Skin/pain Flashcards
Why is protein so important for skin integrity?
It slows repair and preserves intravascular volume.
Vitamin C, zinc, and copper are important for the skin in what way?
They are involved in the formation and maintenance of collagen.
What is maceration of the skin?
When the skin seems pruney.
What is denuded skin?
When the skin is starting to breakdown. The epidermis is gone and the skin is now open.
What does a full thickness wound involve?
All of the layers into the subQ tissue.
What does a partial thickness wound involve?
Epidermis and part of the dermis.
What are the 4 wound tissue types and their characteristics?
Epithelialization -pink and DRY
Granulation - red and MOIST
Slough - yellow, rough, and stringy
Eschar - Black, full thickness tissue destruction however may still have pain, wet or dry, soft or hard.
What are the 4 wound healing processes?
Regeneration, primary intention, secondary intention, and tertiary intention. (The last 3 need more intervention)
What is tertiary intention wound healing?
The wound can’t initially be sutured. We have to wait for granulation tissue to fill it up and then we can suture. Most commonly seen when there is an infection s/p surgery.
What kind of wound healing will we see in pressure injuries?
Secondary intention
What are the 3 phases of wound healing?
Inflammatory-cleansing
proliferative- granulation
maturation- epithelialization
What are the 5 types of wound drainage?
Serous, sanguineous, serosanguinous, purulent, purosanguineous exudate.
What are 5 possible complications of wounds?
Dehiscence, fistula, infection, hemorrhage, evisceration.
What are some nursing interventions for wounds?
Irrigating, debridement, caring for drainage device, and dressing.
What are the characteristics of stage 1 PU?
- skin intact
- non blanchable
- possibly painful
- different from adjacent skin
What are the characteristics of a stage 2 PU?
Partial thickness
Skin not intact b/c Blistering means that there is separation within the layers.
Characteristics of a stage 3 PU?
Full thickness SubQ fat may be visible Underlying structures not exposed Slough present May include undermining and tunneling
What is undermining?
Tissue destruction along wound margins
What is tunneling?
Destruction extends from wound base into tissue
Characteristics of stage IV PU?
Full thickness
Exposed underlying structures
Undermining and tunneling
Slough or Eschar
What is an unstageable PU?
When we are unable to see the wound base either by slough or Eschar. Full thickness tissue loss.
What is a sDTI?
Suspected deep tissue injury that is characterized by bruising skin, it’s intact but may have blood blisters.
What is the Braden scale?
It assesses the risk of developing a PU. The lower the number the higher the risk. Anyone who scores 18 or below is at risk for pressure ulcers.
What are nursing interventions for pressure injuries?
Manage moisture, monitor for 8-12 hours, dressings based on orders, turn and reposition to minimize pressure, optimize nutrition. Patient teaching.
How often should you turn a patient in bed?
Every 2 hours
How often should you reposition a patient in a chair?
Every 15 min
What is visceral pain?
Coming from organs
What is deep somatic pain?
When the pain is deeper than superficial structures like tendons, bone, or joints.
How long is considered chronic pain?
3-6 months
What is intractable pain?
Unable to get any relief
What are some nonverbal signs of pain?
Facial expressions Changes in vital signs Behavioral manifestations Complaining of pain as bad or weak Assess for depression
What are some guidelines for pain therapy?
- use different types of pain relief measures.
- provide relief measures before severe pain.
- use measures patient believes are effective.
- Match measures with paint severity.
- allow sufficient trial.
- keep an open mind.
- keep trying.
- protect the patient.
- provide information/education.
What are seven addictive disease management strategies?
- identify history of substance abuse
- discussed pain management plan
- involve patient
- provide baseline opioid requirement
- larger opioid doses likely needed
- not feasible to “manage” addiction
- seek specialist consult or referrals
What is excoriation?
Secondary crusting lesions after scratching ( like in chicken pox)
What is regeneration wound healing?
The epithelialization stage
What is wound dehiscence?
Usually a surgical complication in which the wound ruptures d/t staples coming out and tissue starts to be exposed
What is a fistula?
An abnormal passage between a hollow or tubular organ
What are 3 types of drainage devices?
Jackson Pratt, hemovac, and penrose.
What is an example if biotherapy?
Using maggots to debried a wound
What is enzymatic debriedment?
Enzymes are used to facilitate the removal of dead tissue from a wound
What is autolytic debriedment?
Applying a moisture retentive dressing so that the body uses its own wound fluids for healing.
Hydrocolloid dressing is an example
What is the difference between a JP drain and hemovac?
A JP drains smaller amounts of fluid and hemovac can also drain blood to give back to the patient. They both use pressure to pull fluids out.
What are 6 nursing interventions for pressure injuries?
- Monitor pressure injuries for 8-12 hours
- manage moisture
- apply dressing based on orders or protocol
- minimize pressure by turning and repositioning
- optimize nutrition and hydration
- patient teaching
What are 6 factors shaping pain experience?
- emotions
- previous pain experiences
- developmental stage
- sociocultural factors
- communication skills
- cognitive impairments
What is a common bias that people have about pain?
Patients who fall asleep do not have pain.
What are biases and common misconceptions about pain? (10)
1) knowledge about opioids = drug seeker
2) No reason for pain if no physical cause
3) regularly administered analgesics leads to tolerance
4) amount of tissue damage indicates pain intensity
5) healthcare workers are the best judge of pain
6) pain threshold & tolerance is the same for everyone
7) pain is part of growing old
8) pain perception/sensitivity decrease with age
9) physical/behavioral signs verify pain existence/ severity
10) patients who fall asleep do not have pain
What are 7 non pharmacological measures to treat pain?
1) therapeutic alliance with the pt (set expectations)
2) positioning
3) heat and cold therapy
4) range of motion to exercises
5) massage, relaxation, acupressure and energy based therapies
6) distraction therapy (chatting)
7) prayer
What are 3 things we need to balance in a patient that had pain but also an addictive disease?
Pain relief, inappropriate use, and risk of relapse
What are 7 management strategies that you should use when treating a patient with an addictive disease?
1) identify hx of substance abuse
2) discuss pain management plan
3) involve patient
4) provide baseline opioid treatment
5) larger opioid doses likely needed
6) not feasible to “manage” addiction
7) seek specialist consult or referrals
What is referred pain?
Pain somewhere else in the body associated with visceral pain.
What is radiating pain?
Pain in a different area proximal to the initial pain. Hip pain radiating down to the leg.
