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Nursing 202 > Skin Integrity and Wound Care > Flashcards

Skin Integrity and Wound Care Flashcards

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1
Q

Dermal-epidermal junction

A

Separates dermis and epidermis

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2
Q

Epidermis

A

Top layer of skin

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3
Q

Dermis

A

Inner layer of skin

Collagen

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4
Q

Common Skin Problems

A

Xerosis (abnormal drying)
Pruritus (itching)
Sunburn
Urticaria (hives)

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5
Q

A Pressure ulcer classifies as

A

Pressure sore, decubitus ulcer, or bed sore

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6
Q

Pathogenesis: 3 Pressure Related Factors contribute to pressure ulcer development

A
  1. Pressure intensity: Tissue ischemia, Blanching
  2. Pressure duration
  3. Tissue tolerance
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7
Q

Tissue ischemia:

A

the pressure applied over a capillary exceeds the normal capillary pressure range (15-32 mmHg)

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8
Q

Blanching:

A

occurs when the normal red tones of the light skinned patient are absent

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9
Q

Pressure ulcer definition:

A

Compression of skin and underlying soft tissue between bony prominence and external surface for extended period

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10
Q

What Mechanical forces create ulcers? (3)

A

Pressure
Friction
Shear

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11
Q

Risk factors for pressure ulcer development?

A 
Impaired sensory perception
Alterations in level of consciousness
Impaired mobility
Shear
Friction
Moisture
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12
Q

Shear:

A

sliding movement of skin and subcutaneous tissue while the underlying muscle and bone are stationary

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13
Q

Stages of Pressure Ulcers:

A
  1. Nonblancable Redness of intact skin
  2. Partial thickness Skin Loss or Blister
  3. Full-thickness skin loss (Fat Visible)
  4. Full thickness tissue loss (Muscle/Bone Visible)
    Unstageable: Full thickness skin or tissue loss-depth unknown (either 3 or 4)
    Suspected deep-tissue injury - depth unknown: boggy, mushy, warmer, or cooler adjacent tissue
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14
Q

Stage 1 description:

A

shiny or dry shallow ulcer without slough or bruising

-Difficult to detect with persons with dark skin = risk

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15
Q

Stage 2 description:

A

Skin not intact, shiny or dry shallow ulcer without slough or bruising. May appear as abrasion, blister, or shallow crater. Should not be used to describe skin tears, tape burns, incontinence-associated dermatitis, maceration, or excoriation

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16
Q

Stage 3 description:

A

Varies by anatomical location - Can be shallow, subcutaneous tissue may be damaged or necrotic
Bone, tendon, muscle not exposed
May have tunneling and undermining

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17
Q

Stage 4 description:

A

Varies by anatomical location - some areas can be shallow, exposed bone/muscle is visible or directly palpable - risks include getting osteomyelitis or osteitis

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18
Q

Ways of Pressure Ulcer Prevention:

A
  • Identify high-risk patients early!: Risk scale, Nutrition assessment
  • Implement aggressive intervention of prevention with pressure relief devices
  • Pressure mapping
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19
Q

Pressure-Relieving Techniques:

A

Capillary closing pressure
Pressure-relief products/devices: support therapeutic beds
Positioning: reduce shearing force to skin

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20
Q

Avoid pressure points by positioning the patient at a ….

A

30 degree angle

Turn every 1-2 hours

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21
Q

Top 3 interventions for pressure ulcers:

A
  1. skin care and management of incontinence
  2. Supporting devices and positioning
  3. Education
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22
Q

Need to perform skin assessment how many times?

A

once a day basis

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23
Q

Wounds consists of ..

A

Classification
Wound healing
Repair

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24
Q

Repairing of wounds has 2 categories:

A

-Partial-thickness wound repair
-Full-thickness wound repair:
Hemostasis (fibrin)
Inflammatory phase
Proliferative phase (epithelialization)
Remodeling

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25
Partial-Thickness Wounds:
- Damage to epidermis, upper layers of dermis - Heal by re-epithelialization within 5 to 7 days - Skin injury immediately followed by local inflammation
26
Full-Thickness Wounds:
- Damage extends into lower layers of dermis, underlying subcutaneous tissue - Must be filled with granulation tissue to heal - Contraction develops in healing process
27
Phases of wound healing:
1. Inflammatory (lag) 2. Proliferative (connective tissue repair) 3. Maturation (remodeling)
28
Process of Wound Healing (3):
1. First intention – Edges brought together with skin lined up in approximated position 2. Second intention – Granulation and contraction; deeper tissue injury or wound 3. Third intention – Delayed closure; high risk for infection with resulting scar
29
1. Hemostasis:
injured blood vessels constrict, and platelets gather to stop bleeding, clots form a fibrin matrix that provides framework for cellular repair
30
2. Inflammatory Phase:
damaged tissue and mast cells secrete histamine, resulting in vasodilation of surrounding capillaries and exudation of serum and white blood cells into damaged tissues
31
3. Proliferative Phase:
begins and lasts from 3-24 days | filling the wound with granulation tissue, contraction of the wound, and resurfacing by epithelialization
32
4. Remodeling:
Takes sometimes more than a year | The collagen scar continues to reorganize and gain strength over several months
33
Wound Assessment:
``` Location Size Color Extent of tissue involvement Cell types in wound base and margins Exudate Condition of surrounding tissue Presence of foreign bodies ```
34
Wound Management: Nonsurgical:
``` Dressings Physical/drug/nutrition therapies Electrical stimulation VAC HBOT Topical growth factors Skin substitutes ```
35
Types of Wound drainage:
Serous Purulent Serosanguineous Sanguineous
36
Serous:
clear, watery plasma
37
Purulent:
thick, yellow, green, tan, or brown
38
Serosanguineous:
pale, pink, watery mixture of clear and red fluid
39
Sanguineous:
bright red, indicates active bleeding
40
Complications of Wound Healing:
``` Hemorrhage Hematoma Infection Dehiscence Evisceration ```
41
An exposed wound is always
contaminated but not always infected!
42
Contamination –
 Presence of organisms without infection
43
Infection –
Pathogenic organisms grow and spread, cannot be controlled by body’s immune defenses
44
Acute care includes:
Management of pressure ulcers | Wound management
45
Wound management includes:
-Debridement (removal of nonviable, necrotic tissue) Mechanical, autolytic, chemical, or sharp/surgical -Education -Nutritional status -Protein status -Hemoglobin
46
First Aid for Wounds:
1. Hemostasis: controls bleeding 2. Cleaning: gentle, normal saline 3. Protection
47
Hemostasis allows what?
Allows puncture wounds to bleed | -Do not remove a penetrating object
48
Assessment of Pressure ulcers:
``` Predictive measures Mobility Nutritional status Body fluids Pain ```
49
Risk assessment scale =
Braden scale
50
Braden scale includes assessment of:
``` Sensory perception Moisture Activity Mobility Nutrition Friction and Shear ```
51
Changes in skin condition can be a
manifestation of a systemic medical conditions
52
Purposes of Dressings:
Protect a wound from microorganism contamination Aid in hemostasis Promote healing by absorbing drainage and debriding a wound Support or splint the wound site Protect patients from seeing the wound (if perceived as unpleasant) Promote thermal insulation of the wound surface
53
Dressing Types:
``` Dry or moist Film dressing Hydrocolloid Hydrogel Wound vacuum assisted closure (V.A.C.) ```
54
Dry or moist dressings:
gauze
55
Hydrocolloid—
protects the wound from surface contamination
56
Hydrogel—
maintains a moist surface to support healing
57
Wound vacuum assisted closure (V.A.C.)—
uses negative pressure to support healing
58
Prepare the patient for a dressing change by
``` Evaluate pain. Describe procedure steps. Gather supplies. Recognize normal signs of healing. Answer questions about the procedure or wound. ```
59
Before directly touching an open or fresh wound, what should you do?
Wear sterile gloves
60
When Packing a wound what should you assess?
Assess size, depth, and shape
61
Comfort measures include:
Carefully remove tape. Gently clean the wound. Administer analgesics before dressing change.
62
Bandages and Binders Functions:
create pressure, immobilize and/or support a wound, reduce or prevent edema, secure a splint, secure dressings
63
When Cleaning a drain site, you should apply what?
noncytotoxic solution
64
When applying suture care you should firstly do what?
Consult health care facility policy.
65
When irrigating a drain site, to remove exudates, what should you do?
use sterile technique with 35-mL syringe and 19-gauge needle.
66
What do drainage evacuators do?
Portable units exert a safe, constant, low-pressure vacuum to remove and collect drainage
67
The GNASC tool is used to assess
stage I pressure ulcers in clients with dark skin tone.
68
The Bates-Jensen tool is used to assess
the wound status
69
Calcium alginate along with secondary dressing is used to
dress stage III pressure ulcers
70
Adherent film is used to cover
unstageable pressure ulcers
71
Composite film dressing is used for
stage II pressure ulcers.
72
A transparent dressing is used to
dress stage I pressure ulcers.

Nursing 202 (20 decks)

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