Skin integrity and wound care

Question 1

What are the primary functions of the skin?

Answer 1

Protection
Temperature regulation
Psychosocial
Sensation
Vitamin D production
Immunological
Absorption 
Elimination

Question 2

What are some factors that affect skin integrity?

things that must be maintained

Answer 2

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

Question 3

What are some factors that place a person at risk for skin alterations and why?

Answer 3

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)

Question 4

What are some developmental considerations for skin integrity?

Answer 4

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,

Question 5

What are some specific skin alterations that occur when aging?

Answer 5

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

Question 6

What conditions of health could cause a person to be more at risk for skin integrity damage?

Answer 6

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)

Question 7

How are wounds classified?

Answer 7

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

Question 8

What is the difference between intentional and unintentional wounds?

Answer 8

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

Question 9

What is open vs closed wounds

Answer 9

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.

Question 10

Acute vs chronic wounds

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

Answer 10

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

Question 11

How is tissue repaired?

Answer 11

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

Question 12

What is primary, secondary, and tertiary intention?

Answer 12

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

Question 13

what can you do to promote healing? (principals)

Answer 13

keep a wound clean and free of debris, positioning for circulation,

Surgical asepsis when caring for the wound

Question 14

What are the phases of wound healing?

Answer 14

hemostasis, inflammation, proliferation, and maturation

Question 15

What is hemostasis?

Answer 15

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

Question 16

What is the inflammatory response ?

Answer 16

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

Question 17

What is the proliferation phase?

What are some considerations in this phase?

Answer 17

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

Question 18

What is the maturation phase?

Answer 18

final stage begins about 3 weeks after injury

deposited collagen is remodeled and forms a scar

Question 19

What are some local negative factors that affect wound healing?

Answer 19

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)

Question 20

What are the systemic factors that affect wound healing?

Answer 20

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

Question 21

When would the symptoms of infection become noticeable and what would you see?

Answer 21

2 - 7 days

purulent drainage, increased drainage, pain, redness, swelling, increased body temp, leukocytosis,

Question 22

What can cause a hemorrhage?
Symptoms?
How often should you check?

Answer 22

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

Question 23

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

signs?

What do you do?

Answer 23

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

Question 24

What is a fistula ?

What causes it?

What does the presence indicate?

Answer 24

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

Question 25

What are some psychological effects of wounds?

Answer 25

Pain, anxiety and fear, changes in body image

Question 26

what populations are at risk for pressure ulcers? what two mechanisms contribute to them?

Answer 26

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

Question 27

what types of malnourishment contributes to pressure ulcers?

Answer 27

protein deficiency, electrolyte imbalances, insufficient calorie intake, vitamin C, poor fit of dentures or bad teeth, dehydration

Question 28

how does urine and fecal matter increase the possibility of damage to the skin?

Answer 28

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

Question 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

Answer 29

blanching of the skin over the area under pressure hyperemia , and it should fade within 60-90 mins

Question 30

What are the stages of pressure ulcer

Answer 30

``` suspected deep tissue injury 1 2 3 4 unstageable ```

Question 31

What is a stage 1,2,3,4 and unstageable pressure ulcer?

Answer 31

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.

Question 32

During an assessment, how would you identify a suspected deep tissue injury

Answer 32

purple or maroon localized area of intact skin, or a blood filled blister wound could be firm, boggy, warmer, or cooler than surrounding tissues

Question 33

What are the values of the Braden scale risk assessement

Answer 33

``` 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 ```

Question 34

What are the assessment parameters for wounds and pressure ulcers?

Answer 34

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

Question 35

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

Answer 35

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

Question 36

how often would you assess for pain with wounds?

Answer 36

before , during , and after changes

Question 37

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

Answer 37

may indicate delayed healing or an infection

Question 38

what are some methods of debridement?

Answer 38

Autolytic, enzymatic, mechanical, biosurgical (fly larva)

Question 39

Transparent films, and use? how long can they stay on? when not to use them

Answer 39

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

Question 40

Hydrocolliods, use? How long can they be left in? dont use?

Answer 40

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

Question 41

hydrogels, use? how long can it be left in? dont use?

Answer 41

maintain moist environment, minimal absorption necrotic wounds, burns, minimal exudate, infected wounds, facilitates autolytic debridement 5-7 days wounds with significant exudate

Question 42

Alginates,use? how often to change? when not to use it?

Answer 42

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)

Question 43

Foams when to change what not to use it for

Answer 43

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

Question 44

Antimicrobials

Answer 44

reduce and prevent infections draining wounds, non healing wounds, (acute and chronic )

Question 45

collagens? how long can they be left in? When dont you use them?

Answer 45

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

Question 46

Composites

Answer 46

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

Question 47

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

Answer 47

write name on edge with date

Question 48

What is a straight binder, T- binder, and a sling for ?

Answer 48

Encircles the torso, secure dressings in the groin area, single for women, double for men used to support an arm

Question 49

what are so.me additional techniques that can be used to promote healing.

Answer 49

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)

Question 50

When do sutures usually come out ?

Answer 50

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

Question 51

what are the systemic effects of prolonged heat?

Answer 51

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

Question 52

what are the systemic effects of prolonged cold exposure?

Answer 52

increased blood pressure, shivering, and goosebumps

Question 53

what are the local effects of applying heat?

Answer 53

dialates peripheral blood vessels, increases tissue metabolism reduces blood viscosity and increases capillary permeability reduces muscle tension helps relieve pain

Question 54

What are the local effects of applying cold?

Answer 54

Constricts peripheral blood vessels reduces muscle spasms promotes comfort

Question 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?

Answer 55

93-99 F 105-109 F 15-20 mins