SKIN Wound Flashcards
Function of skin
- Protection (melanin and sebum)
- Thermoregulation (sweating, vasodilation, vasoconstriction)
- Sensation (touch)
- Metabolism (synthesis of vit D)
- Communication (nonverbal language)
Skin Changes Newborn/ Infant
- Reduced ability to thermoreg
- more susceptible to rashes, chafing, blistering
Skin changes toddler/ preschool
- sunscreen
- playing causes injuries
School age/ adolescent skin changes
- lice, scabies, impetigo
- acne
- sunscreen
Adult and older adult skin changes
- dry skin more common
- wrinkling and poor skin turgor
- slower healing
What can damage skin?
Surgery, burns, mechanical force, cancer causes abnormal growth, health-related (nutrition, circulation, allergy or infection, abnormal growth rate), pressure ulcers (mech friction and shear)
Acute wound
injury such as knife, gunshot, burn or incision heals within 6 mos
Chronic wound
Wound that persists beyond usual healing time (> 6mo) or recurs without new injury to the area
Open wound
Break present in the skin; tissue damage present
Closed wound
No break in skin is seen but soft tissue damage is evident
Clean surgical wound
closed surgical wound that did not enter Gi, resp, genitourinary systems; low infection risk
Clean/ contaminated
wound entering gi, resp, or genitourinary systems; infection risk
Contaminated
open, traumatic wound; surgical wound with break in asepsis; high infection risk
Infected
Wound site with pathogen present; signs of infection
What is pressure?
Localized damage to the skin or underlying tissue, usually over a bony prominence as a result of pressure, or pressure in combination with shear
-heels, sacrum, elbows
Stage 1 pressure ulcer
- skin is intact
- nonblanchable redness
- May be painful or have diff feel to the rest of the skin
- temp sensation
Stage 2 pressure ulcer
- Shallow open ulcer with a pink wound bed
- partial- thickness loss of dermis
- skin tears, tape burns, maceration, excoriation with no sloughing
Stage 3 pressure ulcer
Full thickness tissue loss
- May have slough
- bone,tendon, and muscle not exposed
- undermining and tunneling may be present
Stage 4 pressure ulcer
- exposed bone, tendon, or muscle
- slough and eschar may be present
- tunneling and undermining
tunneling/ undermining
tunneling: narrow passageway in soft tissue of an open wound
undermining: area of tissue destruction under the edge of wound opening
Unstageable pressure ulcer
- Unstageable means that the wound cannot be visualized
- the base is covered with slough or eschar
Pressure ulcer screening
- Braden scale
- numerical tool that calculates a patient’s risk for developing pressure ulcers
Measures to prevent pressure ulcers
- turn every 2 hours
- lift rather than drag patients when pulling up in the bed
- specialty mattresses: air in mattress circulates to keep in flat to distribute pressure evenly
- Specialty beds: combine bed with specialty mattress. Can feel almost like a waterbed to prevent pressure
- Nursing: Protective creams or lotions, zinc, petroleum
Primary lesions
May arise from previously normal skin
-Macule, papule, patch, plaque, nodule, wheal, vesicle, bulla, pustule
Secondary lesions
Result form changes in primary lesions
-Erosion, crust, ulcer, scale, fissure
Hemostasis (immediate) phase
- Vasoconstriction, platelet aggregation, clot formation
Inflammatory phase
- Up to day 3
- vasodilation
- phagocytosis
Proliferative phase
Partial thickness (day 4-day 21) -epithelialization
Full thickness ( day 4- day 21)
- Granulation tissue
- Contracture
Maturation phase
(21 days - 2 years)
-Full-thickness only (brownish- yellowish)
Primary intention
- clear incision
- early suture
- Hairline scar
Secondary intention
- gaping irregular wound
- granulation
- epithelium grows over scar
Tertiary intention
- wound
- granulation
- closure with wide scar
Measures to keep wound edges close together
- Binder
- Steri-strips: adhesive strip to hold edges together
- Sutures, staples, and clips: thread or metal that holds edges together
- Cyanoacrylate Glue: parts of the body that do not experience tension or stretching
- Elastic wraps, bandages, and stretch netting: apply distal to proximal, ensure it is not too tight, check distal circulation
Complications that can occur
- hemorrhage or hematoma
- infection: purulent drainage, inflamed incisional area, fever, elevated leukocyte count
- Dehiscence: partial or total disruption, wound opens up
evisceration: protrusion of viscera through wound opening - Inside body stuff goes outside
Fistula: passage btwn 2 areas that do not normally connect. name= location
Wound assessment?
- Type, size, location, classification, and base
- Drainage
- Undermining and tunneling
- infection or pain
- if connected to a drain, measure output and ensure it works
Sanguineous
bloody
Serosanguineous
pale- pink yellow
Serous
clear yellow watery
Drain types
Penrose: tube placed in wound no suction
Hemovac: suction present, bloody cavity
Jackson-Pratt: gentle suction when bulb compressed
A wound is present who should assess it?
- Wound ostomy continence nurse (WOCN)
- Specialist in wound care who will assess the wound and come up with a specific dressing change for it
- If it is a surgical wound : only surgeon removes the dressing, the surgeon will write orders on how to do the dressing change, follow that order
Alginate Dressing
- Absorption for draining wounds
Collagens
- Partial and full-thickness
Composites
-Use multiple products
Foams
- Hydrophillic polyurethane
- Partial and full-thickness with small to moderate drainage
Hydrocolloids
Water-resistant gel-like wafer dressing
Hydrofiber
Sodium carboxymethylcellulose
-very absorptive
Hydrogels
Assist in autolytic debridement of necrotic tissue in full-thickness wound
Nonadherent dressings
Minimize disruption of new cells
Silver dressings
Antimicrobial for infected wounds
-bacteria
Transparent films
Cover the wound but see it
What dressings need an order?
All but transparent dressings
How often is a dressing changed?
Determined by wound status, type of dressing, amt of drainage, freq of wound assessment.
What supplies are needed?
clean and sterile gloves, tape, syringe with saline flush
Does it involve cleaning or irrigation
mainly saline irrigation
When do you pack and fill a wound?
when tunneling or undermining is present
Neg-pressure wound therapy
Hydrophobic sponge dressing fills a wound cavity
- Cover with transparent dressing
- Connect to a machine that provides negative pressure
Surgical Debridement
- Not done by nurses
- Use of sharp tools to remove debris
Enzymatic Debridement
-Place chemical product on wound to break down debris
Autolytic
Occlusive or hydrogel
- debris gets eroded then irrigated out with saline
- eschar will be affected by hydrogel
Mechanical
Wet-dry dressing
- saline sock gauze pulls exudate
- exudate comes out
Heat: Promote healing and suppuration (consolidation of pus)
Results in vasodilation leading to increased blood flow, thus increasing oxygen and nutrients to the area and promoting removal of waste products.
Heat: Decrease inflammation by accelerating inflammatory process
Increases capillary wall permeability, increases leukocyte and antibody flow to area, and promotes action of phagocytes
Heat: Decrease musculoskeletal discomfort
increases sensory nerve conduction, promotes muscle relaxation, and decreases viscosity of synovial fluid
Cold: controls bleeding
Results in vasoconstriction, decreases blood flow, decreases metabolic tissue demands and the supply of oxygen and nutrients
Cold: Decreases edema
Decreases capillary permeability; cause vasoconstriction
Cold: Relieves Pain
Decreases nerve conduction velocity; induces numbness or paresthesia
Acute sudden pain that may indicate abscessed tooth or appendicitis
- Application of heat may cause rupture and spread a systemic infection
Broken skin or deep open wounds
subq and visceral tissues are more sensitive to extreme temps
Circualtory impairment
cold application constricts, thus decreasing circulation. heat does not disspate well from comprimse areas increasing tissue damage .
Sensory deficits
alterations in nerve conduction limit the sensation of temp or pain incresing the likehood of tissue damage
Mental status impairment
decreased reliability of reporting pain and altered sensation
Age extreme
Young children can not properly thermoregulate and cannot communicate pain or discomfort or alter their enviornment. Elderly may have reduced sensation to pain and often have other impairment that compounds risk. Heat should not be applied to abdomen of a pregnant woman because of fetal growth.
Metallic implants
Metal is a good conductor of heat thus increasing the potential for burns since implants cannot be readily removed
What diet promotes optimal wound healing
Protien, vit A,C,E, zinc, water, arginine, carbs, fats
Meds that are problematic with wound healing
Anticoagulants- increase potential for bleeding
Corticosteroids- reduced body’s ability to fight infection
What lifestyle choice decreases fxn hemoglobin, causes vasoconstriction, and impairs tissue oxygenation
smoking
