Week 3 Skin Integrity Flashcards
What are some of the factors that affect skin integrity, specifically diminished sensation?
Why is it so important to pay attention to
- peripheral vascular disease
- spinal cord injury
- diabetes, stroke
- trauma or fractures
These make them vulnerable
What are some of the factors that can impair cognition and ultimately affect skin integrity
- Alzheimer’s disease
- dementia
- altered level of consciousness
What is maceration
wrinkly toes and fingers after being in water too long
What does denuded mean
skin breakdown (diaper rash on babies)
What are some lifestyle habits that can affect skin integrity
- cigarette smoking
- tanning salons
- piercings and tattoos
What are the two types of wounds?
Give examples of each
Open wound: lacerations, abrasions (breakdown in tissues)
Closed wounds; contusions, bruises (no breakdown in tissues)
What is an example of excoriation
scratching at chicken pox which pops the vesicle
What are the characteristics of an arterial ulcer
- appears punched out
- pale wound base
- shiny, thin, and dry surrounding tissue
- very painful
Is an arterial ulcer considered acute or chronic
chronic
Where are arterial ulcers commonly found
ankles, toes, side of foot
Where are venous stasis ulcers commonly found
inner ankle, lower part of calf
What are the characteristics of a venous stasis ulcer
- shallow with irregular wound margins
- ruddy or beefy red wound base
- red/brown and edematous surrounding tissue
- moderate to heavy drainage
- painful when dependent or with dressing change
Where do diabetic foot ulcers typically occur
plantar surfaces (ball of foot, heel, toes)
What are the characteristics of a diabetic foot ulcer
- drainage, swelling, redness
- painless
- highly susceptible to infection
What are the 4 wound tissue types
Explain the characteristics of each
- epithelization - pink and dry
- granulation - red and moist (good thing)
- slough - yellow
- eschar - black
What are some of the characteristics of slough
- yellow
- liquefying and separating necrotic tissue
- rough and stringy texture
- must be debrided
What is necrotic tissue
dead or avascular or devitalized tissue
What are the characteristics of eschar
- black or brown
- soft or hard
- wet or dry
- full thickness tissue destruction
- black sheets, not just small patches
- need to be surgically removed
- whatever is underneath is likely full thickness
What are the 4 wound healing processes. Explain each
- regeneration: very superficial; heals on its own
- primary intention: typically seen with surgery
- secondary intention: wound w/ more width and depth
- tertiary intention: combination of primary and secondary
Which type of healing will include granulation
secondary and tertiary intention
What are the 3 phases of wound healing found in the book. what happens during each
- inflammatory phase - cleansing
- proliferative phase - granulation
- maturation phase: epithelialization
State and explain the 5 types of wound drainage
- serous: clear
- sanguineous: bloody
- serosanguinous: mix of bloody and clear
- purulent: yellow, contains pus
- purosanguineous: contains blood and pus
What are some of the complications of wounds
explain each
- hemorrhage
- infection
- dehiscence: sutures have burst
- evisceration: protruding organs, particularly with abdominal surgery
- fistula: can be anywhere in the body; a pathway that has occurred between tissues and creates opening to skin
Which 2 complications of wounds are likely to occur with any surgical wound
hemorrhage and infection
What are some of the nursing diagnoses that we can use for skin integrity
- risk for surgical site infection
- risk for infection
- impaired skin integrity
- risk for impaired skin integrity
- impaired tissue integrity
- risk for pressure injury
What are some of the nursing interventions related to wound care
- cleansing or irrigating
- caring for drainage devices (JP drain, hemovac, penrose)
List and explain the different methods of wound debridement
- sharp - surgical (should be under anesthesia)
- mechanical - wet to dry
- enzymatic - medicines with enzymes that you put on dressings
- autolysis - let the body do its own thing
- Biotherapy - using insects to clean wound
What would a negative pressure dressing be used for
a wound that needs constant debridement
What are the characteristics of a stage one pressure ulcer
- skin intact
- non blanchable
- possibly painful
- different from adjacent skin
What are the characteristics of a stage 2 pressure ulcer
- partial thickness loss of dermis
- skin not intact
- open/ruptured serum filled blister (blister does not have to be popped)
What are the characteristics of a stage 3 pressure ulcer
- full thickness tissue loss
- subcutaneous fat may be visible
- bone, tendon or muscle not exposed
- slough present but does not obscure the depth
- may include undermining and tunneling
- you can see wound base
What are the characteristics of a stage 4 pressure ulcer
- full thickness tissue loss
- exposed bone, tendon or muscle
- undermining and tunneling
- slough or eschar
- able to see underlying structures
What are the characteristics of an unstageable pressure ulcer
- base of ulcer covered with either slough or eschar
- full thickness tissue loss
- cannot see the wound base
What are the characteristics of a suspect deep tissue injury pressure ulcer
- purple or marron
- intact skin
- blood filled blister
- preceded by tissue (painful, firm, mushy and firm)
What are the categories of the braden scale?
A score below what is concerning
- sensory perception
- moisture
- activity
- mobility
- nutrition
- friction and shear
Lower score means higher risk: below 18 or less is worrisome
How often should you shift a client’s weight when sitting in a chair to prevent pressure injury
every 15 minutes
When speaking of duration, what does intractable mean
used for patients with cancer
What are some of the factors shaping pain experience
- emotions
- previous pain experiences
- developmental stage
- sociocultural factors
- communication skills
- cognitive impairments
