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foundations > skin integrity and wound healing > Flashcards

skin integrity and wound healing Flashcards

1
Q

wound categories

A

tissue loss: burns, ulcers, lacerations
no tissue loss: surgical incision

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2
Q

primary intention

A

edges are approximated
low risk of infection
minimal scarring

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3
Q

secondary intention

A
  • edges not approx.
  • ulcers
  • burns
  • high risk of infection
  • tissue loss
  • severe scarring
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4
Q

tertiary intention

A
  • delayed approx.
  • purposely delaying closure to observe for infection or get rid of infection
  • let heal from bottom up
  • cleaning out
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5
Q

partial thickness wound

A
  • involves epidermis & portions of dermis
  • inflammatory for 24 hrs
  • moist wound: ab 4 days heal
  • dry wound: 6-7 days heal
  • thin layer of epithel. slowly reestablishes
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6
Q

full thickness

A
  • destroys all layers of dermis
  • vasoconstriction in mins/hrs
  • inflammation
  • takes days-months to heal
  • fibroblasts with granulation tissue to heal
  • remodeling: scar tissue healing (can take months to years)
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7
Q

dehiscence

A

the opening of a previously approximated wound
- at high risk 3-11 days after injury or surgery

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8
Q

hemorrhage

A

bleeding of a wound
- hematoma: collection of a clot and blood under the skin that causes a solid swollen area
- ecchymosis

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9
Q

evisceration

A

wound opens and organs come out
- abdominal most common
- call MD stat
- sterile towels soaked in saline to keep moist

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10
Q

fistula formation

A
  • abnormal connections (anastomosis) between a hollow organ and the skin of another hollow organ
  • classified according to location
  • low output: <200mL/24 hr
  • high output: >500mL/24 hr
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11
Q

serous drainage

A

clear watery plasma

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12
Q

sanguinous drainage

A

bright red, active bleeding

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13
Q

serosanguinous drainage

A

mixture of clear plasma fluid and blood (pale pink and watery)

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14
Q

purulent drainage

A

thick, yellow, green, tan, or brown, odorous

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15
Q

pressure injury

A

a localized injury to the skin and other underlying tissue usually over a bony prominence as as a result of pressure or pressure in combination with sheet and or friction

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16
Q

two problems causing pressure injury

A
  1. no oxygen delivered
  2. no cellular waste removed
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17
Q

pressure related factors

A
  • intensity
  • duration
  • tissue tolerance
  • skin response to pressure
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18
Q

skin response to pressure

A
  • normal reactive hyperemia
  • abnormal: non blanching erythema
  • darker skinned patients are exception for no blanching
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19
Q

braden scale

A

6-23
- low score= high risk
- hiher than 18= low risk
- ability to feel pain and pressure
- moisture
- activity
- mobility
- nutrition
- sheering forces combined with friction

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20
Q

define friction and sheer

A

friction: the resistance of skin rubbing on sheets
sheer: two things sliding against each other

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21
Q

age related risk factors

A
  • reduced skin elasticity
  • decreased amount of collagen
  • polypharmacy
  • decreased inflammatory response
  • malnutrition
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22
Q

pressure injury sites

A

sacrum
greater trochanters
ischial tuberosities
lateral malleolus
tuberosity of calcaneus
olecranon

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23
Q

tunneling

A

channel or pathway that extends in any direction from the wound through subq tissue
- use sterile 9” q tip to measure

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24
Q

undermining

A

tissue destruction underlying the intact skin along the wound margins

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25
Q

slough

A
  • dead non-viable tissue
  • yellow, green, or gray
  • light, thin, wet, stringy
  • remove
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26
Q

eschar

A
  • dead, non-viable
  • usually black, brown, or gray
  • dark, thick, hard
  • leave in place, similar to scab
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27
Q

granulation tissue

A
  • live, viable, good
  • beefy red color
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28
Q

epithelial tissue

A
  • live, viable
  • deep to pearly pink
  • dry
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29
Q

muscle

A
  • highly vascularized
  • pink to dark red, striated
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30
Q

periwound skin

A

skin around the wound

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31
Q

maceration

A

lighter color of moist skin (technical name for grape fingers)

32
Q

erythema

A

redness

33
Q

cyanosis

A

poor blood flow

34
Q

when are wounds staged

A

once at admission

35
Q

stage 1

A
  • no blanching erythema of intact skin
  • no tissue loss
36
Q

stage 2

A
  • partial thickness skin loss with exposed dermis
  • shallow open ulcer– intact or ruptured blister
  • red-pink wound bed
37
Q

stage 3

A
  • full thickness skin loss
  • not seeing bone, tendon, or muscle
  • may see epibole
  • possible slough, escar, undermining, or tunneling
38
Q

stage 4

A
  • full thickness skin and tissue loss
  • seeing muscle and bone
  • often includes epibole, undermining, tunneling
  • may include slough or eschar
39
Q

unstageable/unclassified

A
  • full thickness skin/tissue loss
  • unknown depth
  • base of wound not visualized d/t slough and eschar
40
Q

suspected deep tissue injury

A
  • depth unknown
  • purple or maroon area of intact skin or blood filled blister
41
Q

wound vac

A

assistant in wound closure by applying negative pressure to draw the edges of the wound together

42
Q

can black foam touch healthy skin?

A

no, it will cause tissue death

43
Q

debridement

A
  • the removal of dead, non-viable tissue
44
Q

mechanical debridement

A
  • wet to dry dressings
  • irrigation
  • whirlpool
45
Q

autolytic debridement

A
  • patients own enzymes self digest eschar
  • transparent dressing over wound to seal
46
Q

chemical debridement

A
  • topical enzymes
  • dakins solution
  • maggot therapy
47
Q

surgical debridement

A

sharp instrument used to cut away necrotic tissue

48
Q

proteins role in wound repair

A
  • growth and repair
49
Q

most common way to test protein level

A

serum albumin level

50
Q

BEST measure of overall nutritional status

A

prealbumin

51
Q

vitamin A’s role in wound repair

A
  • helps reduce the negative effects of steroids on wound healing
  • carrots are good source
52
Q

vitamin C’s role in wound repair

A
  • helps synthesize collagen
53
Q

zinc’s role in wound repair

A
  • epithelialization
  • helps synthesize collagen
  • nuts are good source
54
Q

copper’s role in wound repair

A
  • good for collagen fiber linking
  • seafood is good source
55
Q

fluid with highest risk for skin breakdown

A

GI drainage

56
Q

fluid with moderate risk for skin breakdown

A

bile
stool
urine
purulent exudate

57
Q

fluid with low risk for skin breakdown

A

slava
serosanguinous drainage

58
Q

barrier cream

A

preventative measure for pressure injuries

59
Q

reposition pt…

A
  • q2h
  • lift, dont drag
60
Q

teach mobile pts to …

A

reposition q 15 minutes
30 degree lateral position

61
Q

support surfaces for pressure injury prevention

A

specialty beds
waffle mattress

62
Q

mepilex

A

pressure injury preventative dressing
- piece of foam w sticky dressing

63
Q

gold standard for wound cultures

A

tissue biopsy

64
Q

when collecting specimens for wound cultures…

A
  • clean wound first
  • never collect old drainage
65
Q

benefits of heat therapy

A
  • vasodilation
  • helps decrease muscle tension
66
Q

benefits of cold therapy

A
  • vasoconstriction
  • blood vessels take up less space, therefore less pressure
  • decrease muscle tension
67
Q

when to not use hot/cold therapy

A

if pt cannot feel pain

68
Q

types of heat therapy

A
  • warm, moist compress
  • warm soak
  • sitz bath
  • hot pack
  • heat lamps
69
Q

warm soak temp range

A

105-110 degrees F

70
Q

sitz bath

A
  • for perineal area
  • done for 20 minutes
71
Q

heat lamps

A
  • leave on for about 10 minutes
  • should be an arms length away from pt
72
Q

cold therapy

A

cold soak
- 59 degrees F
- 20 mins
cold compress
- 20 mins
ice bag or collar
- 30 mins

73
Q

dressing change: check orders for…

A
  • type of dressing
  • cleaning solution
  • wound specifics
74
Q

clean dressing changes

A
  • done with a clean technique
  • put on gloves
  • remove old dressing
  • clean and assess site
  • apply new dressing
75
Q

wound assessment

A
  • OREEDA
  • closure
76
Q

drainage assessment

A

CCOAL
Color
Consistency
Odor
Amount
Location

77
Q

types of closures

A
  • sutures
  • staples
  • steri strips

foundations (15 decks)

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