Skin, Integrity, Wound Care Flashcards
Intact skin with non-blanchable redness
“at risk” people
Discoloration of skin, warmth, edema, hardness, or p!
Stage 1 ulcer
i. surgical complication in which a wound rupture along a surgical incision
Dehiscence
Hydrogel, what stage to use?
2, 4
Full-thickness tissue loss with visible fat
Slough may be present
Bone/tendon is not directly palpable
Stage 3 ulcer
Hydrocolloid, what stage to use?
1, 2, 3
i. Not closed—fills with scar tissue
ii. Pressure ulcer, burns
iii. Longer healing time—more chance for infection
secondary intention
Combine physically distinct components into a single product to provide multiple functions such as a bacterial barrier
Composite
Intervention of wound care 5 things
a. Post and implement a turning schedule.
b. Obtain and place over the patient’s mattress a low-air-loss overlay.
c. Clean wound and periwound skin; dry periwound skin.
d. Apply a hydrocolloid dressing to the wound
e. Determine in collaboration with dietitian an appropriate diet.
Partial-thickness skin loss involving epidermis, dermis or both
Shallow, open ulcer with red-pink would bed WITHOUT slough
Could be open/ruptured serum-filled or serosanguineous-filled blister
Stage 2 ulcer
i. When surgical incision opens & the abdominal organs then protrude or come out of the incision
ii. EMERGENCY
Evisceration
bright red; indicates active bleeding
Deep wounds
Sanguineous
Factors influencing heat and cold tolerance (5)
- Exposure time
- Exposed skin
- Temperature
- Age
- Perception of sensory stimuli
Complications of wound healing (5)
Hemorrhage Infection (2nd most common) Dehiscence Evisceration Cultures
First aid for Wounds
Hemostasis (control bleeding) Bandage Cleaning Protection Dressing
Full-thickness tissue loss with exposed bone, muscle, or tendon
Stage 4 ulcer
Purposes of dressings (6)
- Protects from microorganisms
- Aids in hemostasis
- Promotes healing by absorbing drainage or debriding a wound
- Supports wound site
- Promotes thermal insulation
- Provides a moist environment
Two surfaces moving against each other
Happens on skin
“Sheet burn”
Friction
Appropriate support surface for stage 1 or 2 ulcer
foam
avoid HOB elevation
limit sitting to 3x per day of 60 min or less
Basic Skin cleaning (3)
- Clean from least contaminated to the surrounding skin
- Use gentle friction
- When irrigating, allow the solution to flow from the least to most contaminated area (circular rotations)
Risk factors for pressure ulcer development (6 things)
Impaired sensory perception impaired mobility Alteration in LOC Shear Friction Moisture
Effects of cold application
Vasoconstriction
Local anesthesia
Reduced cell metabolism & muscle tension
Increased BV
REEDA
Redness Edema Ecchymosis Discharge Approximation (are edges closed)
Wound irrigation, what is done?
a. Sterile technique
b. 35 mL syringe with 19-gauge soft Angiocatheter
c. Delivers safe pressure—doesn’t damage good healing tissue
d. Hold syringe 2.5 cm (1 in) about upper end of wound
Factors influencing pressure ulcer formation and wound healing (5)
Nutrition Tissue perfusion Infection Age Psychosocial impact of wounds
Happens beneath the skin
Sliding movement of skin while the underlying muscle & bone are stationary
Shear
Stage III ulcer treatment
Clean with:
Prescribed dressing
Surgical intervention
Proteolytic enzymes
Nutritional supplements
Analgesic
Antimicrobials (topical or systemic)
Keeps wound slightly moist, releasing water
hydrogel
i. Edges are approximated
ii. A surgical wound, that is closed (approximated)
primary intention
3 pressure related factors
- Pressure Intensity
- Tissue tolerance
- Pressure duration
pale, pink, watery; mixture of clear & red fluid
Most often seen
Serosanguineous
thick, yellow, green, tan, or brown
Purulent
Stage IV ulcer treatment
non adherent dressing change ever 12 hrs
Stage II ulcer treatment (4 things)
Maintain most healing environment
Natural healing while preventing scar tissue
Provide nutritional supplements
Analgesics
Black, brown, tan or necrotic tissue
eschar
Clear, watery plasma
Serous drainage
Appropriate support surface for stage 3, 4, unstageable ulcer
Avoid prolonged HOB elevation low-air loss alternating pressure air fluidized surface consider a wheelchair
Gauze, what stage to use?
3, 4 & unstageable
Transparent film, what stage to use?
1
Usually absorbent, waterproof, adheres to surrounding skin
Hydrocolloid
Effects of heat application
Vaso-
Reduced
Increased
Vasodilation
Reduced BV, muscle tension
Increased tissue metabolism & capillary permeability
Pressure Intensity
Tissue ischemia
blanching
COCA
- Color
- Odor
- Consistency
- Amount
Acute care–wound management (5)
- Debridement: the removal of damaged tissue or foreign objects from a wound
- Education
- Nutritional status
- Protein status
- Hemoglobin: oxygen needed for wound healing
