Skin Integrity & Wound Care Flashcards
1
Q
Pressure injury (definition and rationale behind it)
A
- Pressure injury: skin damage from unrelieved prolonged pressure → damage can extend to adipose tissue or muscle, exposing bone
- Rationale: when pts lie in bed, weight of body compresses capillaries ⇒ can’t deliver required oxygen and nutrients ⇒ skin ischemia ⇒ pain
2
Q
Hyperemia
A
- if pressure isn’t too long or too high and skin can tolerate pressure ⇒ when pressure is relieved, blood vessels dilate ⇒ hyperemia
- Light-colored skin → presents as redness
- Dark-colored skin → presents as purple or maroon
3
Q
Assess for blanchability
A
- If area blanches or turns lighter in color → discoloration is considered transient/temporary blanchable hyperemia
- If area doesn’t blanch or is nonblanchable when you apply pressure → considered a pressure injury that’s developed
4
Q
Shearing & Friction
A
- Shearing: when blood vessels of skin gets kinked as skeletal structure shifts down bed even though skin stays in original space ⇒ decreases blood flow to skin ⇒ ischemia
- Friction: skin rubbing against bed linens, friction damages skin ⇒ when pressure is applied ⇒ skin breaks down faster
5
Q
Moisture from diaphoresis wound drainage fecal or urinary incontinence
A
does not lead directly to pressure injuries ⇒ destabilizes skin ⇒ if pressure is applied to skin, it’ll break down faster
6
Q
Nutritional status
A
- Skin needs proteins esp needed to maintain skin structure
- If underweight → less adipose tissue cushioning bony prominences
- If overweight → pressure on bony prominences
7
Q
Diseases Resulting in Altered Tissue Perfusion
A
- Peripheral vascular disease (PVD): decreases blood flow throughout body and skin
- HTN: only small amt of blood gets thru to skin
- Anemia: decreases blood oxygen carrying capacity of RBCs
- Diabetes: glucose problems and glucose molecules decreases blood flow
8
Q
Meds Affecting Skin Integrity
A
- Corticosteroids → causes skin thinning bc it blunts collagen synthesis (most abundant protein in body, needed for healthy skin structure & strength) ⇒ higher risk of pressure injuries
- Ie. Prednisone
- Pain meds → causes decrease in feeling tenderness/pain in ischemic areas
- Ie. acetaminophen, ibuprofen
- Sedation meds → causes impaired sensations
- Ie. benzodiazepines
9
Q
Moisture Associated Skin Damage (MASD) isn’t a PI !!!
A
Ie. pt incontinence ⇒ urine and feces damaging perineal skin but there’s no pressure from bed or medical devices ⇒ not PI, just MASD
10
Q
No “back staging” of PIs
A
Means that when the wound is healing or shrinking, skin and tissue are never the same
11
Q
Stage 1
A
- Skin intact
- There may be redness maroon or purple discoloration
- Skin is nonblanchable
- Is warm or cool
- Is firm or boggy
- Pt may complain of tenderness or pain
12
Q
Stage 2
A
- Skin layer not intact
- Partial thickness skin loss w/ exposed dermis
- No adipose tissue, muscle, or bone are exposed
- Serum-filled blisters are considered stage 2 pressure injuries whether blister are intact or ruptured as long as nurse knows that it was caused by pressure
13
Q
Stage 3
A
- Full thickness injury through epidermis and dermis w/ exposed subcutaneous fat
- No muscle, tendon, ligament, cartilage, and bone are expose
14
Q
Stage 4
A
- Full thickness skin injuries ⇒ through all layers of skin
- Has exposed muscle, tendon, ligament, cartilage, or bone
15
Q
Unstageable
A
Base of wound covered by layer of dead tissue that may be yellow, green, brown, or black to the point where nurse can’t see base of wound to determine stage
16
Q
Deep Tissue Pressure Injuries (DTPI)
A
- Caused by intense or prolonged sheer pressure and forces, particularly where bone meets muscle ⇒ injury is very deep
- Can present w/ intact or non-intact skin that shows sustained nonblanchable discoloration that may appear deep red, maroon, purple, or darker than surrounding tissue in both light and dark skin tones
- Blood-filled blisters are classified as DTPIs
- Pain and skin temp changes often precede visible color changes
17
Q
Hospital-acquired PI (HAPI)
A
if PI not identified within first 24 hrs of admission and pt was admitted w/ pressure injury ⇒ classified as HAPI ⇒ nurse & hospital’s quality of care is questioned
18
Q
Turnings (Bed & Chair)
A
- Bed → ≥ Q2hr turns
- Chair → Q15min shifts
19
Q
Ensure adequate protein intake:
A
- Pts at risk for or has PI based on Braden Scale → needs 1.25 - 1.5 g/kg/day protein
- Unless they have chronic kidney disease then 0.8 - 1 g/kg/day proteins bc the proteins can be harmful to kidneys
- Other foods to encourage: beef, chicken, seafood, eggs, beans, legumes
20
Q
Abrasion
A
Caused by friction when body scrapes across rough surface
21
Q
Intertriginous Dermatitis
A
- skin folds rubbing against each other causes moisture in those folds to lead to irritation, redness, infection
- Common in geriatric pts, diabetics, and pts on antibiotics
22
Q
Periwound Moisture-Associated Skin Damage
A
results from wounds, exudates, or drainage that leads to maceration and skin breakdown
23
Q
Peristomal Moisture-Associated Skin Damage
A
- skin around stoma subject to moisture from feces
- Happens esp if pouch doesn’t fit well
24
Q
Diabetic Foot Ulcers Cause
A
- Prolonged hyperglycemia ⇒ damages blood vessels & nerves ⇒ poor circulation
- Nerve damage ⇒ Peripheral Neuropathy: can’t feel friction, pressure, or pain
- Peripheral Vascular Disease (PVD): poor circulation ⇒ tissue suffers & delayed wound healing
- Hyperglycemia ⇒ increased risk of infection
25
Cellulitis What + S&S
- What: bacterial infection from wounds or small breaks in skin
- Severe or untreated ⇒ may lead to osteomyelitis
- Ie. severe edema ⇒ micro-skin tear ⇒ fluid leakage “weeping skin” ⇒ bacteria enters skin ⇒ infection
- S&S:
- Redness & Swelling in affected area
- Warmth & Tenderness
- Pain, may ↑ w/ touch
- Fever or Chills in more severe cases
- Skin may appear tight or glossy due to swelling
- Blisters may develop & burst
26
Acute Wounds
- Orderly & Timely healing
- Heals in days - few wks
- Goes through normal healing stages: hemostasis → inflammation → proliferation → maturation
- Ie. surgical wounds, abrasions, insect bites/stings
27
Chronic Wounds
- Non-orderly
- Heals in months - yrs
- Usually gets stuck in inflammatory stage
- Ie. diabetic foot ulcers, PI
28
Hemostasis
- Aims to stop bleeding via vasoconstriction and clotting
- Pts w/ thrombocytopenia (low platelet count) may have delay in hemostasis
- Pts taking anticoagulants or antiplatelet aggregation therapy may also have delayed hemostasis
29
Inflammation
- Neutrophils recruited to wound site to prevent infection
- Pts w/ neutropenia may have delay in this stage
- Note that some wounds don’t bleed and skip to inflammation stage instead
30
Proliferation
- New skin cells are generated to fill in and cover wound
- Wound healing delay in this stage may be caused by…
- Inadequate protein intake
- Infection
- Poor circulation due to high glucose
- HTN
31
Maturation
Scar tissue is remodeled and strengthened over time
32
Primary Intention
- When edges of wound are brought together or well approximated and closed w/ sutures, staples, or adhesive strips
- Approximation of edges allows for rapid healing process w/ minimal scarring
- Wound opening is narrow ⇒ risk of infection low
33
Secondary Intention
- Wound edges not approximate
- Wound needs to heal from inside-out
- Wound intentionally left open until it becomes filled w/ scar tissue
- Healing process is longer than primary ⇒ greater risk for infection bc skin is not intact longer
34
Tertiary Intention
- Delayed primary closure
- Wound left open for several days before being closed w/ sutures, staples, adhesives
- Chosen when surgeons fears that they may trap infectious microbes into wounds by closing it
35
How much nutrients is needed daily minimum?
30 - 35 cal/kg/day minimum
36
How much protein is needed for tissue repair and structure minimum and what are the different sources available?
1.25 - 1.5 g/kg minimum
sources: poultry, beef, eggs, milk
37
Why is Vit A & C important for wound healing and what are their sources?
- Vit A: for reducing negative effects of steroids on would healing
- Sources: green leafy vegetables
- Vit C: for synthesizing collagen
- Sources: citrus, fruits, tomatoes, bell peppers
38
What medications delays wound healing?
- Corticosteroids → ↓ collagen synthesis needed for wound healing and tissue repair
- Anticoagulants → risk for bleeding and delaying hemostasis
- Antiplatelet aggregates → reduces abilities of platelets to clot
- Chemotherapy or Corticosteroids → causing neutropenia ⇒ delays inflammatory stage
39
Hemorrhage (internal & external S&S)
- Internal: S&S
- ↓ BP, ↑ HR as body tries to maintain cardiac output
- Hematoma/Bruising
- If suspected extensive bruising → contact provider for further management
- Distention/Swelling
- Pain
- External → apply firm pressure immediately: S&S
- ↓ BP, ↑ HR as body tries to maintain cardiac output
- Visible bleeding from wound soaked dressings → frequent reinforcing/changing needed
- Drains filling quick → frequent emptying
- Blood pooling under pt
40
Dehiscence (What, Risk Factors, Commonly Occurs in)
- What: when previously approximated wounds opens, causing edges to separate
- Risk factors:
- Any pts at risk of wound healing
- Obese pts
- Commonly occurs in abdominal wounds after coughing, sneezing, vomiting, sitting up in bed, other strains
- Pts often feel as though something has given way inside or describe feeling of a pop inside
41
Evisceration (What)
more severe form of dehiscence where visceral organs end up protruding through wound open (surgical emergency requiring immediate attention 🚩)
42
Interventions for Evisceration !!! 🚩
- Place sterile gauze soaked saline over protruding tissues to prevent bacterial invasion and keep tissues from drying out
- Call provider immediately
- Keep pt NPO
- Monitor for signs of shock (↓ BP, ↑ HR)
- Prepare pt for emergency surgery
43
If you’re able to assess wound itself, record →
- Length
- Width
- Depth
- Tunneling: narrow hole in wound to insert sterile Q-tip
- Undermining: erosion beneath wound edges
44
Assess wound bed appearance
- Granulation tissue: healthy wound healing process that’s red and moist
- Slough: soft yellow-white tissue part of inflammatory process that needs to be removed for proper wound healing
- Eschar: black-brown necrotic tissue that needs to be removed for proper wound healing
45
Assessing drainage via checking…
- Amt (dressing or drain)
- Losing 200 - 300 mLs of blood an hr ⇒ needs to call to provider 🚩!!!
- Color
- Consistency
- For healing wound → should see less and less drainage over time
- For surgical wound → should see typical progression of drainage colors: bloody (sanguineous) → pink (serosanguineous) → yellow (serous) “clear” fluid
- For infected wounds → should see cloudy consistency, green drainage
46
Cellulitis Interventions
- Elevate extremity
- Mark skin w/ indelible ink pen to note progress
- Antibiotics
47
Interventions for Diabetic Foot Ulcers
- Trim toenails straight across and smooth out sharp edges w/ nail file !!!
- Check feet every day for cuts, redness, swelling, sores, blisters, corns, or calluses
- Never go barefoot, even indoors
- Don’t try to remove corns or calluses yourself
- Wash feet every day in warm (not hot) water and dry well
- Wear shoes that fit well and always wear socks
- Get feet checked at every healthcare visit + visit podiatrist at least once a yr
48
Types of Drains
- Penrose: empties right onto dressing
- Jackson Pratt (JP) & Hemovac Drain: suctions drainage out
- Wound Vac (Vacuum-assisted closure)/NPWT (Negative Pressure Wound Therapy): uses negative pressure to remove excess fluid, reduces swelling, and improves blood flow to wound
49
Critical thinking about blood loss
- Av adult has 5-6 liters of blood
- Losing about 15% is when the patient starts feeling the loss (150 mLs)
- Hundreds of mLs loss within an hour is concerning
- Losing 200 - 300 mLs of blood an hr ⇒ needs to call to provider 🚩!!!
50
Check order first !!!
Order should have…
- Reinforce only or change
- Frequency
- Drsg type to be used
- Cleaning solution to be used
51
Wound Cleaning vs Irrigation
- Cleansing: gentle removal of surface debris to prevent infection
- Irrigation: deeper cleaning to flush out slough and necrotic tissue w/ controlled pressure
52
Labeling and Monitoring: Specimen Collection
- Label at bedside
- Note exact wound location for multiple samples
- Monitor culture & sensitivity results to guide Tx
