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Skin/Wound P&P

Potter and Perry 7th Edition Chapter 48

Skin General Info. Largest organ, 15% of total body weight, and synthesizes Vit. D.
Skin how many layers and names? 2; Epidermis and dermis.
Layer separating the Epi/dermis? Dermal-epidermal junction.
Stratum corneum, location and importance? Outermost layer of skin, location where skin cells flatten and die. Protection layer from dehydration and germs.
Dermis, mostly consists of what? Connective tissue and very few skin cells.
Dermis, important functions? Tensile strength, mechanical support, and protection of underlying tissues.
In what layer of skin are blood vessels and nerves located? Dermis.
Collagen, location and origin? Located in the dermis and originates from fibroblasts.
Pressure ulcer define. Localized injury to the skin and other underlying tissue as a result of pressure or pressure in combination with shear or friction.
RF for pressure ulcers? Decreased mobility, sensory perception, fecal/urinary incontinence, poor nutrition.
Pressure ulcer general info. Location of tissue injury/death due to decreased circulation.
Three factors of pressure ulcers? Intensity, duration, and tissue tolerance.
Pressure Intensity, increase damage levels? If reddened areas blanches, transient "blanching hyperemia" If area does not blanch, deep tissue damage possible.
Signs of cellular damage in dark skinned people Page 1281 - Box 48-2
Pressure duration, which is worse... low pressure over long periods of time, or high pressure over a short period? Both are equally damaging.
3 factors related to tissue tolerance? Shear, friction, and moisture.
Other factors related to tissue tolerance? Integrity of underlying structures, nutrition, age, low BP.
Shear define. Force exerted parallel to skin resulting from both gravity pushing down on the body and resistance.
What layer of skin does shearing affect? Deep tissue layers.
Friction define? Force of two surfaces moving across one another such as carpet burn.
What layers of skin does friction affect? Epidermis.
Moisture, how does it increase risk of ulcers? Moisture softens skin undermining its protective properties.
In a four-stage classification system, what level would a Stage III ulcer be as it heals? Healing stage III pressure ulcer.
Describe Stage I of a PU. Intact skin, nonblanching.
Describe Stage II of a PU. Partial-thickness skin loss, Superficial ulcer such as abrasion, blister, or shallow crater.
Describe Stage III of a PU. Full-thickness tissue loss, subcutaneous fat possible visible, no bone, tendon, muscle exposed, may include undermining or tunneling.
Describe Stage IV of PU. Full-thickness tissue loss, exposed bone, tendon, muscle, often includes undermining and tunneling.
Describe an "unstageable" ulcer. Full-thickness tissue loss, base is covered by slough and/or eschar in the wound bed.
What is best lighting to assess dark skin tones and why? Natural or halogen, fluorescent light causes blue tones in some darker pigmented skin.
After staging, what is next step in intervention? Determining viable tissue in wound base.
Assessment of viable/nonviable tissue includes what 2 measurements? Amount (percentage) and appearance (color) of each type of tissue.
What is a sign of healing of a wound? Granulation tissue.
What is granulation tissue? Red, moist tissue composed of new blood vessels.
What does slough look like? Stringy substance attached to wound bed.
What is eschar? Black or brown necrotic tissue.
Wound define. Disruption of the integrity and function of tissues in the body.
"All wounds are not created equally" true or false? True.
What 5 factors should be included in a wound classification? Skin integrity, cause of the wound, severity, cleanliness of the wound, and descriptive qualities.
What are the 2 types of wounds? Tissue loss and non-tissue loss.
What are the 2 types of healing and examples? Primary intention such as surgical wounds that are sutured. Secondary intentions such as burns or ulcers that are left open to heal.
What causes a difference in wound repair? The epidermis regenerates, but damage done to deeper level tissues would only heal via scarring because they do NOT regenerate.
Healing process of partial-thickness wounds involves which 3 components? Inflammatory, epithelial proliferation and migration, and reestablishment of the epidermis.
Should a wound be kept moist or dry in order for it to heal faster and why? Moist, epithelial cells can only move across moist surfaces so it would take longer if the wound is dry.
What are the 3 components of full-thickness wound repair? Inflammation, proliferation, and remodeling.
What is the process in which blood vessels constrict and platelets coagulate to stop blood flow? Hemostasis.
What clots together to form later framework for cellular repair? Fibrin.
What is the primary acting leukocyte? Neutrophil.
What is the role of a monocyte? Transforms into a macrophage and cleans wound of dead cells and debris.
What is the main component in scar tissue? Collagen.
What are the 3 stages of the proliferation stage of full-thickness wounds repair. Vascular bed is reestablished, area filled with new tissue, and surface is repaired.
What occurs during the remodeling stage of wound healing? Collagen continuously reorganizes to gain strength before assuming its final appearance.
When should hemorrhaging stop? After hemostasis occurs, which is within several minutes unless a large vessel is included or poor clotting function.
How do you know if there is internal hemorrhaging? Swelling, change in drainage, color, sensation, warm, mass, or hypovolemic shock.
What is the 2nd most common nosocomial infections? Wound infections.
What defines infected? If purulent discharge is noted, regardless if a culture is taken.
How many organisms/gram would indicate infection? 100,000 or 10^5
What are signs of infection other than discharge? Fever, tenderness, pain, and an elevated WBC count.
What is dehiscence and who is at risk? Partial or total separation of wound layers; Poor wound healers and obese.
What is evisceration and what should be done? Total separation of wound layers in which protrusion of visceral organs may occur; sterile towels soaked in saline should be applied over organs. Surgery is required.
What is a fistula and what are some RFs? Abnormal passage between 2 organs or between an organ and the outside of the body; Crohn's disease, trauma, infection, radiation exposure, or cancer.
Norton scale consist of how many risk factors and what are they? 5; physical condition, mental condition, activity, mobility, and incontinence.
Which is a better score on the Norton scale? Higher the better max score of 20.
Braden scale is composed of how many subscales and what are they? 6; sensory perception, moisture, activity, mobility, nutrition, and friction/shear.
Which is better on a Braden scale: a score of 6 or 23? 23 is the better score and the best possible.
What is the cutoff score for Braden scale for the risk of ulcers in adults? 18.
Which scale is most commonly used to assess risk for pressure ulcers? Braden
How many calories does a well nourished adult need to maintain well-being? 1500 kcal/day.
What are some specific nutrients needed in wound healing? Protein, Vit. A and C, Zinc, and Copper.
What are serum proteins? Biochemical indicators of malnutrition.
What is the best measure of malnutrition and why? Prealbumin because it reflect what has been ingested, absorbed, digested, and metabolized.
What fuels the cellular functions essential to healing? Oxygen perfusion.
When you suspect abnormal reactive hyperemia what should you do and why? Mark it with a marker so you can reassess it later to see if there are changes.
What should be performed upon admission into a care facility? Systematic pressure ulcer risk assessment tool such as Braden or Norton scales.
What acidic bodily fluids are the lowest risk for PU? Silava and serosanguineous drainage.
What acidic bodily fluids are in the moderate range of risk for PU and higher risk for infection? Urine, bile, stool, ascitic fluid, and purulent would exudates.
What acidic bodily fluids carry the highest risk for tissue breakdown? Gastric and pancreatic drainage.
When are 2 times that wounds are generally assessed? At initial time of injury before treatment and after treatment.
A superficial wound with little bleeding and partial-thickness tissue loss is what? An abrasion.
How deep does a laceration go before it causes serious bleeding? Approx. 5 cm or 2 inches long and 2.5 cm or 1 inch deep.
What are the primary dangers of puncture wounds? Internal bleeding and infection.
What is the first thing to assess when looking at a wound? Foreign bodies or contaminant materials.
What is the second step in assessing a wound after checking for foreign materials? Size and depth.
A wound involving a dirty penetrating object, what should be considered next? When last tetanus shot was; if not in previous 5 years, one is necessary.
If a patient has a covered wound and you are assessing it, but the Dr. has not ordered it changed... what should you do? Assess only things you can see without removing the dressings.
While changing dressings, what are some things you should do? Give analgesic 30 mins prior and be careful of drains.
Crust along an incision site would indicate what? Normal healing.
If a brownish or yellow color is noted around a healing wound, what would this indicate? A fading bruise (hematoma)
How would you measure the amount of drainage in a dressing? Measure the dressing while clean and dry and compare the dressing after it has been soiled... weigh them.
What holds a penrose drain in place to prevent it from sliding further into the wound? A pin or clip.
What is the "gold standard" of wound cultures? Tissue biopsy.
Why is it important to know a client's expectations as far as wound care is concerned? Realistic goals/expectations help clients in adhering to the specific treatments and preventions.
List of ND associated with wound/impaired skin integrity. Risk for infection, Imbalanced nutrition: less than requirements, Acute or chronic pain, Impaired physical mobility, Risk/Impaired skin integrity, Ineffective tissue perfusion, Impaired tissue integrity.
How can a concept map help with individualizing a client's care? Assists when multiple health concerns are considered and which NI are the best approaches for the given circumstances.
What is a common time frame for wound improvement? 2-week period.
What are some possible goals for short term wound care? Higher % of granulation tissue, no further tissue breakdown, increase caloric intake, preventing infection, gaining comfort, promoting wound hemostasis.
If a client has a chronic wound, which is more important the wound or other influential factors such as hygiene and diet? Hygiene and diet are more important if the wound is stable.
What is more important in an acute wound, the wound or influential factors such as hygiene and diet? The wound is most important if it is acute and unstable. Other factors need to be considered only after the wound has been stabilized.
What are the most effective interventions for problems involving skin integrity? Prevention and prompt identification.
3 major NIs for prevention of PU are? Skin care, mechanical loading and support devices, and patient education.
When bathing high risk PU clients, which all should you use: hot or warm water, soap, nonionic surfactants, lotion? Avoid hot water and soap... use warm water, nonionic solutions, and lotion.
What is a "moisture barrier" used for and when? It protects the skin against excess moisture usually from bowel/urinary incontinence.
Where should the bed be set at to avoid shearing and decreasing PU? 30 deg or less.
Clients should be moved every how many hours? 2 or less depending on how active they are.
What are some ways to avoid PU during sitting? No longer than 2 hrs generally, shift every 15 minutes, sit on foam, gel, or air cushions.
Would a rigid or donut cushion be good or bad for a high risk PU client and why? Bad because they can restrict blood flow.
Would massage be good or bad for tissue ichemia and why? Bad because it can cause further capillary damage which can increase the damage to the tissue.
Acute wound require more monitoring than a stable chronic wound, how often must an acute wound be checked? At least every 8 hrs.
What evaluation tool would you use to evaluation whether wound care is effective? Pressure Ulcer Status Tool (PSST) which addresses 15 wound characteristics.
What is the main goal of effect wound management? Maintenance of a physiological local wound environment.
What would you use to cleanse a wound? Saline water or a noncytotoxic wound cleanser such as Dakin's solution (sodium hypochlorite solution), acetic acid, povidone-iodine, and hydrogen peroxide.
Why is selecting the correct wound cleanser important? You do not want to use anything that will damage or kill fibroblasts or the healing tissue, but will remove harmful bacteria and debris/ nonviable tissue.
What is a good way to deliver irrigation and at what pressure will it be? 19-gauge needle or an angiocatheter with a 35-mL syringe at a pressure of 8 psi (per square inch)
Why should necrotic tissue be removed from a wound bed? To remove a source of bacteria, clearly see the wound bed, and to provide a clean base to build healthy new tissue.
Where should necrotic tissue not be removed in certain situations? On heels of feet.
Why should necrotic tissue not be removed from the heels of feet? Stable, dry, black eschar on heels should not be debrided if it is non-tender, nonfluctuant, nonerythematous, and non supportive.
What should be observed during wound care to determine possible infection? Exudate amounts, color, odor, and wound size.
What are the 4 types of debridement? Mechanical, autolytic, chemical, and sharp/surgical.
What would the "wet gauze" debridement technique be considered? Mechanical.
Why would "wet gauze" debridement not be used? It is nonselective and may pulled healthy tissue as well as nonviable tissue from wound.
When should "wet gauze" never be used? In a wound with granulation tissue present.
What are other mechanical techniques to use? Irrigation and whirlpool treatments.
What is autolytic debridement? Use of bandages that will allow eschar to be digested via wound fluids already present.
Should moisture be added or removed from autolytic techniques and why? Added when the wound bed is dry and removed when exudate is excessive.
What are some examples of autolytic dressings? Use of transparent film dressings and hydrocolloid dressings.
Why is excess exudate an issue to would healing? Excess moisture presents a prime environment for the growth of bacteria in an excess to what the body can normally fight against.
What are some examples of chemical debridement? Dakin's solution, enzyme preparations, and sterile maggots.
What are some examples of surgical debridement? Use of scalpels, sissors, or other sharp instruments.
What is a key to supporting a wound as it heals? Continuous reassessment of the wound and change as it progresses through healing stages.
When does the Joint Commission recommend a nutritional assessment be performed? Within 24 hrs of admission.
What is the recommended protein intake for an adult? 0.8 g/kg/day.
How much protein is recommended for an adult healing from a wound? 1.8 g/kg/day.
What should hemoglobin levels be? 12 g/100 mL if possible.
When should pressure dressings be used for a wound? The first 24 to 48 hrs.
When should bleeding NOT be stopped and why? A puncture wound, so the blood can wash out any contaminates.
If a client has been stabbed, should the knife be removed, why, and what should be done? No, because the knife provides a source of pressure to control bleeding... pressure should be apply to the surrounding area.
Should you place a dressing over a wound that is still bleeding and why? Yes, it protects the wound from bacteria until the client can be evaluated at a hospital.
When are dressing usually removed from a wound that is healing from primary intention? As soon as drainage stops.
What is a PRIMARY function of wound dressings? Drainage absorption.
If a dressing dries to a wound how should it be removed? Apply saline solution to loosen the dressing to prevent damage to fragile new tissues.
What type of dressing should be used to keep a wound moist as well as wick moisture away? Gauze sponges.
What should be used on a wound with little to no exudate? Nonadherent gauze dressing such as Telfa.
What dressing should be used to trap a wound's fluids over the wound to hold in moisture as a secondary dressing? Self-adhesive transparent film.
What type of dressing can absorb drainage, seal in moisture, and protect the wound at the same time? Hydrocolloid dressings.
What type of dressing is good for burns, necrotic wounds, and radiation damaged skin because it is soothing to the client? Hydrogel dressings.
What is a complication that "dead space" can cause? Wound debris can accumulate in the dead space and cause detrimental occurrences.
VAC techniques should be read... Pages 1319 and on...
VAC Instill is different from VAC/NPWT why? It intermittently "instills" fluids into the wound, which is especially helpful for wounds that don't respond to normal VAC techniques.
Other than wounds, when would NPWT be used? Split-thickness skin grafts.
How should tape be properly applied? Ensure that it is adhered to several inches of skin on each side of dressing, press the tape away from the wound.
How should sutures be removed? Cut the end farthest from the knot generally and pull the suture out without pulling the outer portion through the underlying skin.
What are drainage evacuators and why do they help in healing? Low pressure vacuum that remove and collect drainage. Promotes healing environment by removing excess fluid that can cause bacteria growth.
Where should a piece of cloth be tied if using it as a sling? To the side of the neck to avoid pressure on the cervical spine.
When is heat contraindicated? When localized inflammation is present, bleeding, or cardiovascular problems.
When is cold contraindicated? If the area is already has edema, neuropathy, also if the client is shivering prior to using cold packs.
Before use of heat/cold therapies, what should be done? Assess the patient for conditions that should prohibit the use of heat/cold and assess the condition of the equipment b/c the nurse is legally responsible for the results of these.
What affects does heat cause that could be helpful? If less than 1 hr, causes vasodilation. Removal and reapplication is needed to continue dilation.
What affects does cold cause that could be helpful? Diminishes swelling and pain, vasodilation.
When should warm, moist, compresses be used and why? Open wounds; improves circulation, relieves edema, promotes consolidation of pus and drainage.
Tips for properly applied heat compresses. Warm compresses can have heating pad on it on LOW setting, Dry can have higher settings... Can use plastic or dry cloth to retain heat.
What is a Sitz bath and what purpose does it serve? Soak the pelvis area without soaking the lower extremities. It can be used for relief, cleansing, or medication application.
What are aquathermia pads used for? Used like heating pads, with hot water flowing through plastic pad.
What are ranges for heating pad/water temperatures? 40.5-43C or 105-110F
What should cold pad/water temperatures be? Approx 15C or 59F
How long can an ice pack be applied for? Up to 30 mins, can be reapplied after 1 hr.
Created by: Babble05