Skin Integrity and Wound Healing Flashcards
** The nurse is caring for a client in the hospital. Which type of skin-related issue is most prevalent in healthcare?
pressure ulcer formation
Function of melanin and sebum
protection
Ways skin promotes thermoregulation
sweating
lifespan changes for skin: babies
reduced ability to thermoregulate
more susceptible to rashes, blistering, chafing
lifespan changes for skin: toddler/preschool
sunscreen
injuries from playing
lifespan changes for skin: school/ adolescent
- lice, scabies, impetigo
- acne
- sunscreen
lifespan changes for skin: adult/older adult
- dry skin more common
- wrinkling and poor skin turgor
- slower healing
health related factors that can damage skin
- nutrition
- circulation
- allergy or infection
- abnormal growth rate
mechanical forces that can damage skin
- pressure
- friction
- shear
injury, such as knife, gunshot, burn, or surgical incision; heals within 6 weeks
acute wound
wound that persists beyond usual healing time (>6 mo) or recurs without new injury to the area
chronic
break present in the skin; tissue damage present
open
no break seen in the skin, but soft tissue damage evident
closed
closed surgical wound that did not enter GI, respiratory, or genitourinary tract
clean
wound entering GI, respiratory, or genitourinary systems; infection risk
clean/contaminated
Open, traumatic wound; surgical wound with break in sepsis; high infection risk
contaminated
Wound site with pathogens present; signs of infection
infected
pressure ulcer with sloughing, eschar, potential tunneling. bone/tendon/muscle NOT exposed
stage III
pressure ulcer that’s blanchable
stage I
pressure ulcer that exposes bone/tendon/muscle
stage IV
pressure ulcer that’s partial-thickness loss of dermis
stage II
stage of a full-thickness wound that doesn’t extend to the bone, tendon, or muscle. The wound tunnels and has some sloughing. What stage?
stage III
Measures to prevent pressure ulcers
- repositioning and turning
- lift rather than drag patients when pulling up in bed
- specialty mattress/bed
- protective creams or lotions
immediate phase of wound healing
hemostasis: vasoconstriction, platelet aggregation, clot formation
up to day three of wound healing
inflammatory phase: vasodilation, phagocytosis
day 4-21 of wound healing
proliferative phase:
- partial thickness - epithelialization
- full thickness - granulation/contracture
21 days to 2 years of wound healing
maturation (full thickness only)
small spot, like freckle or peticheae
macule
larger than macule, like vitiligo
patch
clean incision, early suture, hairline scar
primary intention
gaping irregular wound, granulation, epithelium grows over
secondary intention (contraction and epithelialization)
wound, granulation, closure with wide scar
tertiary intension (delayed closure)
measures to keep wound edges close together
- binder
- steri-strips
- sutures, staples, clips
- cyanoacrylate glue
- elastic wraps, bandages, stretch netting
purulent drainage, inflamed incisional area, fever, elevated leukocyte count
infection
partial or total disruption in wound edges, the wound opens up
dehiscence
protrusion of viscera through wound opening (inside goes outside)
evisceration
passage between two areas that don’t normally connect
fistula
elements to assess with wound
- type/location/size/ classification/base
- drainage
- undermining or tunneling
- infection or pain
- if connect to a drain, measure output and confirm it’s working
bloody drainage
sanguinous
pale pink-yellow drainage
serosanguinous
pale yellow, watery (like fluid from a blister) drainage
serous
tube placed in wound, no suction
penrose
drain with suction present and bloody cavity
hemovac
drain with bulb – gentle suction when bulb is compressed and released
Jackson Pratt (JP)
Who should remove a surgical dressing
surgeon first! they’ll write orders
dressing designed to be placed inside wound
alginate
dressing made of woven cotton material. Nonocclusive
gauze
dressing contains ionic silver – either immediate or controlled release of silver into the wound bed
silver
pad of compressed foam with moderate absorptive capacity
polyurethane foam
type of dressing over IV site
transparent
dressing with sodium carboxymethylcellulose fibers
hydrofiber dressing
water-resistant gel-like dressing
hydrocolloid wafer
which type of wound product requires a doctor’s order
silver
All of them except transparent when you’re in a hospital, but silver is never available OTC
When would a wound involve packing or filling?
If tunneling or undermining are present
wound therapy with hydrophobic sponge, negative pressure machine, transparent dressing
negative pressure wound therapy (wound vac)
type of debridement not done by nurses
surgical
debridement using a chemical product to break down debris
enzymatic
debridement that’s occlusive or hydrogel, debris gets eroded then irrigated with saline
autolytic
debridement with wet-to-dry dressing
mechanical
heat or cold: promotes healing and suppuration
heat
heat or cold: controls bleeding
cold
diet to promote wound healing
high in protein, vitamin A, C, E, zinc, water, arginine, carbs, fats
problematic meds for wound healing
blood thinners (anticoagulants), chemo, corticosteroids and other immunosuppressants
lifestyle choice that impairs wound healing
smoking
stage this wound
2
stage this wound
3
stage this wound
1
stage this wound
4