Skin Integrity Flashcards
(108 cards)
1
Q
Who are at risk for developing impaired skin integrity?
A
Older Adults
Decreased Mobility
Bariatric
2
Q
Older Adults skin changes
A
Thinning skin- Decreased collagen (decreased elasticity)
Decreased Hydration
SQ Tissue
Blood Supply
3
Q
Older Adults Problems that is caused due to skin changes
A
Skin tears
PI
Dry flaky skin
Skin infections
4
Q
Decreased Mobility Skin changes
A
Reduced blood circulation
Incontinence
Loss of collagen
Muscles Atrophy
Impaired Sensation
5
Q
Decreased Mobility Problems due to skin changes
A
Skin tears
PI
Skin infections
Incontinence associated dermatitis
6
Q
Bariatric Skin changes
A
Decreased moisture
Dry skin
Maceration
Elevation in temp
Decreased blood and lymph flow
7
Q
Bariatric Problems due to skin changes
A
Skin tear
PI
Diabetic ulcer
Moisture lesions
Skin-fold rashes
8
Q
What are components of the comprehensive skin assessment?
A
Medical history
Risk factors (think about the Braden risk assessment)
Assessing skin for open areas
Redness
Abrasions
Edema
Moisture
Rashes
Texture
Temperature
9
Q
Erythema
A
redness due to dilation of blood vessels
10
Q
Blanchable erythema
A
temporarily becomes pale when pressure is applied, then turns red when pressure is released
11
Q
Nonblancahble erythema
A
redness does not go away when pressure is applied, indicating structural damage to blood vessels
12
Q
Temperature changes
A
Heat indicates inflammation
Coolness with decreased blood flow
13
Q
Where are common areas of skin breakdown?
A
14
Q
What are some Acute wounds?
A
Traumatic
Surgical
Moisture associated skin damage
15
Q
Lacerations
A
tears in skin (blunt or sharp objects)
16
Q
Skin Tear
A
Caused by mechanical forces (removing tape)
Seen in older adults
17
Q
Surgical Wounds
A
created intentionally during surgery
18
Q
Clean, Clean-contaminated
A
minimal bacteria and will be closed after surgery
19
Q
Contaminated, dirty wounds:
A
Higher bacterial load
May be left open at first
20
Q
How should a surgical wound look?
A
Intact, well- approximated edges
21
Q
Day 1-4
A
Red
22
Q
Day 5-14
A
Pink
23
Q
Day 15- 1 year
A
Pale
24
Q
What should the surgical would look by Day 4?
A
Epithelial Closure
25
What should the surgical would look by Day 5?
Edema and exudate should decrease
26
What should the surgical would look by Day 9-14?
Staples, sutures usually removed
27
What kind of moisture causes skin damage?
Urine
Feces
Stoma Effluent
Wound Exudate
Excessive sweating
Deep skin folds
Predisposes patient to PI
28
What is Chronic wounds?
Develops over time
29
What conditions predispose patients to develop chronic wounds?
Disruption of wound healing process in acute wounds
Decreased blood flow (venous insufficiency, peripheral artery disease, DM)
30
Who is more prone to experiencing Chronic wounds?
Those with chronic illnesses
Malnourished
Smokers
Immobilized
Infected wounds have a higher risk for developing chronic wounds
31
What causes Arterial Wound?
Blocked arteries-unable to deliver nutrients
DM
Age
Smoking
HTN
Hyperlipidemia
Kidney failure
Atherosclerosis
Vasculitis
32
Description of Arterial Wound
“Punched out” ankle, feet, heels, toes
Red, yellow, black sores.
Deep. Leg pain at night.
No bleeding.
Cool to the touch
33
Arterial Wound Nursing Interventions
Need to restore perfusion- angioplasty.
Keep wound, clean, dry
34
Venous Wound Causes
Damage to veins- blood has difficulty returning to heart
Varicose veins
HTN
Injuries
Obesity
DVT
HF
Pregnancy
35
Description of Venous Wound
Shallow, irregular margins.
Below knee, inner ankle.
Inflammation, swelling, itchy, hardened skin, scabbing, darkened brownish stained skin, exudate.
36
Venous Wound Nursing Intervention
Keep free of infection. Debridement.
Compression therapy to prevent.
37
Neuropathic Wound Causes
Diabetes, neurological condition.
Neuropathy (decreased sensation)
38
Neuropathic Wound Description
Well defined, punched out.
Soles of the feet.
Surrounding skin is calloused.
Undermining and pockets of infection with risks of osteomyelitis. Painless
39
Neuropathic Wound Nursing Interventions
Infection prevention
Debridement
Keep wound moist
Reduce pressure on area
Therapeutic shoes
40
What causes pressure injuries?
Localized injury to skin or underlying tissue due to pressure and shear (force exerted parallel to surface of the skin- sitting at an incline)
41
What are risk factors for pressure injury development?
Immobility
Malnutrition
Reduced perfusion
Altered sensation
Decreased LOC
Friction
Moisture
42
What areas on the body are most susceptible to pressure injury development?
Bony prominences
Skin folds
Medical devices
43
Describe the pressure injury risk assessment- what is assessed?
Mobility
Nutrition
Skin perfusion
Sensory
44
Stage 1
Non-blanchable erythema
45
Stage 2
Partial thickness skin loss- pink or red viable tissue/moist. Or ruptured serum filled blister
46
Stage 3
Full thickness skin loss with visible adipose tissue.
Granulation tissue will form on surface.
Edges may be rolled under (epibole), undermining and tunneling may exist.
Necrosis may exist
47
Stage 4
Full thickness skin loss with fascia
Muscle, tendons, ligaments, cartilage and/or bone seen.
Edges are rolled, undermining and tunneling may exist.
Necrosis may exist
48
Unstageable Injury
Obscured full thickness- unable to see depth or extent of damage. Covered with slough or eschar
49
Deep Tissue Injury
Localized, non-blanchable, deep red, maroon, purple discoloration.
50
Device Related Tissue Injury
Assumes shape of device
51
Mucosal Membrane Tissue Injury
Respiratory equipment, feeding tubes, drainage tubes.
Can't be staged
52
Patients with Darker Skin Injury Assessment
Harder to stage.
Assess for changes in skin color, temperature, moisture, texture (hardened), pain, shiny
53
Maceration
Irritation caused by moisture
54
Slough
Yellow, Stringy nonviable tissue
55
Eschar
Hard Nonviable brown/ black tissue
56
Granulation Tissue
New Connective Tissue
Pinkish- Reddish color
57
Dermatitis
Red irritation after skin is exposed to irritants
58
Skin Tear
Loss of top layer of skin caused by mechanical forces
59
Skin frailty
At-Risk, Vulnerable skin (chronic disease and old age risk)
60
Skin frailty
At-Risk, Vulnerable skin (chronic disease and old age risk)
61
Cellulitis
Infection of superficial layer of skin
62
What are the different wound drainage?
Serous
Serosanguinous
Sanguineous
Purulent
63
Serous Wound Drainage
Plasma. Clear to yellowish
64
Serosanguinous Wound Drainage
Serum with some blood
Light pink or red tinge
65
Sanguineous Wound Drainage
Fresh blood- bright pink/red
66
Purulent Wound Drainage
Infection
67
How are wounds measured?
Tracing circumference and measuring with see-through film
Length (head to toe) and width (lateral) with ruler and depth with Qtip against ruler
68
What is tunneling and how is it measured?
Narrow channel in any direction from base of the wound. Insert sterile cotton tip applicator until resistance is met, measure with ruler.
69
What is undermining and how is it measured?
Under skin at the edge of the wound. Use clock (example 9 o’clock to 12 o’clock)
70
Wound Color Indication: Pink
Epithelial Tissue.
Need to be protected
71
Wound Color Indication: Pinkish- Red
Healing.
Need to protect
Keep moist (helps with granulation)
Fill dead space
72
Wound Color Indication: Yellow
Slough
Might be stuck in inflammatory stage.
May indicate infection.
Need to clean wound, loosen and debride devitalized tissue, loosely fill dead space and keep separated from healthy skin.
Absorb fluid and exudate.
73
Wound Color Indication: Black
Debridement
Monitor for impaired circulation in surrounding area.
74
What happens if there is hard necrotic tissue, covering the patients heels?
Might be left in place because it is acting as a protective barrier.
75
SIgns of inflammation
Pain
Redness
Swelling
76
Montgomery Straps
Adhesive straps that are affixed to skin to provide method for securing dressing w/o having to replace tape every time.
77
Wound Cleansing
The use of fluids to gently remove loosely adherent contaminants and devitalized material from the wound surface.
78
When do you use Wound Cleansing?
Most wounds should be cleansed initially and at each dressing change.
79
What do you use for Wound Cleansing?
Biofilm- microbes that adhere to wound bed- not always able to see
80
Surgical Debridement
Surgically remove dead tissue to prevent infection
81
When do you use Surgical Debridement?
Chronic wounds
82
Irrigation Wound Care
Removes surface material to decrease bacteria.
Most often use 0.9% NS.
Remember principles of hygiene and infection control- irrigate from least to most contaminated
83
When is Irrigation used?
The goal of wound irrigation is to remove foreign material, decrease bacterial contamination of the wound, and to remove cellular debris or exudate from the surface of the wound.
84
Biologic Debridement
Enzymatic agents (collagenase- targets necrotic tissue) larvae- liquify necrotic tissue
85
When is Biologic Debridement used?
Patients who are unable to undergo surgery
86
What is the ideal environment for wound healing?
Moist when healing
87
What factors are considered when selecting dressing?
Acute v. chronic
Drainage
Stage of healing
Surrounding tissue
88
When are sterile dressings used?
After surgery, usually kept on for 24-48 hours
89
Sutures Closure
Keep wounds secure and intact
90
Suture Closure Complications
Nonabsorbable sutures can cause more pain and suture sinus
91
Staples Closure
Keep wounds secure and intact.
Can be put in place quickly.
And wounds heal faster.
92
Staples Closure Complications
Scarring and difficulty removing
93
Skin Adhesive Closure
Time saving.
Protective waterproof barrier to cover wound.
94
Skin Adhesive Complications
Glue must stay in place for 5-7 days in order to close the wound
95
Negative Pressure Wound Therapy
Assist in healing and closing of wound
Reducing edema
Increases granulation
96
Negative Pressure Wound Therapy Complications
Bleeding
Retained foam
Pain
Granulation tissue growing into foam dressing
97
What is the purpose of wound drains?
Decrease accumulation of fluid, air, collect wound drainage
98
Passive Drains
Rely on gravity
99
Active Drains
Use negative pressure
100
Open Drains
Remove fluids to air
101
Closed Drains
Remove fluids to closed containment system
102
When are drains usually removed?
When drainage is 30-100 mL/24 hours
103
What are complications of early drain removal?
Hematoma and Seroma
104
How do nurses monitor drainage output?
Monitor amount
Type
Consistency
Odor
Surrounding skin
105
What findings would be a cause for concern?
Report significant change in output
Blood clots
Infection
Accidental removal
106
How do nurses prevent skin breakdown?
Identify at risk patients
Repositioning (patients need to be on a turn schedule and be re-positioned a minimum of every 2 hours- sometimes more frequently)
Use proper transfer devices to reduce friction
Position appropriately to reduce shearing forces
Early mobilization
Keep skin clean and dry
Support surfaces
Protect bony prominences
Skin and mucosa under devices
Proper hygiene
Hydration
Nutrition (protein, omega 3, vitamin A and C, zinc)
Promote circulation
107
What factor might impair wound healing?
Diabetes
Infection
Foreign body in wound
Medications
Malnutrition
Tissue necrosis
Hypoxia
Multiple wounds
108
Describe the process for obtaining a wound culture. When would one be indicated?
Any signs of infection-
Purulent drainage
Odor
Pain
Erythema
Edema
