Skin Integrity Objectives Flashcards
A patient has a pressure injury on the coccyx measuring 5 cm by 3 cm that is covered with eschar. How should the nurse classify this wound?
A. Stage 2 pressure injury
B. Stage 3 pressure injury
C. Stage 4 pressure injury
D. Unstageable pressure injury
Answer: D.) Unstageable pressure injury
Rationale: Eschar is a black, leathery covering made up of necrotic tissue. An ulcer covered in eschar cannot be classified using a staging method because it is impossible to determine the depth
A patient is recovering from a ruptured appendix. Because the surgeon did not surgically close the wound, the nurse knows the wound will heal by:
A. Primary intention
B. Secondary intention
C.Tertiary intention
D. Approximation
Answer: A.) Secondary Intention
Rationale: Secondary intention healing occurs when a wound is left open, and it heals from the inner layer to the surface by filling in with beefy, red granulation tissue.
Age factor that affects skin integrity for the older adults include what
Sebaceous and sweat gland activity decreases resulting in drier skin
Xerosis
Lose lean body mass and the subcutaneous tissue layer thins
the dermal layer loses elasticity due to changes in collagen fibers
these changes make the skin prone to breakdown and prolong wound healing - which is why an older persons skin takes twice as long as a younger adult
All chronic wounds should be considered
contaminated
Can you delegate position changes
yes, but your responsibility to make sure its done and done correctly
Can you grade wounds with eschar
no - can not tell how deep it is
Contamination /infection of clean surgical wounds not see until
4th or 5th day
Contamination of traumatic wounds - infection symptoms appear -
within 2-3 days
describe a stage 1 pressure sore
Localized area of intact skin with nonblanchable redness, usually over a bony prominence but not maroon or purple discoloration.
The area may be painful, firm, soft, or warmer or cooler as compared with adjacent tissue.
Discoloration will remain for 30 minutes after pressure is relieved.
Describe stage 2 pressure injury
Involves partial-thickness loss of dermis.
but shallow and with a red pink wound bed.
May also be an intact or open/ruptured serum-filled blister, or a shiny or dry shallow ulcer without slough or bruising.
Describe stage 3 pressure injury
A deep crater characterized by full-thickness skin loss with damage or necrosis of subcutaneous tissue. Adipose is visible.
Bone/tendon is not visible or directly palpable.
Describe stage 4 pressure injury
Involves full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or support structures.
Exposed bone/tendon is visible or directly palpable.
Do not ________ bony prominences
massage
how can chemotherapeutic medications affect skin integrity
delay wound healing due to cellular toxicity
how does anti-inflammatory medications affect skin integrity
EX. NSAIDs and steroids inhibit wound healing
how does anticoagulants medications affect skin integrity
EX. heparin and warfain can lead to extravasation of blood into subcutaneous tissue as a result minimal pressure or injury can cause hematoma
How does blood pressure medications affect skin integrity
decreases the amount of pressure required to occlude blood flow, creating a risk for ischemia
How does edema effect skin
decreases skin elasticity and interferes with the diffusion of oxygen to the cells making skin more prone to breakdown
How long does the Inflammatory phase and what does it consist of?
lasts from 1 to 5 days and consists of two major processes hemostasis and inflammation
impaired ______ restricts activity, produces pain, and leads to muscle atrophy and thin tissue that can lead to ischemia and necrosis
arterial circulation
impaired ______ results in engorged tissues containing high levels of.metabolic waste products making tissue susceptible to edema, ulceration, and breakdown
Venous circulation
impaired _______ interfere with tissues metabolism and delay wound healing
vascular system
lifestyle factors that affect skin integrity
tanning (exposure to UV radiation )
Hygiene (to many washing can break down the skin)
regular exercise and good nutrition is a necessity
smoking compromises the oxygen that can get to the tissues and skin
Mobility factor that affects skin integrity include what
a healthy person moves and shifts position unconsciously when they sense pressure or discomfort
clients who are un able to move independently, increases the pressure on the muscle that is not be using (sitting in a wheelchair)
people with limited mobility can have a higher risk for injury to the skin
Pressure ulcers are directly caused by which condition at the site?
A. Compromised blood flow
B. Edema
C. Shearing forces
D. Inadequate venous return
Answer: A. Compromised blood flow
Rationale: Pressure ulcers are caused by unrelieved pressure that compromises blood flow to an area, resulting in ischemia (inadequate blood supply) in the underlying tissue.
Scars are only _____% as strong as original tissue
80
Stage 2 pressure ulcers do not involve
sloughing or bruising
What are some nursing interventions you can do to minimize pressure injuries
monitoring sites of bony promises (turn client )
Managing moisture (changing when they are wet applying moisture barriers)
Dressings (to keep site dry and away from infection or worsening)
Minimize pressures (by turning client regularly )
What are the advantages/risks of dry heat treatment and how is it applied?
may be applied with electric heating pads, disposable hot packs, or hot water bags. Electric heating pads have the advantage of providing a constant temperature, but the risk of burns is high. Aquathermia pads may also be used for dry heat application. Disposable hot packs and hot water bags or bottles are also available
what are the six categories of the braden scale
sensory perception moisture activity mobility nutrition friction shear
What are the two distinct layers of the skin
Epidermis and the Dermis
What does cold treatment (cooling baths, cold compresses, or dry cooling) do to the body
The application of moist or dry cold causes vasoconstriction and decreases capillary permeability.
It produces local anesthesia, reduces cell metabolism, increases blood viscosity, and decreases muscle tension. It also slows bacterial growth
What does the dermis layer of the skin consists of ?
thinner second layer
contains blood and lymphatic vessels, nerves, bases of hair follicles, and subcutaneous and sweat glands
provides strength and elasticity to the skin and is generously supplied with blood vessels
What does the epidermis layer consist of?
It is the thick outer layer
Consists of stratified squamous epithelial tissue composed of keratinized (dead) cells
and contains melanin
What does the integumentary system consist of?
Skin
Subcutaneous layer
Hair
Nails
Sweat glands
Sebaceous glands
what does the maturation phase consist of and how long does it last?
final phase of healing occurs after proliferation or granulation phase.
continues after the wound has closed, the initial collagen fibers are broken down and remodeled into an organized structure (scar tissue)
What does the subcutaneous layer consist of
connective and adipose tissue
What factor affecting skin integrity is being described below:
excessive exposure leads to maceration increasing the likelihood of skin breakdown
Inconvenience and fever are the most common sources
Moisture
what happens in a brisk hemorrhage?
blood often pools underneath the client as the dressing becomes saturated
what happens in the Proliferation or granulation phase and how long does it last?
these phase occurs from days 5 to 21
Cells develop to fill the wound and resurface the skin. Fibroblasts go to the wound and form collagen adding strength to the healing wound. new blood and lymph vessels form around the edge of the wound forming granulation tissue and seal the wound over
what is a closed wound
exists when there are no breaks in the skin. Contusions (bruises) or tissue swelling from fractures are common closed wounds
what is a full - thickness wound
extends into the subcutaneous tissue and beyond
penetrating is also sometimes added to indicate that the wound involves an organ
what is a hemmorrhage?
profuse or rapid loss of blood. Hemostasis (or cessation of bleeding) usually occurs within minutes of the injury.
what is a internal hemmorrhage?
could be collection of blood under the skin and forms a hematoma because the blood cannot escape, large enough and it can cause pressure on surrounding tissue or impede blood flow. which causes swelling of the affected area, pain and changes in vital signs
what is a open wound
occurs when there is a break in the skin or mucus membranes
what is a partial- thickness wound
extends through the epidermis but not through the dermis
what is a superficial wound ?
involves only the epidermal layer of skin. The injury is usually the result of friction, shearing, or burning
What is caused by unrelieved pressure that compromises blood flow to an area resulting in ischemia in tissue
pressure ulcers
What is colonization
bacteria begin to increase in number but cause no harm.
What is contamination of a wound
refers to the presence of microorganisms in the wound
all chronic wounds are considered contaminated
What is critical colonization
bacteria begin to overwhelm the bodys defense. May be detected in subtle signs, such as increase in drainage
what is directly caused by compromised blood flow
pressure ulcers
what is Hemostasis in the inflammatory phase ?
at the time of injury, tissue and capillaries are destroyed, causing blood and plasma to leak into the wound. Area vessels constrict to limit blood loss, platelets for a clot
What is infection
Microorganisms are causing harm by releasing toxins, invading body tissues, and increasing the metabolic demand of the tissue. Infection of the skin makes it more vulnerable to breakdown and impedes healing of open wounds . If not stopped bacteria can enter the systemic circulation
What is inflammation in the inflammatory phase?
characterized by edema, erythema, pain, temperature elevation, and migration of white blood cells into the wound tissues. macrophages engulf bacteria and clear debris. plasma proteins and fibrin form a scab on the wound surface to seal it
What is melanin? and its function?
a pigment that gives the skin color
Functions: protects against UV rays, together with circulating blood
what is the function of the subcutaneous layer of skin?
provides insulation, protection, and calories in case of starvation
What is the length of healing time for a acute wound ?
expected to be short duration. In a healthy person these wounds heal very quickly with no complications
what is the length of healing time for a chronic wound?
exceed the expected length of recovery because healing has been interrupted or stalled due to infection, continued trauma ischemia, or edema.
Unless the wound is properly diagnosed and the underlying disease process is treated these wounds can linger for months to years
What is the primary goal of the nurse caring for a patient with an open wound?
A. The client will finish their antibiotics.
B. The wound will remain free of infection.
C. The client will increase caloric intake.
D. The wound will heal without scarring
Answer: B.)The wound will remain free of infection
Rationale: Wounds healing by secondary intention are more prone to infection, therefore the primary goal is to prevent infection.
What is the purpose of moist heat treatment and how is it applied?
Adding moisture to heat amplifies the intensity of the treatment. Moist heat can be applied in several forms, depending on the skin condition: a washcloth or towel compress, a gauze compress, or soaks and baths.
what nutrient is being described below:
low levels predispose patients to skin breakdown and inhibits wound healing
aide in providing fuel for wound healing and maintaining a waterproof barrier
Cholesterol
What nutrient is being described below:
Vital to the formation and maintenance of collagen
Vitamin C
Zinc
Copper
What nutrient is being described below:
when inadequate, the body uses proteins for energy (catabolism); they are then unavailable for building and maintenance functions (anabolism)
When prolonged, the person experiences weight loss, loss of subcutaneous tissue, and muscle atrophy.
As a result, padding between the skin and the bones decreases, predisposing the skin to pressure injury.
Caloric intake
What nutrient is being described below:
maintains the skin
repairs minor defects
preserves intravascular volume
As levels decrease minor defects cannot be repaired, fluid leaks from the compartment of dependent areas and edema develops
Protein
What nutrient is being described below:
when deficient skin os prone to injury especially when exposed to pressure, shearing, friction, and moisture
Hydration
What nutrients are essential to the integrity of the skin
protein cholesterol calories fluid vitamin C minerals
What type drain is described
a flexible, flat latex tube that is placed in the wound bed but usually not sutured into place. A clip or pin may be attached to the drain at the insertion site to keep it from slipping into the wound
penrose
What type of drain is described
The provider may order a device to be “placed to suction.” This means you will compress the device to create suction and facilitate removal of drainage
Jackson-Pratt or Hemovac
what type of healing is being described :
occurs when a wound involves minimal or no tissue loss, and edges are clean, little scaring is expected (hairline)
A surgical incision heals this way
primary (first) intention healing
what type of healing is being described below :
involves extensive tissue loss that prevents clean edge closing, or the wound should not be closed because of infection — which makes the wounds heal from the inner layer to the surface with beefy red granulation
these wounds develop more scar tissue
secondary intention healing
What type of healing is being described below:
occurs when two surfaces are sutured by brining the two inner sides of granulation tissue together
these wounds require strict aseptic technique for wound dressings
Tertiary intention healing
What type of healing is being described?
occurs when a wound affects only the epidermis and dermis. No scar forms (means you cannot tell that the skin was ever harmed)
Regenerative/Epithelial Healing
what type of pressure injury is described
An area of skin that is intact but persistently discolored. It might be purplish or deep red, painful, or boggy, or have a blister. Pain and temperature change often come before skin color changes.
Deep tissue pressure injury
What type of pressure injury is described below
Involves full-thickness skin loss.
The base of the wound is obscured by slough or eschar.
Unstageable Pressure Injury
What type of wound complication is being described below
Rupture of one or more layers of a wound. Most likely to occur in the inflammatory phase of healing, before large amounts of collagen have been deposited in the wound to strengthen it.
The most common causes are poor nutritional status, inadequate closure of the muscles, wound infection, or increased tension on the suture line (coughing, lifting an object).
Usually associated with abdominal wounds. Patients often report feeling a “pop” or tear, especially with sudden straining from coughing, vomiting, or changing positions in bed.
Dehiscence
what type of wound complication is being described below:
Microorganisms can be introduced to a wound during an injury, during surgery, or after surgery.
Suspect if a wound fails to heal. Localized swelling, redness, heat, pain, fever foul-smelling or purulent drainage, or a change in the color of the drainage may also indicate
In a contaminated or traumatic wound, the symptoms are likely to occur within 2 to 3 days.
In a clean surgical wound, you will usually not see signs and symptoms until the fourth or fifth postoperative day.
Infection
What wound complication is being described :
An abnormal passage connecting two body cavities or a cavity and the skin.
often result from infection or debris left in the wound. An abscess forms, which breaks down surrounding tissue and creates the abnormal passageway.
Fistula
what wound complication is being described
total separation of the layers of a wound with internal viscera protruding through the incision.
This rare complication is a surgical emergency. Immediately cover the wound with sterile towels or dressings soaked in sterile saline solution to prevent the organs from drying out and becoming contaminated with environmental bacteria.
Evisceration
you would not but a binder on the incision
When is the epidermis completed replaced ?
every 3-4 weeks
where do you normal see an external hemorrhage in a hospital setting
bloody drainage on dressings and in wound draining devices
Why are clients at risk for impaired skin integrity when they have a decreased sensation
they are less able to sense when thier skin is in harm,
EX. they get a cut and are unaware
they put their hand on a burner and they cannot feel it and end up with burns
why are clients with impaired cognitive ability at risk for skin impairment like alzheimers, deminta, etc.
they are not aware of the need to reposition, can be subtle and difficult to recognize
Why does the subcutaneous layer vary in thickness in different body sites?
Sex hormones
Genetics
Age
Nutrition
