Flashcards in Fund SG CH 48 skin integrity & wound care Deck (80):
What is the epidermis?
-the top layer of skin.
What is the dermis?
-inner layer of skin that provides tensile strength and mechanical support.
What is collagen?
-tough, fibrous protein
What is a pressure ulcer?
-localized injury to the skin and underlying tissue over a body cavity.
What is blanching?
-normal red tone of light-skinned patients are absent
What is different about darkly pigmented skin?
-does not blanch.
What pressure factors contribute to pressure ulcer development?
What are the risk factors that predispose a patient to pressure ulcer formation?
-impaired sensory perception
-alteration in level of consciousness
Describe a stage I pressure ulcer:
Intact skin with non- blanchable redness of a localized area over a bony prominence.
Describe a stage II pressure ulcer:
Partial-thickness skin loss involving epidermis, dermis, or both.
Describe a stage III pressure ulcer:
Full-thickness with tissue loss.
Describe a stage IV pressure ulcer:
Full-thickness with tissue loss with exposed bone, tendon, or muscle.
What is granulation tissue?
Red, moist tissue composed of new blood vessels which indicate wound healing.
What is slough?
Stringy substance attached to wound bed that is soft, yellow, or white tissue.
What is eschar?
Black or brown necrotic tissue.
What is exudate?
Describes the amount, color, consistency, and odor of wound drainage.
What is primary intention?
A wound that is closed by epithelialization.
What is secondary intention?
-A wound that is left open until it becomes filled with scar tissue.
-Chance of infection is greater.
What three components are involved in the healing process of a partial–thickness wound?
-epithelial proliferation (reproduction)
-migration with reestablishment of the epidermal layers
What are the four phases involved in the healing process of a full-thickness wound?
What is hemostasis?
-First phase involved in the healing process of a full thickness wound.
-Injured blood vessels constrict, and platelets gather to stop bleeding.
-Clots form fibrin matrix for cellular repair.
What is the inflammatory phase?
-Second phase involved in the healing process of a full thickness wound.
-Damaged tissue and mast cells secrete histamine (vasodilate) with exudation of serum and WBC into damaged tissue.
What is the proliferative phase?
-Third phase involved in the healing process of a full thickness wound.
-With the appearance of new blood vessels as reconstruction progresses, the proliferative phase begins and lasts from 3 to 24 days.
-The main activities during this phase are the filling of the wound with granulation tissue, contraction of the wound, and resurfacing of the wound by epithelialization.
What is remodeling?
-Fourth phase involved in the healing process of a full thickness wound.
-Maturation, the final stage, may take up to one year.
-The collagen scar continues to reorganize and gain strength for several months.
What is hemorrhage?
-Bleeding from a wound site
-Occurs after hemostasis
-Indicates a slipped surgical suture, a dislodged clot, infection, , or erosion of a blood vessel by a foreign object (internal or external)
What is a hematoma?
-Localized collection of blood underneath the tissue.
What is an HAI (Health care-associated infection)?
-The second most common nosocomial infection
-Purulent material drains from the wound (yellow, green, or brown, depending on the organism)
What is dehiscence?
-A partial or total separation of wound layers
-Risks are poor nutritional status, infection, or obesity
What is evisceration?
-Total separation of wound layers with protrusion of visceral organs through a wound opening requiring surgical repair.
What are the sub scales of the Braden Scale?
-friction or shear
What factors influence pressure ulcer formation?
-psychosocial impact of wounds
How does mobility place a pt at risk for a pressure ulcer?
-potential effects of impaired mobility
-muscle tone and strength
How does nutritional status place a pt at risk for a pressure ulcer?
-malnutrition is a major risk factor
-A loss of 5% of usual weight, weight less than 90% of IDW, or a decrease of 10 pounds in a brief period
How do body fluids place a pt at risk for a pressure ulcer?
-continuous exposure of the skin to body fluids, especially gastric and pancreatic drainage, increases the risk for breakdown
How does pain place a pt at risk for a pressure ulcer?
-adequate pain control and patient comfort will increase mobility, which in turn reduces risk
What is an abrasion?
-Superficial with little bleeding
-Considered a partial-thickness wound
What is a laceration?
-Sometimes bleeds more profusely depending on death and location (>5 cm or 2.5 cm in depth)
What is a puncture wound?
-Bleeds in relation to the depth and size, with a high risk of internal bleeding and infection
How does a nurse assess wound appearance?
-Whether the wound edges are closed
-The condition of tissue at the wound base
-Look for complications and skin coloration
How does a nurse assess the character of wound drainage?
-Amount, color, odor, and consistency of drainage
-Depends on the location and the extent of the wound.
How does a nurse assess drains?
-Observe the security of the drain and its location with respect to the wound and the character of the drainage
-Measure the amount of drainage
How does a nurse assess wound closures?
-Surgical wounds are closed with staples, sutures, or wound closures
-Look for irritation around staple or suture sites and note whether the closures are intact
What are potential or actual nursing diagnoses related to impaired skin integrity?
-Risk for Infection
-Imbalanced Nutrition: Less than Body Requirements
-Acute or Chronic Pain
-Impaired Skin Integrity
-Risk for Impaired Skin Integrity
-Impaired Physical Mobility
-Ineffective Tissue Perfusion
-Impaired Tissue Integrity
What are possible goals to achieve wound improvement?
-Higher percentage of the granulation tissue in the wound base
-No further skin breakdown in any body location
-An increase in the caloric intake by 10%
Identify three major areas of nursing interventions for preventing pressure ulcers:
-Mechanical loading and support devices
List the principles to address to maintain a healthy environment:
-cleanse the wound
-remove non-viable tissue
-maintain the wound in moist environment
-protect the wound
Explain the rationale for debriding a wound:
Removal of non-viable necrotic tissue to read the ulcer of a source of infection, enable visualization of the wound bed, and provide a clean base necessary for healing.
What are the four methods of debridement?
-Sharp or surgical
First aid for wounds includes the following:
First aid for wounds includes hemostasis. Explain.
Control bleeding by applying direct pressure in the wound site with a sterile or clean dressing, usually after trauma, for 24 to 48 hours.
First aid for wounds includes cleansing. Explain.
Gentle cleansing rather than vigorous cleansing with NS (physiological and will not harm tissue)
First aid for wounds includes protection. Explain.
Applying sterile or clean dressings and immobilizing the body part.
What are the purposes of dressings?
-Protects a wound from microorganism contamination
-Aids in hemostasis
-Promotes healing by absorbing drainage and debriding a wound
-Supports or splints the wound site
-Protects the patient from seeing the wound
-Promotes thermal insulation of the wound surface
-Provides a moist environment
What are the clinical guidelines used when selecting an appropriate dressing?
-Choose a dressing that will continuously provide a moist environment.
-Perform wound care using topical dressings as determined by assessment.
-Choose a dressing that keeps the surrounding skin dry.
-Choose a dressing that controls exudates.
-Eliminate wound dead space by loosely filling all cavities with dressing material.
What are the advantages of a transparent film dressing?
-Adheres to undamaged skin
-Serves as a barrier to external fluids and bacteria but allows the wound surface to breathe.
-Promotes a moist environment.
-Can be removed without damaging underlying tissues.
-Does not require a secondary dressing.
What are the functions of hydrocolloid dressings?
-Absorbs drainage through the use of exudate absorbers
-Maintains wound moisture
-Slowly liquefies necrotic debris
-Impermeable to bacteria
-Self–adhesive and molds well
-Acts as a preventative dressing for high-risk friction areas
-May be left in place for 3 to 5 days, minimizing skin trauma and disruption of healing
What are the advantages of hydrogel dressings?
-Soothing and reduces pain
-Provides a moist environment
-Debrides the wound
-Does not adhere to the wound base and is easy to remove
What guidelines are followed during a dressing change procedure?
-Assessment of the skin beneath the tape
-Performing thorough hand hygiene before and after wound care
-Wear sterile gloves
-Removing or changing dressings over closed wounds when they become wet or if the patient has s/s of infection
Summarize the principles of packing a wound:
-Assess the size, depth, and shape of the wound
-Dressing (moist) needs to be flexible and in contact with all of the wound surface
-Do not pack tightly (overpacking causes pressure)
-Do not overlap the wound edges (maceration of the tissue)
How does a wound vacuum assisted (wound VAC) closure device work?
-Applies localized negative pressure to draw the edges of a wound together by evacuating wound fluids and stimulating granulation tissue formation
-Reduces the bacterial burden of a wound and maintains a moist environment
What three principles are important when cleaning an incision?
-Cleanse in a direction from the least contaminated area to the surrounding skin.
-Use gentle friction when applying solutions locally to the skin.
-When irrigating, allow the solution flow from the least to the most contaminated area.
Summarize the principles of wound irrigation:
-Use of an irrigating syringe to flush the area with a constant low-pressure flow of solution of exudates and debris.
-Never occlude a wound opening with a syringe.
Explain the purpose for drainage evacuation:
Portable units that connect tubular drains lying within a wound bed and exert a a safe, constant low-pressure vacuum to a remove and collect drainage.
What are the benefits of binders and bandages?
-Creating pressure over a body part
-Immobilizing a body part
-Supporting a wound
-Reducing or preventing edema
-Securing a splint
List the nursing responsibilities when applying a bandage or binder:
-Inspecting the skin for abrasions, edema, discoloration, or exposed wound edges.
-Covering exposed wounds or open abrasions with a sterile dressing.
-Assessing the condition of underlying dressings and changing if soiled.
-Assessing the skin for underlying areas that will be distal to the bandage for signs of circulatory impairment.
What is the physiological response to heat applications?
-Improves blood flow to an injured part
-If applied for more than one hour, the body reduces blood flow by reflex vasoconstriction to control heat loss from the area
What is the physiological response to cold applications?
Diminishes swelling pain, prolonged application results in reflex vasodilation.
What factors influence heat and cold tolerance?
-A person is better able to tolerate short exposure to temperature extremes.
-More sensitive to temperature variation: neck, inner aspect of the wrist and forearm, and perineal region.
-The body responds best to minor temperature adjustments.
-A person has less tolerance to temperature changes to which a large area of the body is exposed.
-Tolerance to temperature variations changes with age.
-Physical conditions that reduce the reception or perception of sensory stimuli.
-Uneven temperature distribution suggests that the equipment is functioning improperly.
What is the rationale for warm, moist compresses?
Improve circulation, relieve edema, and promote consolidation of pus and drainage.
What is the rationale for warm soaks?
Promote circulation, lessens edema, increases muscle relaxation, and provides a means to deride wounds and apply medicated solutions.
What is the rationale for sitz baths?
The pelvic area is immersed in warm fluid, causing wide vasodilation.
What is the rationale for commercial hot packs?
Disposable hot packs that apply warm, dry heat to an area.
What is the rationale for cold, moist, and dry compresses?
Relieves inflammation and swelling.
What is the rationale for cold soaks?
Immersing a body part for 20 minutes.
What is the rationale for ice bags or collars?
Used for muscle sprain, localized hemorrhage, or hematoma.
What questions need to be asked if the identified outcomes were not met?
-Was the etiology of the skin impairment addressed?
-Was wound healing supported by providing the wound base with a moist, protected environment?
-Were issues such as nutrition assessed and a plan of care developed?
Mr. Post is in a Fowler position to improve his oxygenation status. The nurse notes that he frequently slides down in bed and needs to be repositioned. Mr. Post is at risk for developing a pressure ulcer on his coccyx because of:
3. Shearing force
4. Impaired peripheral circulation
3. Shearing force
The force exerted parallel to the skin resulting from both gravity pushing down on the body and resistance between the pt and the surface.
Which of the following is NOT a subscale on the Braden scale for predicting pressure ulcer risk?
4. Sensory perception
Age is not a subscale. Perception, moisture, activity, mobility, nutrition, friction, and shear are the subscales.
Which of these patients has a nutritional risk for pressure ulcer development?
1. Patient A has an albumin level of 3.5
2. Patient B has a hemoglobin level within normal limits
3. Patient C has a protein intake of 0.5 g/kg/day
4. Patient D has a body weight that is 5% greater than his ideal weight
3. Patient C has a protein intake of 0.5 g/kg/day
The recommended protein intake for adults is 0.8 g/kg; a higher intake of up to 1.8 g/kg/day is necessary for healing.