Flashcards in Skin integrity and wound care Deck (55):
What are the primary functions of the skin?
Vitamin D production
What are some factors that affect skin integrity?
(things that must be maintained)
If the skin and mucous membranes are unbroken and undamaged they provide a barrier
Adequately nourished and hydrated cells resist injury and disease easier
Adequate circulation must be maintained for cells to live and remove wastes
What are some factors that place a person at risk for skin alterations and why?
Lifestyle variables like promiscuity, homosexuality, IV drug usage, hemophiliacs, Occupation that gives sun exposure, piercings - (most of these would allow microorganisms entry though puncture or mucous membrane damage)
Changes in health state
dehydration or malnutrition
(skin will become prone to breakdown, lack of senses could cause damage the pt doesnt know about,)
Illness - diabetes
(lack of circulation could cause ulcers or cuts to become necrotic)
Infections (impedes healing)
GI tests could cause diarrhea ( this can cause maceration because of prolonged exposure to moisture)
Casts (masceration and irritation)
Aquathermia unit (masceration)
Radiation therapy (damages normal cells as well as cancerous cells, could destroy skin integrity)
Medications (diarrhea, itching, rashes, ect)
What are some developmental considerations for skin integrity?
Infant skin and mucous membranes are easily damaged and subject to infection
Skin is weaker in children under 2 than it is in adults
as children get older their skin becomes increasingly resistant in injury and infection
When people get older the structure of skin changes. It loses circulation, elasticity, and thickness,
What are some specific skin alterations that occur when aging?
The subcutaneous and dermal layers become thin making them easier to damage, harder to insulate, wrinkle, and pressure and pain is reduced
Sebacious and sweat glands decrease in activity causing the skin to become drier causing pruritis
Cell renewal is shorter, healing time delayed
Melanocytes are fewer in number, causing grey-white hair and uneven pigment
Collagen fiber is less organized , losing elasticity
What conditions of health could cause a person to be more at risk for skin integrity damage?
Very thin or very obese people
Fluid loss through fever, vomiting, or diarrhea (dehydration)
Excessive perspiration in skin folds (masceration, possible infections)
Jaundice (pruritus can cause open lesions)
Diseases of the skin like psoriasis and eczema
Someone that takes Medications (diarrhea, itching, rashes, ect)
How are wounds classified?
Intentional/ unintentional (surgical/accidents)
Open and closed (skin surface broken/unbroken)
Acute and chronic (approximated and short healing time/ unapproximated, long healing time)
Partial thickness, full thickness, complex
What is the difference between intentional and unintentional wounds?
approximated edges, therapeutic in nature, bleeding controlled, low risk of infection, healing is facilitated
accidental, nonapproximated edges, contamination is likely, edges are jagged not clean, bleeding uncontrolled, high risk of infection
What is open vs closed wounds
skin surface is broken ex (incisions and abrasions)
skin surface not broken but soft tissue is damaged, internal hemorrhaging and injury may have occured.
Acute vs chronic wounds
What types of wounds would you expect to see in these categories?
heal within days or weeks, edges are approximated, infection risk is low, go through normal healing process
surgical or therapudic wounds
do not go through normal healing process, edges are not approximated, infection risk is high, healing time is delayed, they remain in the inflammatory phase of healing,
any wound that does not heal along the expected continuum, like pressure ulcers, arterial or venous insufficiency
How is tissue repaired?
by physiologic mechanisms that regenerate functioning and replace connective tissue cells with scar tissue
They increase blood supply to damaged area, wall off and remove cellular and foreign debris, and initiate cellular development
What is primary, secondary, and tertiary intention?
Primary - well approximated wound, intentional,
Secondary - when a large wound is left open to heal, heals slowly causing more scar tissue, edges are not well approximated, often contaminated,
Tertiary - wounds that are left open for a couple days to drain exudate or allow edema and infection to drain, and are then closed
what can you do to promote healing? (principals)
keep a wound clean and free of debris, positioning for circulation,
Surgical asepsis when caring for the wound
What are the phases of wound healing?
hemostasis, inflammation, proliferation, and maturation
What is hemostasis?
bleeding stops and, exudate is produced in this phase creating heat, redness and pain
What is the inflammatory response ?
lasts about 4-6 days
Leukocytes and macrophages arrive to ingest bacteria, and debris.
Macrophages release growth factors 24 hours after cycle starts to help new epithelial cells and blood vessels grow
Acute inflammation here (redness, swelling, heat, pain)
Systemic considerations are elevated temp, leukocytosis, and malaise
What is the proliferation phase?
What are some considerations in this phase?
lasts for several weeks
new tissue is made to fill wound space, especially granulation tissue (foundation for scar tissue development)
Wound will be lighter in color by end of second week
skin forms over granulation tissue
nutrition, oxygenation, preventative strain
What is the maturation phase?
final stage begins about 3 weeks after injury
deposited collagen is remodeled and forms a scar
What are some local negative factors that affect wound healing?
pressure (no circulation )
Desiccation ( cells that dehydrate and die)
Maceration (overhydration related to urinary and fecal incontinence)
Edema (interferes with blood supply to site, causes inadequate oxygen and nutrition)
Infection ( increases stress on the body, leaves no reserves of energy to heal the wound , toxins are also produced when bacteria die)
Necrosis ( dead tissue, healing cannot take place with dead tissue in wound)
What are the systemic factors that affect wound healing?
circulation and oxygenation ( must have enough of both to deliver oxygen and nutrients and remove wastes and debris)
Nutritional status (we require adequate amounts of macro and micronutrients to heal, as well as fluids)
wound condition (including sutures)
Meds and health status ( People taking corticosteriods, radiation therapy, chemotherapy, chronic illnesses, and prolonged antibiotic therapy are at risk)
Immunsupression - from disease, meds, and age
When would the symptoms of infection become noticeable and what would you see?
2 - 7 days
purulent drainage, increased drainage, pain, redness, swelling, increased body temp, leukocytosis,
What can cause a hemorrhage?
How often should you check?
Slipped suture, dislodged clot at wound site, infection, erosion of a blood vessel by a foreign body like a drain
frequently during the first 48 hours then every 8 after that
who would be most at risk for a dehiscence or an evisceration ?
What do you do?
people who smoke, obese, malnourished, use anticoagulants, infected wounds, or have excessive coughing, vomiting , and sneezing
increase in flow of fluid post op about 4 or 5 days.
Medical emergency if in abdomen cover with moistened towel of 0.9 saline and call doctor
DO NOT LEAVE PT ALONE
What is a fistula ?
What causes it?
What does the presence indicate?
abnormal passage from an internal organ to the outside of the body or from one internal organ to another
often the result of an infection that has developed into an abscess
increases the risk for delayed healing, additional infection, fluid and electrolyte imbalances ,and skin breakdown
What are some psychological effects of wounds?
Pain, anxiety and fear, changes in body image
what populations are at risk for pressure ulcers?
what two mechanisms contribute to them?
Elderly, individuals with spinal cord injuries, traumatic brain injuries, neuromuscular disorders, individuals with altered levels of conciousness (may not know if wet or soiled and may not care or be abe to perform hygene) individuals that are fresh out of major surgery
external pressure that compresses blood vessels
friction and shearing forces that tear and injure skin
what types of malnourishment contributes to pressure ulcers?
protein deficiency, electrolyte imbalances, insufficient calorie intake, vitamin C, poor fit of dentures or bad teeth, dehydration
how does urine and fecal matter increase the possibility of damage to the skin?
the skin is normally acidic, it raises the alkalinity, this promotes premature shedding of skin decreasing the skins defenses against bacteria, which results in enhanced growth of pathogens
What is the first indication of a pressure ulcer starting to form?
What should happen once pressure is initially removed at this point since its not a pressure ulcer yet
blanching of the skin over the area under pressure
hyperemia , and it should fade within 60-90 mins
What are the stages of pressure ulcer
suspected deep tissue injury
What is a stage 1,2,3,4 and unstageable pressure ulcer?
1 - intact skin with nonblanchable redness, color may differ from surrounding skin instead of redness in darker pigmented patients. Could be soft, firm, water. or cooler than adjacent tissues. This can indicate at risk people
2- partial thickness loss of dermis, shallow open ulcer with red pink wound bed, NO slough NO bruising, Could also present as an intact serum-filled blister
3 - Full thickness tissue loss of dermis, no muscle or bone present, may have slough that doesnt obscure depth, eschar as well, may include undermining and tunneling,
4 - Full Thickness tissue loss with exposed bone, tendon, or muscle that is directly palpable. Slough or eschar may be present, undermining and tunneling, can extend into muscle and supporting structures.
Unstageable - full thickness tissue loss where the base of the ulcer is covered by slough and or escar in the wound bed. stage cannot be determined until the slough or eschar is removed.
During an assessment, how would you identify a suspected deep tissue injury
purple or maroon localized area of intact skin, or a blood filled blister
wound could be firm, boggy, warmer, or cooler than surrounding tissues
What are the values of the Braden scale risk assessement
9 or lower is very high risk
10-12 high risk
13-14 moderate risk
15-18 is mild risk
19-23 is no risk
What are the assessment parameters for wounds and pressure ulcers?
drainage and drains
wound and tissue pain
What do the edges of a normal surgical wound look like/?
Clean, approximated, crust long the edges, red for about one week
how often would you assess for pain with wounds?
before , during , and after changes
If pain is accompanied by increased purulent drainage, what may be happening
may indicate delayed healing or an infection
what are some methods of debridement?
Autolytic, enzymatic, mechanical, biosurgical (fly larva)
Transparent films, and use?
how long can they stay on?
when not to use them
Occlusive, non absorbative,allow for visual of wound
IV's wounds with minimal drainage, can be used as a cover dressing , stage one and 2 ulcers
7 days unless venous catheter,then 2 days
Hydrocolliods, use? How long can they be left in? dont use?
semi occlusive, minimal absorption
wounds with light to moderate drainage,
stage 1 -3 ulcers
intact skin at risk
Facilitates autolytic debridement
for wounds that are infected
hydrogels, use? how long can it be left in? dont use?
maintain moist environment, minimal absorption
necrotic wounds, burns, minimal exudate, infected wounds, facilitates autolytic debridement
wounds with significant exudate
how often to change?
when not to use it?
wounds with moderate to heavy exudate, infected and non infected,
12hrs to 4 days
DO NOT USE with minimal drainage or dry eschar ( will adhere)
when to change
what not to use it for
highly absorbant, maintain moist environment, promote autolysis and granulation, and around tubes and drains
change every 7 days
NOT FOR dry eschar or wounds with minimal exudate
reduce and prevent infections
draining wounds, non healing wounds, (acute and chronic )
collagens? how long can they be left in? When dont you use them?
absorbent, promotes autolytic debridement, stages 2-4, grafts, tunneling, donar sites
up to 7 days
dont use on dry wounds or wound with dry eschar
combine two or more physically distinct products in a single dressing change 4
wounds with minimal to heavy exudate, mixed tissue wounds, wounds with an infection
what should you always do with a dressing after you are finished with it ? (on the pt)
write name on edge with date
What is a straight binder, T- binder, and a sling for ?
Encircles the torso,
secure dressings in the groin area, single for women, double for men
used to support an arm
what are so.me additional techniques that can be used to promote healing.
Fibrin sealants (stop bleeding and glue wound together)
Negative-pressure wound therapy (used for slow healing, heavy drainage, or failing to heal)
Growth factors (for chronic non healing wounds, promotes granulation, proliferation, and cell migration)
Oxygen therapy ( for slowly healing wounds - in hyperbaric chamber, promotes proliferation , blood flow and growth of new blood vessels)
Heat and cold therapy (heat increases inflammatory response and cold constricts blood vessels reducing spasms and promoting comfort)
When do sutures usually come out ?
6-8 days after the wound has enough tensile strength to hold itself shut
what are the systemic effects of prolonged heat?
increased cardiac output, sweating, increased pulse rate, and decreased blood pressure
what are the systemic effects of prolonged cold exposure?
increased blood pressure, shivering, and goosebumps
what are the local effects of applying heat?
dialates peripheral blood vessels,
increases tissue metabolism
reduces blood viscosity and increases capillary permeability
reduces muscle tension
helps relieve pain
What are the local effects of applying cold?
Constricts peripheral blood vessels
reduces muscle spasms