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skin integrity and wound healing Flashcards

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1
Q

wound categories

A

tissue loss: burns, ulcers, lacerations
no tissue loss: surgical incision

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2
Q

primary intention

A

edges are approximated
low risk of infection
minimal scarring

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3
Q

secondary intention

A
  • edges not approx.
  • ulcers
  • burns
  • high risk of infection
  • tissue loss
  • severe scarring
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4
Q

tertiary intention

A
  • delayed approx.
  • purposely delaying closure to observe for infection or get rid of infection
  • let heal from bottom up
  • cleaning out
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5
Q

partial thickness wound

A
  • involves epidermis & portions of dermis
  • inflammatory for 24 hrs
  • moist wound: ab 4 days heal
  • dry wound: 6-7 days heal
  • thin layer of epithel. slowly reestablishes
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6
Q

full thickness

A
  • destroys all layers of dermis
  • vasoconstriction in mins/hrs
  • inflammation
  • takes days-months to heal
  • fibroblasts with granulation tissue to heal
  • remodeling: scar tissue healing (can take months to years)
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7
Q

dehiscence

A

the opening of a previously approximated wound
- at high risk 3-11 days after injury or surgery

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8
Q

hemorrhage

A

bleeding of a wound
- hematoma: collection of a clot and blood under the skin that causes a solid swollen area
- ecchymosis

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9
Q

evisceration

A

wound opens and organs come out
- abdominal most common
- call MD stat
- sterile towels soaked in saline to keep moist

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10
Q

fistula formation

A
  • abnormal connections (anastomosis) between a hollow organ and the skin of another hollow organ
  • classified according to location
  • low output: <200mL/24 hr
  • high output: >500mL/24 hr
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11
Q

serous drainage

A

clear watery plasma

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12
Q

sanguinous drainage

A

bright red, active bleeding

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13
Q

serosanguinous drainage

A

mixture of clear plasma fluid and blood (pale pink and watery)

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14
Q

purulent drainage

A

thick, yellow, green, tan, or brown, odorous

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15
Q

pressure injury

A

a localized injury to the skin and other underlying tissue usually over a bony prominence as as a result of pressure or pressure in combination with sheet and or friction

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16
Q

two problems causing pressure injury

A
  1. no oxygen delivered
  2. no cellular waste removed
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17
Q

pressure related factors

A
  • intensity
  • duration
  • tissue tolerance
  • skin response to pressure
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18
Q

skin response to pressure

A
  • normal reactive hyperemia
  • abnormal: non blanching erythema
  • darker skinned patients are exception for no blanching
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19
Q

braden scale

A

6-23
- low score= high risk
- hiher than 18= low risk
- ability to feel pain and pressure
- moisture
- activity
- mobility
- nutrition
- sheering forces combined with friction

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20
Q

define friction and sheer

A

friction: the resistance of skin rubbing on sheets
sheer: two things sliding against each other

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21
Q

age related risk factors

A
  • reduced skin elasticity
  • decreased amount of collagen
  • polypharmacy
  • decreased inflammatory response
  • malnutrition
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22
Q

pressure injury sites

A

sacrum
greater trochanters
ischial tuberosities
lateral malleolus
tuberosity of calcaneus
olecranon

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23
Q

tunneling

A

channel or pathway that extends in any direction from the wound through subq tissue
- use sterile 9” q tip to measure

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24
Q

undermining

A

tissue destruction underlying the intact skin along the wound margins

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25
slough
- dead non-viable tissue - yellow, green, or gray - light, thin, wet, stringy - remove
26
eschar
- dead, non-viable - usually black, brown, or gray - dark, thick, hard - leave in place, similar to scab
27
granulation tissue
- live, viable, good - beefy red color
28
epithelial tissue
- live, viable - deep to pearly pink - dry
29
muscle
- highly vascularized - pink to dark red, striated
30
periwound skin
skin around the wound
31
maceration
lighter color of moist skin (technical name for grape fingers)
32
erythema
redness
33
cyanosis
poor blood flow
34
when are wounds staged
once at admission
35
stage 1
- no blanching erythema of intact skin - no tissue loss
36
stage 2
- partial thickness skin loss with exposed dermis - shallow open ulcer-- intact or ruptured blister - red-pink wound bed
37
stage 3
- full thickness skin loss - not seeing bone, tendon, or muscle - may see epibole - possible slough, escar, undermining, or tunneling
38
stage 4
- full thickness skin and tissue loss - seeing muscle and bone - often includes epibole, undermining, tunneling - may include slough or eschar
39
unstageable/unclassified
- full thickness skin/tissue loss - unknown depth - base of wound not visualized d/t slough and eschar
40
suspected deep tissue injury
- depth unknown - purple or maroon area of intact skin or blood filled blister
41
wound vac
assistant in wound closure by applying negative pressure to draw the edges of the wound together
42
can black foam touch healthy skin?
no, it will cause tissue death
43
debridement
- the removal of dead, non-viable tissue
44
mechanical debridement
- wet to dry dressings - irrigation - whirlpool
45
autolytic debridement
- patients own enzymes self digest eschar - transparent dressing over wound to seal
46
chemical debridement
- topical enzymes - dakins solution - maggot therapy
47
surgical debridement
sharp instrument used to cut away necrotic tissue
48
proteins role in wound repair
- growth and repair
49
most common way to test protein level
serum albumin level
50
BEST measure of overall nutritional status
prealbumin
51
vitamin A's role in wound repair
- helps reduce the negative effects of steroids on wound healing - carrots are good source
52
vitamin C's role in wound repair
- helps synthesize collagen
53
zinc's role in wound repair
- epithelialization - helps synthesize collagen - nuts are good source
54
copper's role in wound repair
- good for collagen fiber linking - seafood is good source
55
fluid with highest risk for skin breakdown
GI drainage
56
fluid with moderate risk for skin breakdown
bile stool urine purulent exudate
57
fluid with low risk for skin breakdown
slava serosanguinous drainage
58
barrier cream
preventative measure for pressure injuries
59
reposition pt...
- q2h - lift, dont drag
60
teach mobile pts to ...
reposition q 15 minutes 30 degree lateral position
61
support surfaces for pressure injury prevention
specialty beds waffle mattress
62
mepilex
pressure injury preventative dressing - piece of foam w sticky dressing
63
gold standard for wound cultures
tissue biopsy
64
when collecting specimens for wound cultures...
- clean wound first - never collect old drainage
65
benefits of heat therapy
- vasodilation - helps decrease muscle tension
66
benefits of cold therapy
- vasoconstriction - blood vessels take up less space, therefore less pressure - decrease muscle tension
67
when to not use hot/cold therapy
if pt cannot feel pain
68
types of heat therapy
- warm, moist compress - warm soak - sitz bath - hot pack - heat lamps
69
warm soak temp range
105-110 degrees F
70
sitz bath
- for perineal area - done for 20 minutes
71
heat lamps
- leave on for about 10 minutes - should be an arms length away from pt
72
cold therapy
cold soak - 59 degrees F - 20 mins cold compress - 20 mins ice bag or collar - 30 mins
73
dressing change: check orders for...
- type of dressing - cleaning solution - wound specifics
74
clean dressing changes
- done with a clean technique - put on gloves - remove old dressing - clean and assess site - apply new dressing
75
wound assessment
- OREEDA - closure
76
drainage assessment
CCOAL Color Consistency Odor Amount Location
77
types of closures
- sutures - staples - steri strips

foundations (16 decks)

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