Skin Integrity and Wound Care Power Point Flashcards
______ is a disruption in skin integrity and function of tissues.
wound
Many ways to classify a wound (6)
status of skin integrity cause a wound severity or extent of injury/tissue loss (partial or full thickness) Acute vs. chronic Cleanliness Descriptive qualities (such as color)
______ are the most prevalent cell in the epidermis? or dermis?
fibroblasts
Classifying a wound assists the nurse in understanding the risks of the wound and the _____ for healing.
implications
______ are wounds that, as a rule, are healing normally.
Red wounds
_______ contain fibrinous slough. The slough is usually yellow, cream-colored, or white. Often it is soft and stringy in appearance, but it may be dry and stick tenaciously to the wound bed.
Yellow wounds
_______is an excellent medium for bacterial growth, so it needs to be removed to optimize wound healing.
Slough
_______ are wounds that contain dry necrotic tissue, which can be black, grey, or brown.
Black wounds
Classify the wound based on the least healthy _____.
color
Full-Thickness Wound Repair Phases
Hemostasis
Inflammatory Phase
Proliferative (Reproduction & Reconstruction) Phase
Maturation (Reestablishment or Remodeling Phase)
With Full thickness wound repair includes the inflammatory phase which can last from ____ to ___ days.
3 - 6
With Full thickness wound repair includes the proliferative phase which can last from ____ to ___ days.
3-24 days
With Full thickness wound repair includes the maturation or the remodeling phase which can last from ____ to ___ days.
21 days to greater than 1 year
Full-Thickness Wound Repair Phases
Hemostasis & Inflammatory Phase (ATI)
Proliferative (Reproduction & Reconstruction) Phase
Maturation (Reestablishment or Remodeling Phase)
Partial thickness wounds heal by _____.
regeneration
_______ is little or no tissue loss, edges approximated, heals rapidly, low risk of infection, no or minimal scarring
Primary Intention:
_______ is the loss of tissue, wound edges are not close together, longer healing time, increase risk of infection and scarring, heals by granulation
Secondary Intention
________ is the widely separated deep, spontaneous opening of a previously closed wound, risk of infection, closed at a later time.
Tertiary Intention
Types of Wounds
Abrasion Laceration Skin Tear Puncture Degloving?
With wound management prevent and _____ infection.
manage
With wound management ______ is important.
cleansing
With wound management it is necessary to _____ nonviable tissue.
removal
Macrophages like to attract _____.
fibroblasts (help synthesize collagen - begin the process of healing)
With wound management eliminate or minimize ___.
pain
With wound management protect the wound and ______.
periwound skin
What cell helps synthesize collagen?
fibroblasts
Scars can be strong and have good structure, but will never be as strong as the _____.
previous tissue (prior to injury)
Scars can be strong and have good structure, but will never be as strong as the _____.
previous tissue (prior to injury)
Proliferative phase is starting to repair the wound bed and _____.
edges
Facts in the restoration and tensile strength of healed tissue.
Staples Sutures Clips Skin closure strips (Steri-strips) Topical Adhesions (Dermabond
Suture Types
Interrupted
Continuous
Blanket
Retention
The purpose of _______ are to protect a wound from microorgansisms contamination, aids in hemostasis, promote healing (absorbing drainage), support or splint the site, insulation, and provide a moist environment.
dressings
Various types of dressings, chosen based on _____ of wound.
treatment goal
______ and binders purpose is to provide extra support to the wound.
bandages
Types of Bandages
Rolled gauze elasticized knit elastic webbing flannel muslin
______ are large pieces of material to fit a specific body part like a breast or abdominal ____.
binder
binder
Plan for wellness includes promoting healthy skin through _____, nutritional status, and mobility and safety.
fluid intake
Plan for wellness with wound healing (5)
Promote healthy skin prevent skin wrinkles prevent dry skin early detection of skin lesions be aware of pertinent medications
Risk Factors for Poor Skin Wellness (6)
UV exposure Immobility or limited mobility Dehydration Dementia Genetics Progressive illnesses
Risk Factors for Poor Skin Wellness (6)
UV exposure Immobility or limited mobility Dehydration Dementia Genetics Progressive illnesses
Dressings can be ____ or moist (guaze)
dry
______ is a type of dressing that provides a moist environment and serves as a protective barrier.
transparent film
_____ supports healing in clean granulating wounds and can debride necrtoic wounds.
hydrocolloid
_____ cannot absorb excessive drainage.
hydrocolloid
Use a _____ dressing on shallow to moderately deep dermal ulcer.
hydrocolloid
_____ hydrates wounds; maintaining a moist surface to help support healing.
hydrogel
_____ is used with used with partial-thickness, full-thickness wounds, burns, radiation damaged skin.
Hydrogel
The disadvantage to using _____- is that it requires a secondary dressing.
hydrogel
The disadvantage to using _____- is that it requires a secondary dressing.
hydrogel
A _____ uses negative pressure to support healing.
wound V.A.C
When changing a dressing know the type of dressing, placement of ____, and equipment needed. Review orders.
drains
To ____ dressings use tape, ties, or binders.
secure
When applying and removing dressings use ______. Make sure to carefully remove tape, gently cleanse the wound, and administer _____ before dressing changes.
comfort measures
analgesics
_____ wound healing requires ongoing assessment and intervention.
impaired
Wound ____ is an emergency.
hemorrhage
Hemorrhages can external or internal, internal is known as ______.
hematoma.
Hemorrhages can external or internal, internal is known as ______.
hematoma.
For external hemorrhages notify the _____ team immediately and apply a pressure dressing.
medical
A hematoma is not a medical emergency, but it is a pooling of blood that looks like a ______.
goose egg
With an _____ microorganisms invade the wound tissues
infection
Signs and Symptoms of Infection
Erythema, increased wound drainage, change in appearance of wound drainage, pain, edema, warmth, elevated WBC, or fever.
Purulent Drainage: Odor, brown, yellow, green (depending on organism)
If a wound is ____- it changes the way we care for the patient and the types of dressings being used.
infected
A complication with wounds include _____ which is when wound layers separate (total or partial) of a sutured wound.
dehisccence
A ____ will cause a significant increase in flow of serosanguineous fluid on wound dressing.
dehiscence
A history of straining or reports of something “given way” or “popping” occurs with ______.
dehiscence
Your organs can die quickly if ______ occurs and visceral organs protude.
evisceration
NCLEX Question
A dehiscence that involves protrusion of the visceral organs through a wound opening is called _____.
evisceration
______ is a serum. Clear, watery or slightly yellow drainage (i.e. fluid in blisters)
Serous
______ fluid that contains blood. Thick. Bright red (active bleeding) and darker drainage (older bleeding)
Sanguineous
______ fluid that contains blood. Thick. Bright red (active bleeding) and darker drainage (older bleeding)
Sanguineous
________ contains serum and blood. Water and appears blood streaked.
Serosanguineous
________ is the result of infection. Thick, contains WBC, tissue debris and bacteria. May have foul oder. Yellow, green, tan or brown.
Purulent Drainage
A big increase in particularly _____ drainage could be a sign dehicencese might occur.
serosanguineous
3 pressure-related factors
pressure intensity
pressure duration
tissue tolerance
Intact skin with nonblanchable redness is classified as stage ____ pressure ulcers.
1
Partial-thickness skin loss involving epidermis, dermis, or both is considered a ______ stage pressure ulcer.
2
Full-thickness tissue loss with visible into subcutaneous tissue is classified as a stage _____ pressure ulcer.
3
Full-thickness tissue loss with exposed bone, muscle, or tendon is classified as a stage ____ pressure ulcer.
4
One pressure related factor is pressure intensity resulting from ______.
blanchable hyperemia
One pressure related factor is pressure duration resulting from _____ prolonged pressure or _____ intensity pressure for a short duration.
low
high
One pressure related factor is _____ which is dependent on skin integrity and underlying skin structures.
tissue tolerance
Shear, friction, and _____ increase suceptibility to pressure ulcers which is a pressure related factor (tissue tolerance)
moisture
______ is a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage or underlying soft tissue from pressure and/or shear.
suspected deep tissue injury
A suspected deep tissue injury may be preceded by tissue that is painful, firm, mushy, boggy, warmer or _____ as compared to adjacent tissue.
cooler
A suspected deep tissue injury may be preceded by tissue that is painful, firm, mushy, boggy, warmer or _____ as compared to adjacent tissue.
cooler
A ____ ulcer appears as a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue, or purple hues.
stage 1
A ____ ulcer is superficial and present clinically as an abrasion, blister, or shallow crater.
stage 2
A _____ ulcer presents clinically as a deep crater with or without undermining of adjacent tissue.
stage 3
A ____ ulcer presents as full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone, or supporting structures (i.e. tendon, or joint capsule). Undermining and sinus tracts may also be present.
stage 4
The ____ scale is a risk assessment tool for both the physical and mental condition, activity, mobility and continence of patients and may be used during assessment for wounds/pressure ulcers.
norton
The ____ scale assesses the sensory perception, moisture, activity, mobility, nutrition, and friction and shear. This is used during the nursing assessment for wounds/pressure ulcers.
braden
With the Braden Scale assess each of the six categories and selecct the description for each category that best describes the client’s current condition. The score can range from ______ to _____ points.
6 to 23 points
Clients scoring 18 or less on the Braden scale are considered to be ____.
at risk
Braden Scale 15-18
at risk
Braden Scale 12-14
moderate risk
Braden scale 10-12
high risk
Braden scale 9 or less
very high risk
Nursing Diagnosis for Skin Integrity and Wounds
Impaired Tissue Integrity Impaired Skin Integrity Risk for Infection Acute Pain Body Image Knowledge Deficit
Characteristic Signs of Aging
Increased pigmentation around the eyes Wrinkles Shifting of subcutaneous fat -Leads to skin sag Delayed wound healing Gray hair or balding
Skin Changes with Aging
Decrease in melanocytes
Thinner, flatter dermis layer
Skina lesions
Photoaging
Two types of common skin cancer in older adults
Basal Cell Carcinoma
Melanoma
Skin cancer is due to (4)
UV exposure
family history
fair skin or frequent sun burn
presence of large/irregular moles
Nail changes with aging
Growth slows Visible changes: -Dull, opaque Longitudinal striations develop -Soft, brittle nails
Nail changes with aging
Growth slows Visible changes: -Dull, opaque Longitudinal striations develop -Soft, brittle nails
Hair changes with aging
Changes in color and distribution Graying: -Decreased melanin production and an increase of nonpigmented hairs Increased facial hair growth: -Ears, nares, eyebrows, on upper lip Loss of body hair: -Truck, pubic area, axillae, head
Risk Factors for Poor Skin Wellness
UV exposure Immobility or limited mobility Dehydration Dementia Genetics Progressive illnesses
Plan for Wellness
Promote Healthy Skin Fluid intake Nutritional status Mobility and Safety Prevent Skin Wrinkles Prevent Dry Skin Early Detection of Skin Lesions Be aware of pertinent medications
