skin integrity & wounds Flashcards
1
Q
what are pt risk factors for impaired tissue integrity?
A
- age
- maceration (extremely skinny)
- chronic illness
- skin tears
- frail skin
- pressure injuries
2
Q
what is a wound?
A
- any disruption in the composition of the skin
3
Q
what is a pressure injury?
A
- localized damage to skin / tissue from pressure or pressure & sheer over boney prominences
4
Q
what is blanchable erythema?
A
- when you press down on skin around the wound and the color goes away and then returns, same process of capillary refill
5
Q
what is non blanchable erythema?
A
- skin around the wound when it stays white when pressed
6
Q
when finding & inspecting a wound, what should the nurse look for?
A
- location, color, distribution, pattern edges, depth and size
- classify wound
- determine treatment
7
Q
what is an acute wound?
A
- something that happened on the surface immediately (unintentional)
- ex: bruise
8
Q
define a trumatic wound?
A
- messy, causes trauma to the skin
- ex: puncture wound
9
Q
what’s are the two categories of surgical wounds?
A
- clean and contaminated
- contaminated
10
Q
what’s a chronic wound?
A
- don’t heal the way we expect and are there for longer periods of time
- could have disease process
- could unable infected and unable to close
- long lasting
11
Q
why is it important to measure wounds?
A
- that’s a way to assess how its healing, if the measurement gets smaller
12
Q
how do nurses assess for tunneling?
A
- going around the edges of the wound and looking for a tunnel in the wound, that extends back further in some areas
13
Q
what are signs of an infected wound?
A
- looking for redness around the area & exudate
14
Q
what is serosanguinous drainage?
A
- blood tinged, thin
- normally w/ a new wound
15
Q
what is serous wound drainage ?
A
- yellow, blood tinged, straw color
- normally w/ a clean wound
16
Q
what is sanguineous would drainage?
A
- blood colored
- normally with a deep or highly venous wound
17
Q
what purulent drainage?
A
- infected wound
- white, green, yellow, and its thicker
18
Q
what is a Bradyen skin scale?
A
- risk assessment to assess for likelihood of pressure injuries
- Immobility (can PT turn themselves, can they walk, can they get out of bed)
- Malnutrition (more at risk for pressure injuries, VIT D & C more than anything)
- activity level
- Sensory loss (confused pt, delirium)
- Moisture level (more of a risk for pressure ulcers)
- Sheer level (how they could get sheers)
19
Q
what does a stage 1 pressure injury look like?
A
- non blanchable skin, red skin
- (turns white due to lack of perfusion)
20
Q
what does a stage 2 pressure ulcer look like?
A
- partial thickness skin loss, top layer of skin is gonew
21
Q
what does a stage 3 pressure ulcer look like?
A
- full thickness skin loss, deep
22
Q
what does a stage 4 pressure ulcer look like?
A
- full thickness skin & tissue loss = bones, muscles ect
23
Q
what makes a pressure ulcer unstagable?
A
- something is in the way and nurses cant see the extent of wound (due to what wessly had on his wound, black, necrotic eschar)
24
Q
what is undermining on a wound?
A
- skin is over the wound, but we can feel over the wound, we want to get underneath the area of undermining to properly treat the wound
25
how can nurses classify pressure injuries in dark sinned patients?
- Pay attention to skin temp & moisture in the wound
- Difficult to assess blanchable, look @ surrounding tissue
- Skin may appear taut, shiny or indurated
- Black / brown skinned ppl may be risk and assessment may be underrated
26
what is surgical debridement?
- start healthy tissue growing by removing old skin
27
what is irrgation?
- cleaning the wound with products, to promote healthy growth
28
what is biological debridment?
- chemical that helps clean and remove skin
29
what are some wound management interventions?
- Protect wound dressing
- Identify at risk clients: incontinent of pee, environment, ect
- Prevent and manage infection
- Client education
- Nutritional support
- Hydration
30
what are nursing interventions for healthy skin?
- Skin care = PH balanced soaps, use products to match the needs of client
- reposition every 2 hours, don’t have their bed more than 30 degrees
- put something under heels & other prominences
31
what is Dehiscence?
- wound healing complication
- partial or complete separation of tissue layers during healing process (cover open wound with sterile wound and call provider)
32
what is Evisceration?
- wound healing complication
- total separation of tissue layers, allowing the protrusion of viscera; organs through the incision
33
what is maceration?
- wound healing complication
- condition is which excessive moisture causes a softening of the skin
