T4: Skin integrity and wound care Flashcards
Use an __________ to flush the wound with a constant low-pressure flow of solution
irrigation syringe
irrigation cleans wound of __ and ____
exudate and debris
irrigation is particularly useful for
- open, deep wounds
- wounds involving an inaccessible body part such as the ear canal
- when cleaning sensitive body parts such as the conjunctival lining of the eye
Use ____ syringe with a ___ gauge soft angiocatheter for open wound irrigation
- 35 mL syringe
- 19 gauge
Never occlude a wound opening with a syringe because
this results in the introduction of irrigating fluid into a closed space
Major drawback of staging system is that
you cannot stage an injury when it is covered with necrotic tissue
Necrotic wound must be _______ to expose the wound base to allow for assessment
debrided or removed
intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin
stage 1 pressure injury
wound color change of purple or maroon discoloration indicate
deep tissue pressure injury
- partial-thickness skin loss with exposed dermis
- Wound bed is visible, pink or red, and moist and may also present as an intact or ruptured serum-filled blister
- Adipose tissue is not visible and deeper tissue is not visible
- Granulation tissue, slough, and eschar are not present
stage 2 pressure injury
stage 2 pressure injury commonly result from
adverse microclimate and shear over pelvis and heel
- Full-thickness skin loss
- Adipose tissue is visible
- Granulation tissue and epibole (rolled wound edges) are often present
- Slough and/or eschar may be visible
- Depth of tissue damage varies by anatomical location
- Undermining and tunneling may occur
- Fascia, muscle, tendon, ligament, cartilage, and/or bone are not exposed
Stage 3 pressure injury
- full thickness and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer
- Slough and/or eschar may be visible
- Epibole, undermining, and/or tunneling often occurs
stage 4 pressure injury
obscured full-thickness skin and tissue loss
unstageable pressure injury
If slough or eschar is removed on an unstageable pressure injury:
staging is possible
Stable eschar on heel or ischemic limb:
should not be softened or removed
intact or nonintact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration, or epidermal separation revealing a dark wound bed or blood-filled blister
deep tissue pressure injury
on deep tissue pressure injury, ______ and ______ often precede skin color changes
pain and temperature change
deep tissue pressure injury results from
intense/prolonged pressure and shear forces at the bone-muscle interface
deep tissue pressure injuries are not used to describe:
vascular, traumatic, neuropathic, or dermatologic conditions
occurs when the skin or underlying tissues are subjected to sustained pressure or shear from medical devices or equipment
Medical adhesive-related skin injury (MARSI)
MARSI occur because
Attachment between the skin and an adhesive is stronger than the skin cells, causing the surface epidermal to detach from the underlying layers
localized damage to the skin and underlying soft tissue, usually developing over a bony prominence or related to pressure from a medical device or other device
pressure injury
tolerance of soft tissue for pressure and shear can be affected by (5)
- microclimate
- nutrition
- perfusion
- comorbidities
- conditions of soft tissue
contributing factors of pressure injuries
- decreased mobility
- decreased sensory perception
- fecal/urinary incontinence
- poor nutrition
______ is the major element that causes pressure injuries
pressure
top down skin damage is caused by
superficial shear or friction
bottom-up skin damage is caused by
pressure intensity
pressure duration
tissue tolerance
minimal amount of pressure required to collapse a capillary
capillary closing pressure
pressure exceeds normal capillary pressure and the vessels occlude for a prolonged period
tissue ischemia
redness from an excess of blood in the vessels supplying a particular area
hyperemia
area appears red and warm and turns a lighter color with palpation
blanchable hyperemia
redness that persists after palpation, indicating tissue damage
nonblanchable hyperemia
sliding movement of skin and subcutaneous tissue while the underlying muscle and bone are stationary
shear
force of two surfaces moving across one another
friction
friction injuries affect the
epidermis
t/f: friction injuries are classified as a pressure injury
false
disruption of the integrity and function of tissues I the body
wound
two major types of wounds
open and closed
surface of skin remains intact, but the underlying tissues may be damaged
closed wound
skin is split, incised, or cracked, and the underlying tissues are exposed to the outside environment
open wound
classification of wounds based on onset and duration
acute vs chronic
proceeds through an orderly and timely reparative process that results in sustained restoration of anatomical and functional integrity
acute wound
wound that fails to proceed through an orderly and timely process to produce anatomical and functional integrity
chronic wound
cause of acute wound
trauma and/or surgical incision
cause of chronic wound
vascular compromise
chronic inflammation
repetitive insults to tissue
indications of acute wound
wound edges are clean and intact
indications of chronic wound
continued exposure to insult impedes wound healing
Primary intention of wound healing
approximated: wound is closed
cause of primary intention
hematoma, surgical incision that is sutured or stapled
indication of primary intention
healing occurs by epithelialization; heals quickly with minimal scar formation
wound edges not closed or approximated
secondary intention
cause of secondary intention
surgical wounds that have tissue loss or contamination
indication of secondary intention
wound heals by granulation tissue formation, wound contraction, and epithelialization
wound that is left open for several days; then wound edges are approximated
tertiary intention
cause of tertiary intention
wounds that are contaminated and require observation for signs of infection
indication of tertiary intention
closure of wound is delayed until risk of infection is resolved
partial loss of skin layers (epidermis and superficial dermal layers)
partial-thickness wounds
partial-thickness wounds loss heals by
regeneration
three components of regeneration
- inflammatory response
- epithelial proliferation
- reestablishment of the epidermal layer
in regeneration, inflammatory response occurs within:
first 24 hours
in regeneration, epithelial proliferation and migration starts at ______1_______
if kept moist, can resurface in __2___
if left open to air, can resurface within __3___
- starts at both the wound edges and the epidermal cell lining the epidermal appendages
- 4 days
- 6-7 days
total loss of skin layers (epidermis and dermis)
full-thickness wound
full-thickness wound heals by:
forming new tissue
4 phases of forming new tissue
- hemostasis
- inflammatory phase
- proliferation and new tissue formation
- remodeling and maturation
injured blood vessels constrict and platelets gather to stop bleeding
hemostasis
hemostasis is a physiological event designed to:
control blood loss, establish bacterial control, and seal the defect that occurs when there is an injury
hemostasis is impaired when patients are on ___1______ or have specific diseases that affect _____2_____
- anticoagulants
2. platelet production or blood clotting
damaged tissue and mast cells secrete histamine, resulting in vasodilation of surrounding capillaries, and movement or migration of serum and white blood cells into the damaged tissue
inflammatory phase of new tissue formation
inflammatory phase of new tissue formation results in
localized redness, edema, warmth, and throbbing
leukocytes reach wound within _____ during _______ phase
- few hours
- inflammatory phase
primary acting leukocytes
neutrophils
neutrophils function:
ingest bacteria and small debris
secondary acting leukocytes
monocytes
monocytes function
transform into macrophages that clean a wound of bacteria, dead cells, and debris by phagocytosis
macrophages release ______ that attract fibroblasts, which ______
growth factors
synthesize collagen
collagen appears as early as ________ during inflammatory phase and is the ______ component of scar tissue
- 2nd day
- main component
proliferation and new tissue formation begins _______ after injury and can last as long as _______
- 3-4 days
- 2 weeks
main activities of proliferation and new tissue formation
- Filling wound with granulation tissue
- Wound contraction
- Wound resurfacing by epithelialization
during proliferation and new tissue formation, collagen mixes with ______ to from a _____
- granulation tissue
- matrix
impairment of proliferation and new tissue formation results from
systemic factors such as age, anemia, hypoproteinemia, and zinc deficiency
the final stage of full-thickness wound healing, ____________, begins _______ after injury and continues for more than ______, depending on the depth and extent of the wound
- remodeling and maturation
- several weeks
- more than a year
removal of nonviable, necrotic tissue
debridement
complications of wound healing (4)
- hemmorhage
- infection
- dehiscence
- evisceration
partial or total separation of wound layers
dehiscence
total separation of wound layers
evisceration
Risk assessment for pressure injuries
braden scale
Braden scale for predicting pressure ulcer risk includes: (6)
- Ability to respond appropriately to pressure-related discomfort
- Degree to which skin is exposed to moisture
- Degree of physical activity
- Ability to change and control body position
- Usual food intake pattern
- Exposure to friction and shearing
nutrients in wound healing (6)
- calories
- protein
- vitamin C
- vitamin A
- zinc
- fluids
types of wound drainage (4)
- serous
- purulent
- serosanguineous
- sanguineous
wound drainage is clear, watery plasma
serous
wound drainage is thick, yellow, green, tan, or brown
purulent
wound drainage is pale, pink, watery; mixture of clear and red fluid
serosanguineous
wound drainage is bright red; indicates active bleeding
sanguineous
types of drains
- penrose
- Jackson-pratt
- hemovac
lies under a dressing; at the time of placement a pin or clip is placed through the drain to prevent it from slipping farther into the wound
Penrose drain
bulb at end of drainage tube that helps pull drainage from site
Jackson-pratt drain
larger, disk like container attached to end of drainage tube that helps pull drainage from site
hemovac drain
assessment of drains (4)
- number and type
- drain placement
- character of drainage
- condition of collecting equipment
application of subatomospheric pressure to a wound through suction toe facilitate healing and collect wound fluid
Negative-pressure wound therapy
Negative-pressure wound therapy supports wound healing by
removing wound exudates and reducing edema, macro-deformation and wound contraction, and micro-deformation and mechanical stretch perfusion
secondary effects of negative-pressure wound healing
- angiogenesis
- granulation tissue formation
- reduction in bacterial bioburden
indications of negative-pressure wound therapy (5)
- chronic, acute, traumatic, subacute, and dehisced wounds
- Partial-thickness burns
- Injuries
- Flaps and grafts once nonviable tissue is removed
- Select high-risk postoperative surgical incisions
wear time for dressing after negative-pressure wound therapy is anywhere from _____ to ______
24 hours to 5 days
contraindications of negative pressure wound therapy (7)
- Necrotic tissue with eschar present
- Untreated osteomyelitis
- Non-enteric and unexplored fistulas
- Malignancy in the wound
- Exposed vasculature
- Exposed nerves, anastomotic sites, or organs
- High risk for bleeding or hemorrhage
device that helps in wound closure by applying localized negative pressure to draw the edges of a wound together
Vacuum-assisted closure (VAC)
therapeutically beneficial in increasing muscle and ligament flexibility; promoting relaxation and healing; and relieving spasms, joint stiffness, and pain
moist heat application
moist heat application is most commonly used following
- acute phase of a musculoskeletal injury
- during and after childbirth surgery, and superficial thrombophlebitis
physiological response to moist heat application (5)
- Vasodilation
- Reduced blood viscosity
- Reduced muscle tension
- Increased tissue metabolism
- Increased capillary permeability
therapeutic benefits of moist heat application (6)
- Improves blood flow to injured body part
- Promotes delivery of nutrients and removal of waste
- Improves delivery of leukocytes and antibiotics to wound site
- Promotes muscle relaxation
- Reduces pain from spasm or stiffness
- Provides local warmth
__________ also used to reduce pain and increase healing by increasing blood flow in tissues and can be used at a low level for a longer period with little chance of tissue injury
dry heat
refers to the superficial application of cold to the surface of the skin, with or without compression and with or without a mechanical recirculating device to maintain cold temperatures
cold therapy
cold therapy is designed to treat
localized inflammatory response of an injured body part that presents as edema, hemorrhage, muscle spasm, or pain
cold therapy is most commonly used
immediately after soft tissue and musculoskeletal injuries such as sprains or strains
cold therapy has been used postoperatively with patients who have under gone: (3)
- orthopedic surgeries
- spinal fusion
- lumbar discectomy
physiological response to cold therapy (5)
- Vasoconstriction
- Local anesthesia
- Reduced cell metabolism
- Increased blood viscosity
- Decreased muscle tension
therapeutic effect of cold therapy (6)
- Reduces blood flow to injury site, preventing edema formation
- Reduces inflammation
- Reduces localized pain -Reduces oxygen needs of tissue
- Promotes blood coagulation at injury site -Relieves pain
conditions that increase risk of injury from heat and cold application (7)
- age (very young and very old)
- open wounds, broken skin, or stomas
- areas of edema or scar formation
- peripheral vascular disease
- confusion or unconsciousness
- spinal cord injury
- abscessed tooth or appendix
supports large abdominal incisions that are vulnerable to tension or stress as a patient moves or coughs
abdominal binder
extra protection and therapeutic benefits of abdominal binders (6)
- Creating pressure over a body part
- Immobilizing a body part
- Supporting a wound
- Reducing or preventing edema
- Securing a splint
- Securing dressing
abdominal binders allow patients to _______ sooner and reduce ________
- ambulate
- postoperative complications
