Chapter 37 Skin Integrity And Wound Care Flashcards by Cindy Rush

Impaired skin integrity resulting from pressure
Localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure or pressure in combination with shear and/or friction

Pressure ulcer

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Braden scale

Lower score higher the risk

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Body’s largest organ

Skin

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Primary defense against infection

Skin

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Disruption in the integrity of the body tissue

Wound

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Surface damage caused by the skin rubbing against another surface that often results in an abrasion

Friction

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Loss of the epidermis
Eschar
Abrasion

Abrasion

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Thick layer of dead dry tissue that covers a pressure ulcer or thermal burn
It may be allowed to be sloughed off naturally or it may need to be surgically removed
Like a scab

Eschar
Abrasion

Eschar

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A wound with little or no tissue loss such as a clean surgical incision which heals by
Skin edges approximate or close together and risk for infection is minimal
Healing rapidly with minimal scarring
Low risk for infection
Healing occurs in four stages

Primary intention

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A wound involving loss of tissue such as a severe laceration or a chronic wound such as a pressure ulcer heals by
The skin edges cannot come together because of the extensive tissue loss and healing occurs gradually
Edges widely separated
Large scar occurs
Increased potential for infection
Healing time longer
Healing from bottom up

Primary
Secondary

Secondary intention

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Pink pebbly tissue
Red moist tissue consisting of blood vessels and connective tissue, covers the wound base
Wound contraction brings the wound together and the wound closes with scar formation
Layers of pink pebbly tissue is new granulation tissue
As layer gets thick it becomes beefy red

Ecchymosis
Granulation

Granulation tissue

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Cessation of bleeding

Hemastasis

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Partial or total separation of layers of skin and tissue above the fascia in a wound that is not healing properly

Dehiscence

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Occurs when wound layers separate below the fascial layer and visceral organs protrude through the wound opening
This is a medical emergency. This happens in abdominal incision where it splits open when you may sneeze or pick up something heavy.
Have patient lay on floor so things will not fall out, take pressure off, sterile equipment, moisten soak in sterile solution and put it in wound and cover do internal organs will not dry out and call surgeon and schedule for surgery. Do not push things back in. Do not put anything on it to bind it.

Evisceration

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Discoloration of the skin or bruise caused by leakage of blood into subcu tissues as a result of trauma to the underlying tissues

Ecchymosis
Dehescience

Ecchymosis

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Softening of the skin caused by moisture

Maceration

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Removal of dead tissue from a wound

Debridement

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Sensitive vascular layer of the skin directly below the epidermis composed of collagenous and classic fibrous connective tissues that give the dermis strength and elasticity

Dermis
Exudate

Dermis

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Approximate

To come close together as in the edges of a wound

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Injury to the skins surfaced caused by abrasion

Excoriation

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Fluid, cells or other substances that have been slowly discharged from cells or blood vessels through small pores or breaks in cell membranes

Exudate

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Clear, watery plasma

Serous

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Fresh bleeding

Sanguineous

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Pale, more watery
Combination of plasma and red cells
May be blood streaked

Serosanguinous

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Thick, yellow, green or brown, indicating the presence of dead or living organisms and WBCs

Purulent

Abnormal passage from an internal organ to the body surface or between two internal organs

Fistula

Skin and subcu layers adhere to surface of bed and muscle and bone slide in the direction of body movement

Shearing force

Protective reaction that neutralizes pathogens and repairs body cells Remodeling Inflammatory response

Inflammatory response

Nonblanchable erythema of the intact skin Only the epidermis is involved Reversible if pressure removed Which stage pressure ulcer

Stage I

Partial thickness skin loss involving epidermis and/or dermis Skin tears Superficial Presents as an abrasion, blister or shallow crater May be swollen or painful More painful than IV which stage of pressure ulcer

Stage II

Full thickness skin loss with damage or necrosis of subcu tissue that may extend to but not through the underlying fascia Presents as deep crater with or without undermining May have foul smelling drainage Which stage of pressure ulcer

Stage III

Full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone or supporting structures Undermining/tunneling may be present Which stage of pressure ulcer

Decreased blood supply to a body part such as a skin tissue or to an organ such as the heart

Ischemia

External factors that increase patients risk for developing an ulcer

Pressure Shear Friction Moisture

Internal factors that increase patients risk for a pressure ulcer

Nutrients Infection Age

What nutrient is needed to maintain skin

Protein

Low protein levels cause

Edema or swelling

Edema increases the risk for pressure ulcer formation because

Changing pressures in capillary circulation and capillary bed resulting in decreased blood supply and retention of waste products in the edematous tissue

Does edema increase or decrease elasticity

Decease

Inhibit wound healing

NSAID | Steroids

Most common sources of moisture

Incontinence | Fever

Exposure of moisture leads to

Maceration

``` Temperature greater than 101 Leads to swearing and maceration Increases metabolic Sign of infection Triggers immune response which uses calories and nutrients ```

Fever

Are these primary or secondary defenses ``` Skin and normal flora Mucous membranes Sneeze, cough, tearing reflexes Elimination and acidic environments Circulatory system ```

Primary

Physical barrier | Inhibits growth traps infection

Mucous membranes

Trap and propel mucous from lung

Cilia

Physical expulsion

Sneeze/cough

Flushing mechanism

Tears

Primary or secondary defenses Inflammatory response Immune response

Secondary

White blood cells Second line of defense Ingest and destroy microbes

Leukocytes

Normal range of leukocytes

Less than 10,000

Which stage of inflammatory response Initial injury precipitates release of chemicals Activates the inflammatory response

Stage 1

Which stage of inflammatory response Erythema Produces the characteristic signs of redness and increased warmth

Stage 2

Increased blood flow to inflamed area

Erythema

Which stage of inflammatory response Increases capillary permeability with leakage of large quantities of plasma into damaged tissue Infection is walled off Nonpitting edema occurs

Stage 3

Which stage of inflammatory response Damaged tissue invaded by leukocytes that engulf the bacteria and necrotic tissue Produces purple to exudate (pus)

Stage 4

Which stage of inflammatory response

Destroyed tissue cells replaced by identical/similar cells and/or fibrous tissue Promotes tissue healing or formation of scar tissue Functional capacity of tissue may be reduced

Cardinal signs and symptoms of inflammation

Redness - blood accumulation in dilated capillaries Warmth - the heat of the blood Swelling - fluid accumulation Pain - pressure or injury to local nerves

Does inflammation equal infection

Is inflammation a normal response

Yes

When the body's defenses are overwhelmed

Infection

Setting up for trouble in individuals

``` Breaks in skin and mucous membranes Invasive devices Stasis of body fluids Inadequate nutrition Stress Immune system dysfunction ```

Common sites of infection

Surgical wounds Urinary tract Respiratory tract

Major cause for hospital morbidity which accounts for 60% of extra hospital days

Surgical wounds

Most common nosocomial infection UTI Respiratory

Urinary tract

Second most common site and associated with most deaths

Respiratory tract

Does wound infection double or triple for each hour a patient is in surgery

Doubles

Most common mechanism of respiratory infection

Aspiration

Major causative agent of a UTI Caths Wounds

Catheters

Very little tissue loss Primary Secondary Tertiary

Primary

Delayed primary Secondary Tertiary

Tertiary

A wound that just happened Acute Chronic

Acute

A wound that has been there for two months or longer

Chronic

Granulating healing wound Red Yellow Black

Red

Pus Yellow Red Black

Yellow

Necrosis Brown Black

Black

What are the four stages of healing

Hemostasis Inflammatory Proliferate Remodeling

Also called delayed primary healing A widely separated wound is later brought together with some type of closure material Usually fairly deep Often contains extensive drainage and tissue debris

Tertiary

Physiology of wound healing

Vascular response/inflammation (hemostasis and inflammatory) Proliferation/regeneration Maturation/remodeling

``` Reaction phase Begins in minutes and lasts about 3-6 days Hemostasis Slight fever Inflammation ``` Proliferation Vascular response Remodeling

Vascular response

Proliferation/regeneration

Day 3-4 to day 21 Macrophage clears area of debris Begins with appearance of new blood vessels Fills wound with connective or granulation tissue and top is closed with epithelialization Fibroblasts synthesize collagen which closes wound (forms scar) Scar is pink and raised

Grows from edges and covers over the granulation | New skin/scar

Epithelial tissue

Maturation/remodeling

``` Starts day 21 and can go long periods Collagen scar gains strength Scar remodels resuming normal appearance Scar becomes smaller, flatter and whiter Takes months to years to complete ```

Types of exudates

Serous Sanguinous Serosanguinous Purulent

Act of forming pus

Suppuration

Complications of healing

``` Infection Hemorrhage Dehiscence Evisceration Fistulas ```

Used in clean and granulating wounds

Wet to moist

Only solution for wound care recommended by Agency for Health Care Policy Research

Normal saline

Best agent to use for wound and isotonic

Normal saline

Solutions that delay healing

Hydrogen peroxide | Dakin's solution (bleach solution)

Solution that slow healing

Acetic acid (vinegar solution)

Major no no, removes moisture from wound bed

Betadine

``` Intermittent current to wound bed Stimulates migration of cells involved in repair Stimulates granulation Inhibits bacterial growth Limited clinical use ```

Electrical stimulation

Oxygen delivered at increased atmospheric pressure Stimulates fibroblasts, collagen synthesis and epitheliumtunica Improves blood capacity to carry O2 thus leading to increased oxygenation

Hyperbaric oxygen

Sponge inside wound covered with occlusive dressing and connected to negative pressure machine Eliminates excess exudates Good for large/deep wounds, heavy exudates and nonhealing wounds

Negative pressure wound treatment

Acute wounds in inflammatory phase Cold or heat

Cold

Chronic wound - direct heat contraindicated in arterial insufficiency

Heat

Scrub, rub, wet to dry damp dressing, irrigation, whirlpool, maggots ``` What kind of debridement Mechanical Enzymatic Automatic Sharp ```

Mechanical

Topical medication, collagenase are enzymes

Enzymatic

Body does it to itself Dressings that contain moisture that make use of the body's enzymes to break down necrotic tissue ``` What kind of debridement Mechanical Enzymatic Autolytic Sharp ```

Autolytic

Use of scalpel/scissors Requires special training What kind of debridement Mechanical Enzymatic Autolytic Sharp

Sharp

What are some common misconceptions of pressure ulcers

``` Develop because of poor nursing care Are preventable Are caused from pressure alone Massaging reddened tissue helps prevent Use of specialty equipment will prevent ulcers indefinitely and independently ```

What would you use with a wound with a lot of drainage

Collagen

Does a wound vac limit ambulation

Yes

What are the most susceptible areas for a pressure ulcer

Coccyx-sacral area Heels Elbows

Contributing factors leading to pressure ulcer

``` Prolonged pressure Shearing force Friction Moisture Nutrition Infection Impaired peripheral circulation Obesity Age ```

Abrasion Two surfaces rubbing against each other Injury is shallow and without necrosis Limited to the epidermis (skinned knee, road rash)

Friction

Most vulnerable areas with a friction injury

Heels and elbows

Suspects deep tissue injury - localized area of purple/maroon discoloration Intact skin or a blood filled blister that is due to damage of underlying soft tissue from pressure and/or shear Tissue that is painful, firm, mushy, boggy, or warm/cool in comparison to adjacent tissue

Suspected deep tissue injury

Base of the ulcer is covered by slough and/or eschar A necrotic ulcer, or one with eschar, cannot be graded or staged - depth of wound and tissue type cannot be visualized Cannot see bottom of wound bed, can't tell stage

Unstageable

Which stage related treatment | Relieve pressure

Stage 1

Stage related treatment | Moist healing environment

Stage 2

Which Stage related treatment | Debride

Which stage related treatment | Non adherent dressing, skin grafts

Head of bed position to prevent a pressure ulcer

Lowest possible level

Hemostasis and inflammatory

``` Reaction phase Begins in mins and lasts about 3-6 days Blood vessels constrict providing a clot Vasodilation brings nutrients and WBCs Blood flow reestablishedafter epithelial cells begin to grow ``` Phagocytosis Slight fever less than 101. Normal and product of inflammation. Not infection

Day 3 to 4 and lasts 21 days Macrophages clear area of debris Begins with appearance of new blood vessels Fills wound with connective or granulation tissue and top is closed by epithelialization Fibroblasts synthesize collagen which closes Scar is pink and raised

Proliferation/regeneration

Starts around three week mark and can go on for long periods Collagen scar gains strength Scar remodels resuming normal appearance Scar becomes smaller, flatter and whiter Takes months/years to complete

Maturation/remodeling

Clear water plasma

Serous

Sanguinuous

Fresh bleeding

Pale, more watery, combination of plasma and red cells, blood streaked

Serosanginuous

Thick, yellow, green, brown indicating presence of dead or living organisms and white blood cells

Purulent

Complications of wound healing

``` Infection Hemorrhage Dehiscence Evisceration Fistulas ```

Reduces skins resistance to pressure and shearing Originates from Wound drainage, perspiration, incontinence, vomitus, condensation from equipment

Moisture

``` Causes atrophy and lose subcu tissue Less tissue present to pad bones Poor nutrition Often overlooked because of obesity Fluid/electrolyte imbalance Anemia: reduced amount 02 ```

Poor nutritional status

Chapter 37 Skin Integrity And Wound Care Flashcards

(125 cards)