Skin integrity & wounds Flashcards
(56 cards)
1
Q
What are some basic principals that would affect skin integrity
A
a. Unbroken and healthy skin and mucous membranes defend against harmful agents
b. Resistance to injury is affected by age, amount of underlying tissues, and illness
c. Adequately nourished and hydrated body cells are resistant to injury
d. Adequate circulation is necessary to maintain cell life
2
Q
What are some factors affecting skin integrity
A
- Aging → thinner skin, delayed cell renewal, increased fragility.
- Impaired circulation & collagen → reduced elasticity, higher risk of pressure injuries.
- Hygiene practices influence skin health throughout life.
- Overall health & medical treatments affect skin condition.
- Proper nutrition & hydration are crucial for maintaining skin integrity.
3
Q
What skin related change causes: increased fragility & slower healing.
A
Thinner skin
4
Q
What skin related change causes: decreased elasticity, higher risk of damage.
A
Reduced circulation & collagen
5
Q
What skin related change causes: temperature sensitivity & more prone to injury
A
Less subcutaneous fat
6
Q
What skin related change causes: drier skin, higher risk of cracking
A
Decreased oil & sweat gland activity
7
Q
What skin related change causes: uneven pigmentation, increased sun damage risk.
A
Fewer melanocytes
8
Q
What skin related change causes: delayed wound healing, more skin tears
A
Weaker collagen fibers
9
Q
What are some nursing considerations for skin related changes
A
- Monitor skin for breakdown & wounds.
- Encourage hydration & use of moisturizers.
- Promote repositioning to prevent pressure ulcers.
- Use mild soaps & avoid harsh skin products.
- Educate on sun protection & proper skin care.
10
Q
What are the 4 classification CAUSES for wounds
A
- Intentional (Surgical): Controlled, sterile wounds.
- Unintentional (Traumatic): May require interventions (e.g., fluids, tetanus shot).
- Neuropathic or Vascular: Related to nerve or circulatory issues.
- Pressure-Related: Due to prolonged pressure on the skin.
11
Q
What are the two CONDITIONS for wounds
A
- Open vs. Closed: Break in skin vs. damage beneath intact skin.
- Acute vs. Chronic: Heals normally vs. prolonged healing process.
12
Q
What are the 3 wound depths
A
- Partial Thickness: Involves epidermis & part of dermis.
- Full Thickness: Extends through dermis, may expose fat/muscle.
- Complex: Deeper wounds affecting multiple layers of tissue.
13
Q
Name the 4 stages of wound healing
A
- Hemostasis
- Inflammation
- Proliferation
- Maturation
14
Q
Hemostasis is
A
Clot formation to stop bleeding
15
Q
Inflammation is
A
Increased blood supply, removal of debris, immune response
16
Q
Proliferation is
A
Tissue regeneration and new tissue formation
17
Q
Maturation is
A
Remodeling and strengthening of tissue
18
Q
How may factors affect wound healing?
A
TWO: Local and systemic
19
Q
What are some local factors affecting wound healing?
A
● Pressure
● Desiccation (dehydration)
● Maceration (overhydration)
● Trauma
● Edema
● Infection
● Excessive bleeding
● Necrosis (death of tissue)
● Presence of biofilm (thick grouping of microorganisms)
20
Q
What are some systemic factors affecting wound healing?
A
● Age
● Circulation and oxygenation
● Nutritional status
● Wound etiology
● Health status
● Immunosuppression
● Medication use
● Adherence to treatment plan
21
Q
Explain what each local factor does
A
- Pressure: Reduces blood flow, delaying healing
- Desiccation (Dehydration): Dries out cells, slowing healing
- Maceration (Overhydration): Weakens skin, increasing infection risk
- Trauma: Repeated injury disrupts healing
- Edema: Impairs oxygen and nutrient delivery
- Infection: Increases inflammation, delays healing
- Excessive Bleeding: Prevents clot formation, increases infection risk
- Necrosis (Tissue Death): Delays healing and requires removal
- Presence of Biofilm: Thick bacterial growth, increases infection risk
22
Q
Explain what each systemic factor does
A
- Age: Children and healthy adults heal faster
- Circulation & Oxygenation: Adequate blood flow is essential
- Nutritional Status: Proper nutrients are needed for healing
- Wound Etiology: Cause of wound impacts healing rate
- Health Status: Conditions like diabetes or chronic diseases slow healing
- Immunosuppression: Weak immune system delays recovery
- Medication Use: Corticosteroids, radiation therapy, and certain drugs slow healing
- Adherence to Treatment Plan: Following care instructions promotes recovery
23
Q
What are some common wound complications
A
a. Infection
b. Hemorrhage
c. Dehiscence and evisceration
d. Fistula formation
24
Q
How would an infection complicate wound healing?
A
- Delays healing process
- Requires continuous monitoring for signs & symptoms
25
How would a hemorrhage complicate wound healing?
* Excessive bleeding can lead to complications
* Requires prompt intervention
26
How would Dehiscence and evisceration complicate wound healing?
* Dehiscence: Wound reopening due to stress or poor healing
* Evisceration: Internal organs protruding through the wound
* Requires immediate medical attention
27
How would a Fistula formation complicate wound healing?
* Abnormal connection between organs or tissues
* Can result from poor wound healing or infection
28
Identify factors involved in pressure injuries
a. Aging skin
b. Chronic illnesses
c. Immobility
d. Malnutrition
e. Fecal and urinary incontinence
f. Altered level of consciousness
g. Spinal cord and brain injuries
h. Neuromuscular disorders
29
What are some Mechanisms in Pressure Injury Development
* External pressure compressing blood vessels
* Friction or shearing forces tearing or injuring blood vessels
* Microclimate: temperature and moisture of the skin
30
Nutrition and hydration, Immobility, Mental status, and Age are all...
Risks for Pressure Ulcer Development
31
How many stages are in the pressure injury staging system
4 stages
32
What is the 1st stage of pressure injuries and how it may appear
Stage 1:
* Non-blanchable erythema of intact skin
* Skin is red but does not turn white when pressed
33
What is the 2nd stage of pressure injuries and how it may appear
Stage 2:
* Partial-thickness skin loss with exposed dermis
* May appear as a blister or shallow open wound
34
What is the 3rd stage of pressure injuries and how it may appear
Stage 3:
* Full-thickness skin loss, not involving underlying fascia
* Fat may be visible, but muscle, tendon, or bone is not exposed
35
What is the 4th stage of pressure injuries and how it may appear
Stage 4:
* Full-thickness skin and tissue loss
* Muscle, tendon, or bone may be exposed
36
Explain an Unstageable Pressure Injury
* Full-thickness skin and tissue loss
* True depth cannot be determined due to slough or eschar covering the wound
37
Explain a Deep Tissue Pressure Injury
* Persistent non-blanchable deep red, maroon, or purple discoloration
* May indicate underlying tissue damage before skin breakdown occurs
38
What would a care plan for impaired skin integrity be comprised of?
Skin assessment, wound assessment, history/ recent changes, activity level, pain, nutrition, elimination, prevention...
39
What would a history/ recent changes for impaired integrity consist of?
● Do you have any sores on your body? If so, how many, and where are they? Have they changed in size? Do you have any drainage from them?
● Have you noticed that the skin over your hips or backbone gets red/discolored if you sit or lie in one position for a long time? Any associated temperature changes in the skin? Does this disappear in a short time when you are up?
● Have you gotten a piercing or tattoo recently?
● Any recent surgical incisions or existing scars?
40
What would an activity level/ pain assessment for impaired integrity consist of?
Activity/mobility
● Do you need assistance to walk or move? If so, how much?
● Are you confined to your bed or a chair?
● Can you independently change your position when you want to?
Pain
● If you have a sore, is it painful?
● Do you take anything for pain? If so, what do you take, and how often? Does it help?
41
What would a nutrition/ elimination assessment for impaired integrity consist of?
Nutrition
● Have you gained or lost weight recently?
● Describe your usual meals each day.
● How many glasses or cups of liquid do you drink each day?
● Do you take any food supplements or vitamins?
● Do you prepare your own meals?
● Do you wear dentures? How do they fit?
● Do you have any difficulty chewing or swallowing?
● Has a doctor ever told you that you are anemic?
Elimination
* Have you noticed any problems (frequency, color, consistency, odor) with your bowels or urination? If so, describe.
* Have you ever used pads or special pants because you can’t control your urine or stools?
42
What would a skin assessment for impaired integrity consist of?
● Do you have any skin areas that are discolored from your baseline coloration? Any gray (ashy) patches on your arms, elbows, lower legs, knees, or heels?
● Have you noticed any texture changes in your skin? Bumps? Rough patches? Cracked thin lines?
● Do some areas of skin on your body feel warmer or colder than others?
● Describe the moisture in your skin: is it damp, dry, oily?
● Have you noticed that your skin seems to be thinner? Where?
● Have you noticed any swelling in your feet, ankles, or fingers?
● Tell me about how you take care of your skin. For example, do you take a tub bath or shower? How often? Do you regularly use oils or lotions?
43
What would a wound assessment for impaired integrity consist of?
i. Appearance
1. Size of wound
2. Depth of wound
3. Presence of undermining, tunneling, or sinus tract
ii. Drainage
1. Serous
2. Sanguineous
3. Serosanguineous
4. purulent
44
What would prevention for impaired integrity consist of?
* Assess at-risk patients daily
* Cleanse skin regularly
* Maintain skin moisture with humidifiers & moisturizers
* Protect skin from moisture (urine, sweat, wounds)
* Prevent friction & shear during movement
* Reposition patients properly (turning, transferring)
* Use appropriate support surfaces (pressure-relieving mattresses, cushions)
* Provide nutritional supplements if needed
* Encourage mobility & activity to improve circulation
45
What do the different types of wound dressings do
maintain moisture, absorb moisture, add moisture
46
Why would you want to maintain moisture
Keep the wound environment stable
47
Why would you want to absorb moisture
For wounds with excess drainage
48
Why would you want to add moisture
For dry wounds to promote healing
49
What are some common wound dressings
* Dry gauze – Basic covering.
* ABD pads – Thick, high absorbency.
* Non-adherent gauze – Petrolatum or Telfa, prevents sticking.
* Specialty gauze – Pre-cut for tubes and drains.
* Transparent dressings – Allow wound visualization, waterproof
50
As a nurse how would you select the appropriate dressing
Based on wound location, size, depth, infection status, drainage amount/type, and need for debridement.
* Consult a wound care nurse/team for complex cases
51
Length, width, depth, comparison method, and clock method are all....
Wound Measurement Techniques
52
Explain the Wound Measurement Techniques
* Length – Measure head-to-toe.
* Width – Measure side-to-side.
* Depth – Measure using a sterile applicator.
* Comparison Method – Compare to common objects (pencil eraser, coin).
* Clock Method for Tunneling – Pt’s head = 12 o’clock, measure in a clockwise direction.
53
Circular turn, Spiral turn, and Figure-of-eight turn are all...
Types of Bandaging Techniques
54
Explain the Types of Bandaging Techniques
* Circular turn – Used for cylindrical body parts (e.g., wrist).
* Spiral turn – Wraps around limbs with slight overlap.
* Figure-of-eight turn – Provides extra support around joints.
55
Open and closed systems are what types of systems
Drainage Systems
56
Explain the Drainage System
* Open system (Penrose drain) – Passive drainage with no suction.
* Closed system (Jackson-Pratt, Hemovac) – Uses suction to remove exudate, reduces infection risk.
