q

Actions to take in dehiscence

A
  • 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
22
Q

Pressure ulcer definition

A

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

23
Q

How do most pressure ulcers develop?

A
  • 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
24
Q

Most pressure ulcers occur in?

A

Older adults

25
Q

Risk factors for pressure ulcers?

A
  • Age
  • Chronic illness
  • Poor nutritional status
  • Immobility
  • Fecal and urinary incontinence
  • Altered level of consciences
  • Spinal cord injuries
  • TBI patients
  • Neuromuscular disorders
26
Q

Where do most pressure ulcers develop?

A

Coccyx and sacrum

27
Q

Other areas common for pressure ulcer development?

A

Trochanter and heal

28
Q

Major predisposing factor for pressure ulcer development?

A

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

29
Q

How quickly can a pressure ulcer develop?

A

1-2 hours if patient hasn’t been repositioned

30
Q

Friction

A

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
31
Q

Shear

A

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

32
Q

First indication of pressure ulcer development?

A

Blanching of skin-> skin becomes pale and white

33
Q

Suspected deep tissue injury

A

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

34
Q

Stage 1 pressure ulcer

A

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

35
Q

Stage 2 pressure ulcer

A

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
36
Q

Stage 3 pressure ulcer

A

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
37
Q

Stage 4 pressure ulcer

A

Full thickness tissue loss, exposing bone, tendons, muscle

  • Slough and eschar may be present
  • Osteomyelitis is a possible complication
38
Q

Unstageable

A

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

39
Q

Eschar color

A

tan, brown, black

40
Q

Slough

A

yellow, tan, gray, green, brown

41
Q

Braden assessment

A

For pressure ulcer risk

Lower number= Higher risk

42
Q

RYB wound classification

A

Red=Protect
Yellow= Cleanse
Back= Debride

43
Q

Serous drainage

A

clear, serous watery fluid

Normal

44
Q

Sanguineous drainage

A

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

45
Q

Serosanguineous drainage

A

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

46
Q

Purulent drainage

A

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

47
Q

Impaired Skin Integrity

A

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
48
Q

Risk for Infection

A

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

Fundamentals of Nursing (1 decks)

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