Chapter 36 Skin Integrity N Wound Care

Question 1

Functions of the skin

Answer 1

Protection
Temperature regulation
Sensation

Question 2

Factors Affecting Skin Integrity

Answer 2

Genetics and heredity  
Age 
Chronic illnesses and their treatments ex diabetics can be affected because of sensation not able to feel (touch) 
Medications ex protozoan 
Poor nutrition 
Trauma

Question 3

Define wounds

Answer 3

An injury to living tissue (especially an injury involving a cut or break in the skin)

Question 4

Types of Wounds
Incision
Laceration
Abrasion

Answer 4

Incision sharp instrument
Laceration tissues torn apart often from accidents
Abrasion surface scrape either unintentional ex scraped knee from a fall

Question 5

Types of Wounds
Contusion
Avulsion
Penetrating wound

Answer 5

Contusion blow from a blunt instrument
Avulsion injury of which the body structure is forceful detached by either trauma or injury
Penetrating wound penetration of the skin and the underlying tissues usually unintentional ex from a bullet or mental fragments

Question 6

Assessment of Wounds

Objective judgement

Answer 6

Wound assessment charts provide a useful framework
Wound measurement is an important aspect of the assessment
Photographs
Ex week or two of no healing contact physician

Question 7

Assessments of wounds

Related to lab work

Answer 7

WBCS decrease leukocyte count can delay healing and increase possibility of infection
Hemoglobin indicates poor oxygenation delivery to the tissues
Coagulation tests indicates excessive blood loss and prolonged clothing absorption
Serum protein indicates nutritional reserves for rebuilding cells
Albumin indicates nutritional status
Wound cultures confirm or rule out the presence of infection

Question 8

Pressure Ulcers

Answer 8

Are areas of necrosis and ulceration where tissues are compressed between bony prominences and hard surfaces

Question 9

Safety Alert

Answer 9

From the joint commission 2010 national patient safety goals (NPSGs)
Goal 14 prevent health care associated pressure ulcers (decubitus ulcers)
Rationale pressure ulcers continue to be problematic in all health care settings Most pressure ulcers can be prevented and deterioration at state 1 can be halted

Question 10

Healthy skin vs Fragile skin

Answer 10

Healthy skin the subcutaneous layer contains blood vessels and cushioning fat new cells are made in the dermis
Fragile skin the subcutaneous layer has fewer and flatter fat cells the dermis produce cells slowly

Question 11

Skin Integrity

Answer 11

Intact skin refers to the presence of normal skin and skin layers uninterrupted by wounds

Question 12

What are the four stages of pressure ulcers?

Answer 12

Stage 1 nonblanchable erythema signaling potential ulceration
Stage 2 partial thickness skin loss (abrasion,blister,or shallow crater) involving the epidermis and possibly the dermis
Stage 3 full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to but not through underlying fascia
Stage 4 full thickness skin loss with tissue necrosis or damage to muscle bone or supporting structures such as a tendon or joint capsule

Question 13

Assessment of Pressure Ulcers

Answer 13

Location r/t a bony prominence 
Size 
Stage (can't stage in Fl) 
Color of the wound bed 
Necrosis or Escher 
Wound margins 
Surrounding skin 
Clinical signs of infection

Question 14

Pressure Ulcers Interventions

Answer 14

Obtaining wound culture ex aerobic or anaerobic
Administer analgesic ex remove moist or outer dressing
Discard in bad
Cleanse wound ex irrigate or cleanse wound with NS

Question 15

Assessment Risk Assessment Tools

Answer 15

Braden Scale predict risk a total 23 points below 18 considered at risk
Norton’s Pressure Area Risk Assessment total score of 24, 15-16 considered indications not predictions of risk
Push pressure ulcer scale for healing national pressure ulcer advisory panel

Question 16

Pressure Ulcer Risk Factors

Answer 16

Friction and shearing 
Immobility 
Fecal/ Urinary incontinence 
Inadequate Nutrition
Decreased mental status/ diminished awareness
Elevated body heat

Question 17

Treating Pressure Ulcers

Answer 17

Minimize/ reduce pressure 
Scheduled position changes 
Pressure reducing devices 
Surgical asepsis for wound care 
Obtain C&S if infected 
Educate client 
ROM

Question 18

What are the four types of debridement

Answer 18

Sharp use of scalpel
Mechanical scrubbing force and damp to damp dressing
Chemical collagenase enzyme agents
Autolytic hydrocolloid and clear absorbent dressing fly larvae (maggots)

Question 19

Arterial Ulcers
Location
Associated Skin Assessment
Associated Wound Assessment

Answer 19

Arterial Ulcers is caused by impaired arterial blood flow
Location is the toes foot malleolus area
Associated skin assessment is cool skin temp,thin shiny skin,painful, decreased pulse strength
Associated wound assessments is minimal exudate, pale wound bed,well defined wound margins

Question 20

Venous Ulcer

Answer 20

Decrease in blood flow return from the lower extremities to the heart can cause a blood clot
Location lower calf and ankle in the area covered by a sock
Associated Skin Characteristics brown discoloration of lower calf and ankle skin edema dry scaly skin
Associated Wound Characteristics
Irregular margins n drainage

Question 21

Diabetic Ulcers

Answer 21

Often caused by sensory motor and autonomic neuropathy
Usual location metatarsal heads tops of the toes and the foot
Associated Skin Assessments
Dry cracked skin warm skin decreased sensation

Question 22

Name the Stages of wound healing

Answer 22

Inflammatory Phase 3-6 days
Proliferation Phase 3-21 days
Maturation Phase 21-1 year or longer

Question 23

Primary intention healing

Answer 23

Tissue surfaces closed
Minimal or no tissue loss
Formation of minimal granulation and scarring

Question 24

Secondary Intention Healing

Answer 24

Extensive tissue loss 
Edges cannot be closed 
Repair time longer 
Scaring greater 
Susceptibility to infection greater

Question 25

Tertiary Intention Healing (Dealing Primary Intention)

Answer 25

Initially left open Edema infection or exudate resolves Then closed Exudate is to drain the heal wounds after they are left open

Question 26

Wound Exudate

Answer 26

Material such as fluid and cells that have escaped from blood vessels during inflammatory process deposited in tissue or on tissue surface

Question 27

Serous Exudate

Answer 27

Mostly serum Looks watery Few cells Ex fluid in blister

Question 28

Sangulineous Exudate

Answer 28

Bloody Large amount of RBCs Seen in open wounds

Question 29

Purulent Exudate

Answer 29

Pus Thicker than serous Blue green or yellow color Suppurations process of pus formation

Question 30

Factors affecting wound healing

Answer 30

``` Poor surgical techniques Poor wound management Lifestyle ex smoking Age Impaired nutritional status Dehydration Diabetes Impaired bloody supply Stress and anxiety or depression ```

Question 31

Factors to support wound healing

Answer 31

Maintain moist healing Provide sufficient nutrition and hydration Prevent wound infection Proper positioning

Question 32

Purpose for Dressing Wounds

Answer 32

Protection from mechanical injury against microbial contamination Provide moist wound healing thermal insulation Absorbs drainage Debridement Pressure hemorrhage Splint or immobilize site

Question 33

Maggot Debridement Therapy

Answer 33

Medical use of live maggots (fly larvae) for treating no healing wounds Disinfected medicinal fly larvae applied to wound Maggots secrete a proteolytic (tissue dissolving) enzyme There primary actions 1. Clean wound by dissolving dead and infected tissue debridement 2. Disinfect wound 3. spread rate of healing 3,

Question 34

Rebound Phenomenon Using Heat and Cold Therapies

Answer 34

Maximum therapeutic effect is achieved then opposite effect begins Heat produces vasodilation Max 20-30 minutes 30-45 minutes = tissue congestion then vessels constrict Cold application produces vasoconstriction Review pg 951 table 36-7

Question 35

Complications of Wound Healing

Answer 35

Hemmorrhage massive bleeding Infection REED Assessment Dehiscence Evisceration

Question 36

Nursing Diagnoses and Goals

Answer 36

Risk for impaired skin integrity * Maintain skin integrity n avoid or reduce risk factors Impaired Skin Integrity * Progressive wound healing n regain intact skin Impaired Tissue Integrity * risk for infection n pain

Question 37

Physician official effects of heat *not in PowerPoint but chart in chpt

Answer 37

``` Vasodilation Increases capillary permeability Increases cellular metabolism Increases inflammation Sedative effect ```

Question 38

Physiological effects of cold *not in PowerPoint but in book

Answer 38

``` Vasoconstriction Decreases capillary permeability Decreases cellular metabolism Slows bacterial growth Decreases inflammation Local anesthetic effect ```