Skin integrity and wound care Flashcards Preview

Nursing fundamentals > Skin integrity and wound care > Flashcards

Flashcards in Skin integrity and wound care Deck (55):
1

What are the primary functions of the skin?

Protection
Temperature regulation
Psychosocial
Sensation
Vitamin D production
Immunological
Absorption
Elimination

2

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

3

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
reduced sensation
(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)

Diagnostic measures
GI tests could cause diarrhea ( this can cause maceration because of prolonged exposure to moisture)

Therapeutic measures
Bedrests (immobility)
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)

4

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,

5

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

6

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)

7

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

8

What is the difference between intentional and unintentional wounds?

intentional

approximated edges, therapeutic in nature, bleeding controlled, low risk of infection, healing is facilitated

Unintentional

accidental, nonapproximated edges, contamination is likely, edges are jagged not clean, bleeding uncontrolled, high risk of infection

9

What is open vs closed wounds

open

skin surface is broken ex (incisions and abrasions)

Closed

skin surface not broken but soft tissue is damaged, internal hemorrhaging and injury may have occured.

10

Acute vs chronic wounds

What types of wounds would you expect to see in these categories?

acute

heal within days or weeks, edges are approximated, infection risk is low, go through normal healing process

surgical or therapudic wounds

Chronic

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

11

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

12

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

13

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


14

What are the phases of wound healing?

hemostasis, inflammation, proliferation, and maturation

15

What is hemostasis?

bleeding stops and, exudate is produced in this phase creating heat, redness and pain

16

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

17

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

18

What is the maturation phase?

final stage begins about 3 weeks after injury
deposited collagen is remodeled and forms a scar

19

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)

Trauma

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)

20

What are the systemic factors that affect wound healing?

Age

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

21

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,

22

What can cause a hemorrhage?
Symptoms?
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

hematoma
frequently during the first 48 hours then every 8 after that

23

who would be most at risk for a dehiscence or an evisceration ?

signs?

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.
"something popped"

Medical emergency if in abdomen cover with moistened towel of 0.9 saline and call doctor

DO NOT LEAVE PT ALONE

24

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

25

What are some psychological effects of wounds?

Pain, anxiety and fear, changes in body image

26

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

27

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

28

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

29

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

30

What are the stages of pressure ulcer

suspected deep tissue injury
1
2
3
4
unstageable

31

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.

32

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

33

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

34

What are the assessment parameters for wounds and pressure ulcers?

Body location
Wound type
Size
Periwound
odor
drainage and drains
wound and tissue pain
nutritional status

35

What do the edges of a normal surgical wound look like/?

Clean, approximated, crust long the edges, red for about one week

36

how often would you assess for pain with wounds?

before , during , and after changes

37

If pain is accompanied by increased purulent drainage, what may be happening

may indicate delayed healing or an infection

38

what are some methods of debridement?

Autolytic, enzymatic, mechanical, biosurgical (fly larva)

39

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

40

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

7 days


for wounds that are infected

41

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

5-7 days

wounds with significant exudate

42

Alginates,use?

how often to change?

when not to use it?

absorb exudate,

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)

43

Foams

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

44

Antimicrobials

reduce and prevent infections

draining wounds, non healing wounds, (acute and chronic )

45

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

46

Composites

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

47

what should you always do with a dressing after you are finished with it ? (on the pt)

write name on edge with date

48

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

49

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)

50

When do sutures usually come out ?

6-8 days after the wound has enough tensile strength to hold itself shut

51

what are the systemic effects of prolonged heat?

increased cardiac output, sweating, increased pulse rate, and decreased blood pressure

52

what are the systemic effects of prolonged cold exposure?

increased blood pressure, shivering, and goosebumps

53

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

54

What are the local effects of applying cold?

Constricts peripheral blood vessels
reduces muscle spasms
promotes comfort

55

What should the water temp of a sitz bath be?

What should the water temp of a warm soak be?

How long should they both take?

93-99 F

105-109 F

15-20 mins