Skin Integrity & Wound Care Flashcards
tool used to predict pressure sore risk used in conjuction with nursing judgment…low score= high risk…15-18 low risk, 13-14 moderate risk, 10-12 high risk, <9 very high risk
Braden Scale
removal of necrotic tissue
Debridement
partial or total separation of layers of skin and tissue above the fascia in a wound that is not healing properly (obese pt at high risk, most common in abdominal wounds post-surgery)…BE ALERT WHEN SEROSANGUINEOUS DRAINAGE INCREASES!
Dehiscence
thick layer of dead, dry tissue that covers a pressure ulcer or thermal burn; slough present in stage IV ulcers (may be allowed to naturally remove or may be surgically removed)
Eschar
occurs when wound layers separate below the fascial layer and visceral organs protrude through the wound opening…medical emergency requiring placement of sterile towels soacked in sterile saline over the extruding tissues to reduce chances of bacterial invasion & drying before surgery
Evisceration
surface damage caused by the skin rubbing against another surface that often results in an abrasion
Friction
red, moist tissue consisting of blood vessels and connective tissue
Granulation Tissue
softening of the skin caused by moisture
Maceration
impaired skin integrity resulting from pressure
Pressure Ulcer
force exerted against the skin while the skin remains stationary and the bony structures move
Shearing Force
healing that occurs in a wound with little or no tissue loss such as a clean surgical incision; the skin edges approximate and risk for infection is minimal
Primary Intention
healing that occurs in wounds involving loss of tissue such as a severe laceration or chronic wound; skin edges cannot come together because of the extensive tissue loss and healing occurs gradually
Secondary Intention
healing that occurs when a wound is later brought together some type of closure material; occurs in wounds that are fairly deep and contain extensive draining & tissue debris; “delayed primary healing”
Tertiary Intention
sensitive vascular layer of skin directly below the epidermis composed of collagenous and elastic fibrous connective tissues that give it it’s strength and elasticity
Dermis
fluid, cells or other substances that have been slowly discharged from cells or blood vessels through small pores or breaks in cell membranes
Exudate
clear, watery plasma drainage
Serous Drainage
fresh bleeding drainage
Sanguinous Exudate
pale, more watery, combination of plasma and red blood cells, blood-streaked drainage
Serosanguinous Exudate
thick, yellow/green/brown drainage indicating presence of dead or living organisms and white blood cells
Purulent Exudate
act of forming pus
Suppuration
closing together of wound edges in which an injury has been caused on the skin by abrasion
Approximated Excoriation
occurs when epithelial tissue grows from edges and covers over the granulation (new skin/scar)
Epithelialization
abnormal passage from an internal organ to the body surface or between two internal organs
Fistula
decreased blood supply to a body part, such as skin tissue, or to an organ, such as the heart
Ischemia
the death of tissue in response to disease or injury
Necrosis
discoloration of the ski nor bruise caused by leakage of blood into subcutaneous tissues as a result of trauma to underlying tissues
Ecchymosis
present in Stage IV ulcers…a narrow canal underneath surface
Tunneling/Undermining
abdominal binder used to support large incisions that are vulnerable to stress when the patient moves or coughs
Montgomery Straps
the process of drying up
Desiccation
pressure sore/ ulcer
Decubitus
a soft tube placed in an operative site connected to a small, compressed, plastic bulb to drain blood & inflammatory fluid
Jackson-Pratt Drain
a thin-walled rubber tubular drain made in various widths for use in surgery
Penrose Drain
reaction phase of wound healing that begins within minutes of injury and lasts 3-6 days; characterized by vasoconstriction then dilation & slight fever (<101)
Inflammatory Phase of Wound Healing
phase of wound healing that starts on day 21 and can last long periods of time in which collagen scars gain strength, resume normal appearance becoming smaller, flatter, whiter; can take months-years to complete
Maturation/Remodeling Phase of Wound Healing
phase of wound healing that starts around day 3 and lasts until day 21 in which macrophages are clear of debris and new blood vessels appear; granulation fills wound and then topped with epithelilization; pink, raised scar forms
Proliferative Phase of Wound Healing
redness and edema are the first response, bringing WBC to the site (wound appears red & swollen), a scab forms when WBC dry; this response is limited and subsides in less than 24 hours
Inflammatory Response
injury precipitates release of chemicals; complement and blood-clotting systems; activates inflammatory process
Stage 1 of Inflammatory Process
stage characterized by erythema (increased blood flow to the area), redness, and increased warmth
Stage 2 of Inflammatory Process
stage characterized by capillary permeability with leakage of large quantities of plasma into damaged tissues and non-pitting edema; infection walled-off
Stage 3 of Inflammatory Process
stage in which damaged tissue is invaded by leukocytes that engulf bacteria and necrotic tissue; purulent exudate (pus) produced
Stage 4 of Inflammatory Process
stage in which destroyed tissue cells are replaced by identical cells which promotes healing and formation of scar tissue; functional capacity of tissue may be reduced
Stage 5 of Inflammatory Process
water-loving colloids applied to draining wound that forms gel to provide moisture for wound healing; has limited absorption; not adequate for large amts of exudate
Hydrocolloids
used with primary dressing to prevent dehydration of wound base; can be used on infected wounds
Foam
used for wounds with large amts of exudate; conforms to size/shape of base; must be irrigated to remove; not used in wounds with tunneling or sinus tracts
Absorption Dressing
semi-permeable first dressings used to promote moist wound healing; water vapor passes through reducing periwound maceration; non-absorptive so drainage accumulates
Transparent Dressing
soft, non-woven fibers made from seaweed, sodium & calcium acids that turns into non-adhesive gel when in contact with exudate; highly absorbent so will dry out wound bed; easy to irrigate out of wound; non-toxic; can control minor bleeding
Calcium Alginates
dressing with cooling effect that enhances epithilization without reinjuring tissue and does not adhere to wound base; softens slough and necrosis; can be used on infected wounds; can macerate periwound skin
Hydrogels
4x4’s and roller gauze made of woven & non-woven fibers (cotton, rayon, polyester, combination); fine mesh gauze used in packing; coarse mesh used in debridement dressings; synthetic more absorbent than cotton; may be impregnated with wound products to promote healing
Gauze Dressings
Factors that Affect Wound Healing
age, mobility, nutrition, hydration, diminished sensation, impaired circulation, medications, moisture on skin, fever, lifestyle
vasodilation, reduced blood viscosity, reduced muscle tension, increased tissue metabolism, increased capillary permeability
Physiological Responses to Heat Therapy
vasoconstriction, local anesthesia, reduced cell metabolism, increased blood viscosity, decreased muscle tension
Physiological Response to Cold Therapy
Conditions Treated with Heat Therapy
arthritis, joint pain, muscle strains, low back pain, menstrual cramping, hemorrhoidal, perianal, vaginal, local abscesses
Conditions Treated with Cold Therapy
direct trauma, superficial laceration or puncture, minor burn, after injections, arthritis, joint trauma
Conditions that Increase Risk for Injury from Heat/Cold Therapy
very young or old; open wounds; edema or scar formation; peripheral vascular disease; confusion or unconsciousness; spinal cord injury
stage of ulcer characterized by nonblanchable erythema of intact skin where only the epidermis is involved; it is refeversible if the pressure is removed; TREATMENT: RELIEVE PRESSURE
Stage I Pressure Ulcer
stage of ulcer characterized by partial-thickness skin loss involving epidermis and/or dermis; superficial skin tears; presents as abrasion, blister or shallow crater; may be swollen and painful; TREATMENT: MOIST HEALING ENVIRONMENT (SALINE OR OCCLUSIVE DRESSING)
Stage II Ulcer
stage of ulcer characterized by full-thickness skin loss with damage or necrosis of subcutaneous tissue that may extend to but not through the underlying fascia; presents as deep crater with or without underminding; may have foul-smelling drainage; TREATMENT: DEBRIDE WITH WET-TO-DRY, SURGERY, ENZYMES
Stage III Ulcer
stage of ulcer characterized by full-thickness skin loss with extensive destruction, tissue necrosis or damage to to muscle, bone or supporting structures with undermining possible present; TREATMENT: NON-ADHERENT DRESSINGS, SKIN GRAFTS
Stage IV Ulcer
localized area of purple/maroon discoloration; intact skin or blood blister due to damage of underlying soft tissue from pressure/shear; painful, mushy, boggy, warm/cool in comparison to adjacent tissue
Deep Tissue Injury
ulcer in which the base is covered in slough and/or eschar and therefore, cannot visually be graded or staged
Unstageable Ulcer
Changes in Skin Associated with Aging
decreased tears/blink reflex, drying of oral mucosa, thinning of skin, decreased oil production, decreased body mass
