Chapter 48: Skin Integrity and Wound Care (IRAT/GRAT #3) Flashcards
(98 cards)
1
Q
stratum corneum
A
the thin outermost layer of the epidermis which allows for evaporation of water and permits absorption of certain topical medications
2
Q
dermis
A
inner layer of the skin
protects underlying muscles bones and organs
3
Q
pressure ulcers
A
localized injury to the skin and underlying tissue, usually over a body prominence as a result of pressure combination with shear and/or friction
4
Q
What patients are at risk for pressure ulcers?
A
any patient experiencing decreased mobility, decreased sensory perception, fecal or urinary incontinence and/or poor nutrition
5
Q
Pressure Ulcer: Pathogenesis (3 Factors)
A
- Pressure Intensity
- Pressure Duration
- Tissue Tolerance
6
Q
Tissue ischemia
A
occurs when the normal capillary pressure and the vessel is occluded for prolonged periods of time.
7
Q
What happens if a patient cannot respond to the discomfort of ischemia?
A
tissue ischemia and tissue death result
8
Q
Hyperemia
A
redness over a pressure point from a prolonged position
9
Q
Pressure Intensity includes
A
- hyperemia
- blanching
- non-blanchable hyperemia
10
Q
blanching
A
pressing into a hyperemic area and having the affected skin turn white in color (lighter skinned individuals)
11
Q
non-blanchable hyperemia
A
deep tissue damage is probable (stage 1 pressure ulcer)
12
Q
pressure duration
A
either low pressure over a prolonged period of time OR intensity pressure over a short period
13
Q
Common locations for pressure ulcer formation in a supine position
A
- occiput
- scapula
- sacrum
- heels
14
Q
Common locations for pressure ulcer formation in a lateral position
A
- ear,
- acromion process
- elbow
- trochanter
- medial & lateral condyle
- medial & lateral malleolus
- heels
15
Q
Common locations for pressure ulcer formation in a prone position
A
- elbow
- ear, cheek, nose
- breasts (female)
- genitalia (male)
- iliac crest
- patella
- toes
16
Q
Tissue Tolerance
A
the ability of the tissue to endure pressure
17
Q
Tissue Tolerance is dependent on
A
- integrity of the tissue and supporting structures
- extrinsic factors of shear, friction and moisture
- nutritional status
- age
- hydration
- low blood pressure
18
Q
Risk Factors for the formation of pressure ulcers
A
- impaired sensory perception
- impaired mobility
- alteration in LOC
- shear
- friction
- moisture
19
Q
impaired sensory perception include
A
pain and pressure
20
Q
alterations in LOC include
A
confusion, aphasia, coma
21
Q
shear
A
- gravity pulling the bony skeleton towards the foot of the bed while the skin remains against the sheets.
- outer layers of the skin may appear intact.
22
Q
friction
A
force of two surfaces moving across one another
23
Q
Unstageable/Unclassified Pressure Wound
A
- until the slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) is removed, a pressure wound cannot be staged.
- however it is most likely a Stage III or IV
24
Q
What wounds are staged?
A
- only pressure wounds are staged.
- diabetic ulcers and stasis ulcers are not staged!
25
Deep tissue injury
- purple or maroon in color
| - localized area of discolored intact skin or blood filled blister
26
A deep tissue injury may
- be preceded by tissue that is painful, firm, mushy, boggy, warm or cooler to the touch
- be difficult to detect in dark skin
27
Granulation Tissue
- red
- moist
- composed of new blood vessels
- progression toward healing
28
Slough
- stringy substance attached to a wound bed
| - requires debriding
29
Eschar
- black, brown, tan, or necrotic tissue
| - must be debrided
30
Exudate
- wound drainage
| - describe amount, color, consistency and odor
31
Wound classification systems enable the nurse to do what?
understand the risks associated with a wound and implications for healing
32
Wound Classification Systems describe:
1. state of skin integrity
2. cause of the wound
3. severity or extent of tissue injury or damage
4. cleanliness
5. descriptive qualities of wound tissue (i.e color)
33
Wound Classification
classified by the amount of tissue loss
34
Wound Classification includes
1. Partial Thickness Wounds
| 2. Full Thickness Wounds
35
Partial Thickness Wounds
- involves only a partial loss of skin layers (epidermis, superficial dermal layer).
- healing is by regeneration
36
Partial Thickness Wound Characteristics
- shallow in depth
- moist
- painful with red wound base
37
Full Thickness Wounds
- involves total loss of the skin layers (epidermis and dermis)
- heals by forming new tissue.
38
Full Thickness Wound Characteristics
- depth varies
| - extends into the subcutaneous layer
39
Process of Wound Repair includes
1. primary intention
| 2. secondary intention
40
Primary Intention
- skin edges are approximated (surgical incisions)
- risk for infection is low
- healing occurs quickly w/ minimal scar formation
41
Secondary Intention
- involves loss of tissue (burn, pressure ulcer, severe laceration)
- wound is left open until it becomes filled by scar tissue
42
Healing of partial thickness wounds involve what 3 components?
1. inflammatory response
2. epithelial proliferation and migration
3. reestablishment of the epidermal layers
43
epithelial proliferation and migration
- starts at the wound edges and the epidermal cells
- allows for quick resurfacing
- epithelial cells begin to migrate across the wound bed soon after wound occurs
44
reestablishment of the epidermal layers
- left open to air: resurfaces in 6-7 days
| - keep moist: resurfaces in 4 (ish) days: epidermal cells only migrate across a moist surface
45
Healing of full thickness wounds involve what 4 phases?
1. hemostasis phase
2. inflammatory phase
3. proliferative phase
4. maturation or remodeling phase
46
Hemostasis Phase
blood vessels constrict and platelets gather to stop bleeding
47
Inflammatory Phase
include mast cells, neutrophils and monocytes
48
function of neutrophils
ingests bacteria and small debris
49
function of monocytes
transforms into macrophages -> cleans the wound of bacteria, dead cells and debris by phagocytosis
50
function of mast cells
secretes histamine -> vasodilation -> WBCs to damaged tissues = localized edema, redness, warmth, throbbing
51
Proliferative Phase
-lasts 3-24 days
52
Main activities of the Proliferative Phase include
1. filling of the wound with granulation tissue
2. contraction of the wound
3. resurfacing of the wound by epithelialization (fibroblasts synthesize collagen providing strength and structural integrity to a wound)
53
In a clean wound, what happens during the Proliferative Phase?
- vascular bed is reestablished (granulation tissue)
- the area is filled with replacement tissue (collagen, contraction, and granulation tissue)
- surface is repaired (epithelialization)
54
Impairment in wound healing during the proliferative stage is usually related to
age, anemia, hypoproteinemia and zinc deficiency.
55
Maturation or Remodeling Phase
- maturation, the final stage of healing
| - may take place over a year
56
What are some complications of wound healing?
- hemorrhage
- infection
- dehiscence
- evisceration
57
dehiscence
total or partial separation of wound layers
58
evisceration
protrusion of visceral organs
59
How does fatty tissue effect wound closure?
contains poor blood supply which can be a challenge in wound closure due to the extra pressure on the incision
60
What is the major nursing priority related to caring for pressure ulcers?
PREVENTION.
- important indicator of nursing quality
- use of a standardized tool is essential.
61
Braden Scale
widely used risk assessment tool composed of 6 subscales
62
What are the 6 subscales of the Braden Scale?
1. sensory perception
2. moisture
3. activity
4. mobility
5. nutrition
6. friction/shear
63
Very high risk on Braden Scale is a score of
9 or less
64
High risk on Braden Scale is total score of
10-12
65
Moderate risk on Braden scale is a total score of
13-14
66
Mild risk on Braden Scale is a total score of
15-18
67
No risk on Braden Scale is a total score of
19-23
68
Factors Influencing Pressure Ulcer Formation
1. Nutrition
2. Tissue Perfusion
3. Infection
4. Age
69
Nutrition
- 1500 cal/day
- protein (for the formation of collagen)
- vitamins (A and C)
- trace minerals (zinc and copper)
70
Tissue Perfusion
adequate amounts of oxygenated blood
71
How does infection affect wound healing?
- prolongs inflammatory phase
- delays collagen synthesis
- prevents epithelialization
- increases production of proinflammatory cytokines (leads to more tissue destruction)
72
Psychosocial Impact of Wounds
- body image changes
| - self-concept (scars, drains, odor from drainage, temporary or permanent prosthetic devices)
73
Nursing Process: Assessment
- skin
- predictive instrument for pressure ulcer risk (braden scale)
- mobility
- nutritional status
- body fluids (moisture)
- pain
- wound
74
Wounds are usually assessed under what 2 conditions?
1. at the time of injury before treatment
| 2. after therapy
75
Wound Characteristics Include
1. appearance
2. wound drainage and character
3. drains
4. wound closures: staples, steri-strips, dermabond
5. need for wound cultures: aerobic and anaerobic
76
Nursing Process: Diagnosis
- Risk for infection
- Imbalanced Nutrition
- Acute or Chronic Pain
- Impaired Physical Mobility
- Impaired Skin Integrity
- Risk for Impaired Skin -Integrity
- Ineffective Peripheral Tissue Perfusion
77
Acute Wound
requires immediate intervention
78
Chronic Wound
the patient's hygiene may be more important
79
Preventative Practices:
- skin care practices (clean, dry, moisturized)
- elimination of shear
- positioning/movement
80
Major Nursing Priority
promotion of wound healing
81
Prevention of Wounds
1. skin care and management of incontinence
2. positioning
3. mechanical loading and support devices (proper positioning and use of therapeutic surfaces/beds)
4. education
82
No single device eliminates the
effects of pressure on the skin
83
Acute Care Management
- documentation
| - wound management
84
Documentation of Wounds
- photo documentation to establish baseline then periodically to track healing (or lack of healing)
- may be performed by the RN or wound ostomy RN according to hospital policy
85
Wound Management
maintain a healthy wound environment
86
Maintaining a healthy wound environment
- Prevent and manage infection
- Clean the wound *only with noncytotoxic wound cleaners
- Remove nonviable tissue. (debridement)
- Maintain a moist environment
- Eliminate dead space
- Control odor
- Eliminate/minimize pain
- Protect the wound and periwound skin
87
Debridement
removal of nonviable necrotic tissue
88
Debridement includes
1. mechanical debridement
2. autolytic debridement
3. chemical debridement
4. surgical debridement
89
mechanical debridement
wet to dry saline gauze, wound irrigation, whirlpool treatments
90
autolytic debridement
- synthetic dressings to allow eschar to be self-digested by the action of enzymes.
- hydrocolloid dressings, transparent film
91
chemical debridement
topical enzyme preparation: dakin's solution, sterile maggots
92
surgical debridement
using a scalpel, scissors or other sharp instrument
93
Nursing Process: Collaboration
-utilize resources: interdisciplinary health care professionals
94
Collaboration: Interdisciplinary health care professionals
- Health care provider
- Wound care nurse specialist
- Physical therapist
- Occupational therapist
- Nutritionist
- Case Manager
- Pharmacist
95
Nursing Process: Dressings
- follow institutional policy and procedure
- consider medicating the patient 30" before a dressing change
- wound vac
- hot and cold packs
96
Nursing Process: Evaluation
- response to nursing therapies
- was the goal reached?
- was the etiology of the skin impairment addressed? pressure, friction, shear, moisture
- photo documentation
97
excessive exudate may be a sign of
infection
98
Characteristics of Secondary Intention
- takes longer to heal
- increased risk for infection
- increased scarring
- severe scarring may lead to loss of tissue function
