Chapter 36 Skin Integrity N Wound Care Flashcards Preview

Fundamentals Exam 3 > Chapter 36 Skin Integrity N Wound Care > Flashcards

Flashcards in Chapter 36 Skin Integrity N Wound Care Deck (38):
1

Functions of the skin

Protection
Temperature regulation
Sensation

2

Factors Affecting Skin Integrity

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

3

Define wounds

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

4

Types of Wounds
Incision
Laceration
Abrasion

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

5

Types of Wounds
Contusion
Avulsion
Penetrating wound

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

6

Assessment of Wounds
Objective judgement

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

7

Assessments of wounds
Related to lab work

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

8

Pressure Ulcers

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

9

Safety Alert

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

10

Healthy skin vs Fragile skin

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

11

Skin Integrity

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

12

What are the four stages of pressure ulcers?

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

13

Assessment of Pressure Ulcers

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

14

Pressure Ulcers Interventions

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

15

Assessment Risk Assessment Tools

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

16

Pressure Ulcer Risk Factors

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

17

Treating Pressure Ulcers

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

18

What are the four types of debridement

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)

19

Arterial Ulcers
Location
Associated Skin Assessment
Associated Wound Assessment

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

20

Venous Ulcer

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

21

Diabetic Ulcers

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

22

Name the Stages of wound healing

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

23

Primary intention healing

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

24

Secondary Intention Healing

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

25

Tertiary Intention Healing (Dealing Primary Intention)

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

26

Wound Exudate

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

27

Serous Exudate

Mostly serum
Looks watery
Few cells
Ex fluid in blister

28

Sangulineous Exudate

Bloody
Large amount of RBCs
Seen in open wounds

29

Purulent Exudate

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

30

Factors affecting wound healing

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

31

Factors to support wound healing

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

32

Purpose for Dressing Wounds

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

33

Maggot Debridement Therapy

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,

34

Rebound Phenomenon Using Heat and Cold Therapies

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

35

Complications of Wound Healing

Hemmorrhage massive bleeding
Infection REED Assessment
Dehiscence
Evisceration

36

Nursing Diagnoses and Goals

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

37

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

Vasodilation
Increases capillary permeability
Increases cellular metabolism
Increases inflammation
Sedative effect

38

Physiological effects of cold *not in PowerPoint but in book

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