Skin Integrity & Wound Care Flashcards
This is the largest organ of the body and protects the body from injury =
Skin
How do you assess a wound using your senses?
Sight:
Assess Location + Size Shape + Color + Exudate + Bleeding Necrosis
Feel:
Textural Changes
Smell:
Can tell about the presence of infectious organisms
What are all of the important things to assess about a wound?
Location
Measure length, width, and depth in centimeters
Any odor?
Describe drainage
Stage the ulcer
Describe surrounding tissue
Undermining or sinus tracts?
Describe wound bed tissue
Any clinical signs of infection?
What is Serous Exudate like?
Clear, Watery Serum
What is Purulent Exudate like?
Thick Yellow, Green, Tan, or Brown
What is Sanguineous Exudate like?
Bright Red
What is Serosanguineous Exudate like?
Pale, Red, Watery
What is Purosanguineous Exudate like?
Pus & Blood
What do you do for a Red wound?
Protect & Cover
What do you do for a Yellow wound?
Cleanse
What do you do for a Black wound?
Debride
What does the color of an open wound determine?
It determines the treatment
What do you do if there is more than one color present on a wound?
Treat the most serious first. Black, then Yellow, then Red.
Does the depth or size determine what kind’ve treatment you’d give for a wound?
No, just the color
Most common site for pressure ulcers =
Sacral Area
What is a Pressure Ulcer?
Localized injury to the skin and/or underlying tissue, caused by force or a combination of force and movement over bony prominences
Most Pressure Ulcers are-
Preventable + Heal by secondary intention
How many recognized stages of Pressure Ulcers are there?
4
How do Stage 3 and Stage 4 Pressure Ulcers heal?
By filling in with scar tissue (Not new dermis and subcutaneous tissue)
What is Granulation?
Scar Tissue
A stage 4 Pressure Ulcer is healing nicely. Can it be downgraded to a Grade 3 after a month passes?
No, Pressure Ulcers can not be downgraded
As a Stage 4 Pressure Ulcer heals, what should it be referred to as?
A healing / healed Stage 4 Pressure Ulcer (Because they can’t be downgraded)
What is a Stage 1 Pressure Ulcer like?
No tissue loss, but non-blanchable red skin over a bony prominence
Pressure ulcer with a loss of Epidermis tissue and possibly Dermis tissue =
Stage 2 Pressure Ulcer
Pressure ulcer with a loss of Epidermis, Dermis, and Hypodermis Tissue =
Stage 3 Pressure Ulcer
Full-thickness skin loss involving muscle, bone, or other supporting structures such as tendons or joint capsules. Undermining and sinus tracts may be present also =
Stage 4 Pressure Ulcer
Subcutaneous Tissue is the same thing as-
Hypodermis Tissue
A stage 2 pressure ulcer may be present as-
An Abrasion, a Blister, or a Very Shallow Crater
You have a pt with a pressure ulcer that you can’t visually see the wound bed and the depth is unknown. What would you call this pressure ulcer?
An Unstageable Pressure Ulcer
What can make a Pressure Ulcer Unstageable?
Full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar on the wound bed
What is Slough?
Yellow, Tan, Gray, Green, or Brown (Dead Tissue)
What is Eschar?
Tan, Brown, or Black (Dead Tissue)
Necrotic Tissue means the same thing as-
Dead Tissue
What are the 3 phases of wound healing?
Inflammatory Phase
Proliferative Phase
Maturation (Remodeling) Phase
This phase starts immediately after injury =
Inflammatory Phase
How long does the Inflammatory Phase last?
3-6 Days
What are the 2 processes that occur during the Inflammatory Phase?
Hemostasis
Phagocytosis
Hemostasis =
The mechanism that leads to cessation of bleeding from a blood vessel
Phagocytosis =
Cells ingesting and eliminating other cells
Granulation =
Scarring
What’s the second phase of wound healing called?
Proliferative Phase
What does the Proliferative Phase of wound healing start?
Begins 3-4 days after injury, lasts until 21 days post-injury
What are the processes that occur during Proliferative Phase?
Granulation
Epithelialization
Epithelialization =
The formulation of epithelial tissue covering an injury
What’s the last phase of wound healing?
The Maturation Phase
When does the Maturation Phase start? When does it end?
Starts from about day 21, lasts 1-2 years post surgery
What process occurs during the Maturation Phase?
The continued synthesis of Collagen
What intrinsic factors affect wound healing?
Age (Kids heal faster, elderly heal slower)
Chronic Illness
Altered Sensation
What extrinsic factors affect wound healing?
Meds, Chemotherapy, Stress, Illness, Diet
What does the type of dressing for a wound depend on?
Location, size, and type of wound
Amount of exudate
Wound require debridement?
Wound infected?
Frequency of dressing change
Ease or difficulty of dressing application
Cost
Why do we Irrigate a wound?
To remove debris, excess slough, necrotic tissue, bacteria, and other microbes
To irrigate a wound, you should use a piston syringe with pressures of-
4-15 Pounds Per Square Inch (psi)
How many psi can a 30-60 mL syringe with 19 G needles provide?
8 psi
Can you delegate a wound irrigation to a UAP?
Nah
What are the 4 types of Debridement?
Sharp Debridement / Surgical Debridement
Mechanical Debridement
Chemical Debridement
Autolytic Debridement
Using a Scalpel or Scissors for Debridement is an example of-
Sharp Debridement / Surgical Debridement
Using a Scrubbing or Wet-To-Dry Dressing for Debridement is an example of-
Mechanical Debridement
Using an Enzyme Agent for Debridement is an example of-
Chemical Debridement
Using the body’s own enzymes to break down Necrosis for Debridement is an example of-
Autolytic Debridement
What is done for Negative Wound Therapy?
Sterile foam sponges placed in clean wound
Covered with transparent occlusive drape
Hole cut in drape to insert vacuum tubing
Negative pressure applied
What can be done to prevent a Pressure Ulcer?
Nutrition
Good skin hygiene
Bathe
Lotion
Avoid skin trauma
Proper lifting & turning
Wrinkle free sheets
Provide Supportive devices
Turn & reposition frequently
Pressure reduction devices
Used to identify clients at risk for pressure ulcer development =
Braden Scale
How many subscales does the Braden Scale consist of?
6
What are the subscales that the Braden Scale consists of?
Sensory Perception
Moisture
Activity
Mobility
Nutrition
Friction & Shear
What score is a severe risk on the Braden Scale?
9
What score is a high risk on the Braden Scale?
10-12
What score is a moderate risk on the Braden Scale?
13-14
What score is a mild risk on the Braden Scale?
15-18
What lab data can be used to assess wound progression?
WBC Count + Hemoglobin + Platelet Count + Serum Protein + Albumin + Wound Cultures + Sensitivity Reports
Decreased WBC’s =
Delayed wound healing + more risk of infection
Low hemoglobin =
Less oxygen being delivered to tissues, delayed wound healing
Low Platelet count =
Not enough coagulation, excessive bleeding, prolonged clot absorption
What can a serum protein analysis provide?
An indication of the body’s nutritional reserves for rebuilding cells
Low serum protein =
Less rebuilding cells, delayed wound healing
Low albumin =
Indicates that the pt’s nutrition is bad.
Decreased wound healing time + more risk of infection
A wound culture can analyze the presence of -
An Infection
Sensitivity reports can indicate-
Which antibiotic is appropriate for healing
Can you delegate obtaining a Wound Culture to a UAP?
Nope
What do you need to do 30 minutes prior to obtaining a wound culture?
Administer Analgesics
Aside from administering analgesics, what else do you need to do prior to obtaining a wound culture?
Cleanse the wound, determine if the wound culture is anaerobic or aerobic
How do you obtain a wound culture?
Obtain by rotating swab back & forth over clean granulated wound tissue
What is Debridement?
The removal of necrotic tissue or foreign tissue from a wound
