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foundations exam 2
skin integrity and wound care
| Question | Answer |
|---|---|
| structures of the skin | epidermis, dermis, subcutaneous |
| epidermis | Protective waterproof layer of keratin Cells have no blood vessels of their own Regenerates easily and quickly |
| dermis | Elastic tissue made primarily of collagen Nerves, hair follicles, glands, immune cells, and blood vessels |
| Subcutaneous | Anchors the skin layers to underlying tissues |
| functions of the skin | protection, body temperature regulation, psychosocial, sensation, vit D production, immunologic, absorption, elimination |
| Factors Affecting the Skin | Unbroken and healthy skin and mucous membranes defend against harmful agents Resistance to injury is affected by age, amount of underlying tissues, and illness Adequate nutrition, hydration and circulation is needed |
| in children younger than 2, | the skin is thinner and weaker than it is in adults |
| infants skin | An infant’s skin and mucous membranes are easily injured and subject to infection; a child’s skin becomes increasingly resistant to injury and infection |
| structure of skin changes as | a person ages because the maturation of epidermal cells is prolonged, leading to thin, easily damaged skin |
| older adults developmental considerations | circulation and collagen formation are impaired, leading to decreased elasticity and increased risk for tissue damage from pressure |
| causes of skin alterations | Very thin and very obese people are more susceptible to skin injury Fluid loss during illness causes dehydration and predisposes skin to breakdown Jaundice Diseases of the skin, such as eczema and psoriasis, may cause lesions that require special care |
| jaundice causes | yellowish, itchy skin |
| Types of Wounds | Intentional (surgical) or unintentional (traumatic) Neuropathic or vascular Pressure related Open or closed Acute or chronic Partial thickness, full thickness, complex |
| intact skin is the | first line of defense against microorganisms |
| careful hand hygiene is | used for caring for a wound |
| Principles of Wound Healing | An adequate blood supply is essential for normal body response to injury Normal healing is promoted when the wound is free of foreign material The extent of damage and the person’s state of health affect wound healing |
| Response to wound is more effective if | proper nutrition is maintained |
| phases of wound healing | hemostasis, inflammatory, proliferation, maturation |
| when does hemostasis occur | immediately after injury |
| what does hemostasis involve | blood vessels that constrict and blood clotting begins |
| what happens during hemostasis | Exudate is formed, causing swelling and pain Increased perfusion results in heat and redness Platelets stimulate other cells to migrate to the injury to participate in other phases of healing |
| Inflammatory Phase follows | hemostasis and lasts about 2 to 3 days |
| what happens during the inflammatory phase | White blood cells, move to the wound Macrophages ingest debris and release growth factors Exudate is formed and causes pain, redness, and swelling at the site of injury |
| Proliferation Phase lasts | for several weeks |
| what happens during the proliferation phase | New tissue is built to fill the wound space through the action of fibroblasts Capillaries grow across the wound A thin layer of epithelial cells forms across the wound Granulation tissue forms a foundation for scar tissue development |
| Maturation Phase is | the final stage of healing |
| when does Maturation Phase begin | about 3 weeks after the injury, possible continuing for months or years |
| what happens during maturation phase | Collagen is remodeled New collagen tissue is deposited, causing a scar |
| scar | flat, thin, white line; avascular collagen tissue that does not sweat, grow hair, or tan in sunlight |
| Local Factors Affecting Wound Healing | Pressure Desiccation (dehydration) Maceration (overhydration) Trauma Edema Infection Excessive bleeding Necrosis (death of tissue) Presence of biofilm (thick grouping of microorganisms) |
| Systemic Factors Affecting Wound Healing | age, circulation and oxygenation, nutritional status, wound etiology, health status, immunosuppression, medication use, adherence to treatment plan |
| age | children and healthy adults heal more rapidly |
| circulation and oxygenation, nutrition | adequate blood flow and nutrition is essential |
| would etiology | specific condition of the wound affects healing |
| Health status | corticosteroid drugs and postoperative radiation therapy delay healing |
| wound complications | infection, hemorrhage, dehiscence, evisceration, delayed wound healing |
| Dehiscence | Unintentional separation of wound edges, especially a surgical wound |
| Evisceration | separation of wound with protrusion of abdominal contents through the opening. Obese, malnourished, immunocompromised, medical emergency!!! |
| what to do for dehiscence and evisceration | cover the area with sterile moist normal saline-soaked 4X4s. Return patient to bed (supine) and call provider or code immediately. Monitor LOC and vital signs. |
| Factors Affecting Pressure Injury Development | Aging skin Chronic illnesses Immobility Malnutrition Fecal and urinary incontinence Altered level of consciousness Spinal cord and brain injuries Neuromuscular disorders |
| Risks for Pressure Injury Development | Nutrition and hydration Immobility Mental status Age |
| Stage 1 pressure injury | intact skin with nonblanchable erythema |
| Stage 2 pressure injury | Partial-thickness loss of skin with exposed dermis; wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister |
| Stage 3 pressure injury | Full-thickness skin loss in which adipose is visible and ulcer and granulation tissue and epibole (rolled wound edges) are often present |
| Stage 4 pressure injury | Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer |
| Unstageable pressure injury | Obscured full-thickness skin and tissue loss; extent of damage cannot be confirmed as it is obscured by slough or eschar |
| Deep tissue pressure injury | Persistent nonblanchable deep red, maroon, or purple discoloration. Skin may be intact or nonintact |
| Nursing Responsibilities Related to Skin Integrity | Assessment of the patient and the wound and staging of pressure injuries Development of the nursing plan of care Providing specific wound care skills Ongoing assessment for possible skin or wound complications and pain |
| Development of the nursing plan of care | Identification of appropriate outcomes, nursing interventions, and evaluation of the nursing care |
| Psychological Effects of Wounds | Pain Anxiety Fear Impact on activities of daily living Change in body image |
| Health History to consider | Recent changes in skin Activity and mobility Nutrition Pain Elimination |
| Skin Assessment | Inspection and palpation Systematically—head to toe Include bony prominences On admission and at regular intervals |
| skin assessment if pt in acute care | every shift change |
| skin assessment if pt in long term care settings | weekly for 4 weeks then quarterly |
| skin assessment if pt in has home health care | each visit |
| Wound Assessment | appearance, drainage |
| what to note about appearance | Size of wound Depth of wound Presence of undermining, tunneling, or sinus tract |
| what to note about drainage | Serous Sanguineous Serosanguineous purulent |
| pressure injury definition | Localized damage to the skin and underlying tissue usually over a bony prominence or related to a medical device or object |
| pressure relieving measures | Frequent turning Pressure-relieving devices Positioning |
| how to prevent pressure injuries pt 1 | Assess at risk patients daily Cleanse the skin routinely Maintain higher humidity; use moisturizers Protect skin from moisture |
| how to prevent pressure injuries pt 2 | Minimize skin injury from friction or shearing Proper positioning, turning, transferring Appropriate support surfaces Nutritional supplements Improve mobility and activity |
| Assessments Made Preventing Pressure Injuries | Assess the patient's skin at least daily Pay special attention to skin over boney prominences Examine skin in contact with medical devices Assess nutrition status and pressure injury risk |
| Measuring Wounds and Pressure Injuries | Size of wound Depth of wound Wound tunneling |
| Color Classification of Open Wounds | R = red—protect Y = yellow—cleanse B = black—débride Mixed wound—contains components of RY&B wounds |
| Assessments Made When Cleaning a Wound and Applying a Dressing | Assess to determine the need for cleaning or dressing change, asses the pts comfort, assess the current dressing, assess for excess drainage, bleeding, saturation of the dressing, approximation of wound edges, color of wound, and signs of dehiscence |
| Assessments Made When Cleaning a Wound and Applying a Dressing | Assess for the presence of sutures, staples, or adhesive closure strips Note the stage of the healing process and characteristics of any drainage Assess the surrounding skin for color, temperature, edema, and ecchymosis or maceration |
| Purposes of Wound Dressings pt 1 | Provide physical, psychological, and aesthetic comfort Prevent, eliminate, or control infection Absorb drainage Maintain moisture balance of the wound Protect the wound from further injury |
| Purposes of Wound Dressings pt 2 | Protect the skin surrounding the wound Debride (remove damaged/necrotic tissue), if appropriate Stimulate and/or optimize the healing response Consider ease of use and cost-effectiveness |
| Types of Wound Dressings | Those that maintain moisture Those that absorb moisture Those that add moisture |
| Changing the Dressing process | Prepare the patient Use appropriate aseptic techniques Hand hygiene before and after Adhere to standard and transmission-based precautions Remove the old dressing Cleanse the wound Apply a new dressing Secure the dressing |
| Cleaning a Pressure Injury/Wound | Clean with each dressing change Use new gauze for each wipe, clean top to bottom/center to outside Use 0.9% normal saline solution to irrigate and clean the injury |
| what should you report when cleaning a pressure injury/wound | Any drainage or necrotic tissue |
| Once the wound is cleaned, | dry the area using a gauze sponge in the same manner |
| Type of Drainage Systems | Open systems Closed systems |
| open systems | penrose drain |
| closed systems | JP drain, hemovac drain |
| Penrose Drain | Hollow, soft, flexible, open-ended rubber tube used after surgical procedures or to drain an abscess |
| Penrose Drain allows | Allows fluid to drain passively via capillary action into absorbent dressings |
| penrose drain is help in place by | a large safety pin placed in the part outside the wound |
| what is included in the wound assessment with a penrose drain | Patency and placement of the drain |
| uses for a JP drain | Collects wound drainage in a bulblike device that is compressed to create low suction (negative) pressure Consists of perforated tubing connected to a portable vacuum unit; is usually sutured in place Typically used with breast and abdominal surgery |
| care for a JP drain | Usually, drains are emptied and recompressed when the bulb is approximately 25% to 50% full or emptied and recompressed as needed Patency, placement, and the amount and characteristics of the drainage are assessed |
| use s for a hemovac drain | Perforated tubing connected to a portable suction (vacuum) unit Placed into a vascular cavity where blood drainage is expected after surgery Suction is maintained by compressing a spring-like device in the collection unit |
| care for a hemovac drain | Typically, the drain is emptied every 2 to 4 hours and when it is half full of drainage or air Patency, placement of the drain, and the amount and characteristics of the drainage are assessed |
| Negative Pressure Wound Therapy promotes | wound healing and wound closure through the application of controlled, uniform suction (vacuum) |
| Negative Pressure Wound Therapy results in | reduction in bacteria in the wound and the removal of excess wound fluid, while providing a moist wound healing environment |
| Negative Pressure Wound Therapy works by | Stimulating cell proliferation, blood flow to wounds, and the growth of new blood vessel |
| Assessments Made Prior to Removing Sutures | Assess the surgical incision and surrounding tissue/skin for color, temperature, edema, maceration, or ecchymosis Assess the appearance of the wound |
| Assess the appearance of the wound before removing sutures | Approximation of wound edges, color of the wound and surrounding area Presence and characteristics of wound drainage, noting color, volume, and odor and signs of dehiscence, drainage |
| The staples are removed without | without contaminating the incision area without causing trauma to the wound without causing the patient pain or discomfort |
| Expected Outcomes When Removing Surgical Staples | The patient remains free of complications that would delay recovery The patient verbalizes positive aspects about self |
| Applying External Heat Action | Accelerates the inflammatory response promoting healing Reduces muscle tension Relieves muscle spasm Relieves joint stiffness |
| External Heat: Applied by moist and dry methods | Aquathermia pads, microwavable hot packs, air-activated heat therapy patches |
| Effects of Applying Heat | Dilates peripheral blood vessels Increases tissue metabolism Reduces blood viscosity and increases capillary permeability Reduces muscle tension Helps relieve pain |
| Devices to Apply Heat | Hot water bags Electric heating pads Aquathermia pads Hot packs Warm, moist compresses Sitz baths Warm soaks |
| Factors Affecting the Response to Hot and Cold Treatments | Method and duration of application Degree of heat and cold applied Patient’s age and physical condition Amount of body surface covered by the application |
| Effects of Applying Cold | Constructs peripheral blood vessels Reduces muscle spasms Promotes comfort |
| Devices to Apply Cold | Ice bags Cold packs Hypothermia blankets Cold compresses to apply moist cold |
| Topics for Home Health Care Teaching | Supplies Infection prevention Wound healing Appearance of the skin/recent changes Activity/mobility Nutrition Pain Elimination |
Created by:
leh195