Chapter 36: Skin Integrity and Wound Care

Therapies used to treat wounds include ____________________________ which refers to the use of suction equipment to apply negative pressure to a variety of wound types

Vacuum assisted closure (VAC)

When does rebound phenomenon occur?

at the time of maximum therapeutic effect of the hot or cold application and the opposite begins

altered epidermis or dermis

impaired skin integrity

Describe a wound that is classified as full thickness.

involving the dermis, epidermis, subcutaneous tissue, and possibly the muscle and bone; requires connective tissue repair.

What is a disadvantage of the local effects of heat?

it increases capillary permeability, which allows extracellular fluid and substances such as plasma proteins to pass through the capillary walls and may result in edema or increase preexisting edema.

In regards to thermal tolerance why shouldn't heat be applied immediately after surgery or injury?

it increases swelling and bleeding

The major goals for clients at Risk for Impaired Skin Integrity (pressure ulcer development) are to:

maintain skin integrity and to avoid potential associated risks.

drainage that only stains the dressing

minimal drainage

How does impaired peripheral arterial circulation affect skin integrity?

poor circulation may cause the skin to become damaged more easily.

What are some other factors that contribute to pressure ulcers?

poor lifting and transferring techniques, incorrect positioning, hard support surfaces, and incorrect application of pressure relieving devices.

A value below _____ g/dL indicates

poor nutrition and may increase the risk of poor healing and infection.

Heat produces maximum vasodilation in how many minutes?

20-30

A total of ___ points are possible and an adult who scores below ___ points is considered at risk.

23 and 18

What is the normal albumin level

3.5-4.8 g/dL

What are the three ways Primary Intention healing differs from Secondary?

1. The repair time takes longer. 2. The scarring is greater. 3. The susceptibility to infection is greater

How should the nurse secure the dressings?

1. place the tape strips at the ends of the dressing and the middle so it can't unfold to expose the wound 2. Ensure that the tape is long and wide enough to adhere to several inches of skin 3. Place the tape in the opposite direction from the body action.

What or why are some ways to avoid skin trauma?

1. to prevent injury due to friction and shearing forces clients must be positioned, transferred, and turned correctly. 2. baby powder and cornstarch are never used as friction or moisture prevention they create a harmful grit that is damaging to the tissues and they are a respiratory hazard 3. frequent shifts in position even if it is just slightly 4. when lifting a client to change position nurses should use a lifting device rather than dragging the skin against the bed 5. At risk clients confined to bed should be repositioned at least every 2 hours

Dressing wounds are applied for the following purposes

1. to protect the wound from mechanical injury 2. to protect the wound from microbial contamination 3. to provide or maintain moist wound healing 4. To provide thermal insulation 5. To absorb drainage or debride a wound or both 6. To prevent hemorrhage 7. to splint or immobilize the wound site and thereby facilitate healing and prevent injury

Normal hemoglobin level in women

12-15 g/dL

Normal hemoglobin level in men

13.5-18 g/dL

What scores should be viewed as indicators not predictors of risk according to Norton's Assessment Scale

15 or 16

Which items are used to perform wound irrigation? Select all that apply. A. Clean gloves B. Sterile gloves C. Refrigerated irrigating solution D. 60-mL syringe E. Eye protection Basin

A, B, D, E. Rationale: To irrigate a wound, the nurse uses clean gloves to remove the old dressing and to hold the basin collecting the irrigating fluid plus sterile gloves to apply the new dressing. A 60-mL syringe is the correct size to hold the volume of irrigating solution plus deliver safe irrigating pressure. The irrigation fluid should be room or body temperature—certainly not refrigerated.

Which are primary risk factors for pressure ulcers? Select all that apply. A. Low-protein diet B. Insomnia C. Lengthy surgical procedures D. Fever E. Sleeping on a waterbed

A, C, D. Rationale: Risk factors for pressure ulcers include low-protein diet, lengthy surgical procedures, and fever. Protein is needed for adequate skin health and healing. During surgery, the client is on a hard surface and may not be well protected from pressure on bony prominences. Fever increases skin moisture, which can lead to skin breakdown, plus the stress on the body from the cause of the fever could impair circulation and skin integrity. Insomnia (option 2) would generally involve restless sleeping, which transfers pressure to different parts of the body and would reduce the chances of skin breakdown. A waterbed (option 5) distributes pressure more evenly than a regular mattress and, thus, actually reduces the chances of skin breakdown.

Cold applications reach a maximum vasoconstriction when the involved skin reaches a temperature of ________ degrees F

60

what level indicates anemia

<10.5

Thirty (30) minutes after application is initiated, the client requests that the nurse leave the heating pad in place. The nurse explains to the client that A. Heat application for longer than 30 minutes can actually cause the opposite effect (constriction) of the one desired (dilation). B. It will be acceptable to leave the pad in place if the temperature is reduced. C. It will be acceptable to leave the pad in place for another 30 minutes if the site appears satisfactory when assessed. D. It will be acceptable to leave the pad in place as long as it is moist heat.

A. Rationale: The heating pad needs to be removed. After 30 minutes of heat application, the blood vessels in the area will begin to exhibit the rebound effect resulting in vasoconstriction. Lowering the temperature, but still delivering heat—dry or moist—will not prevent the rebound effect. The visual appearance of the site on inspection (option 3) does not indicate if rebound is occurring.

Proper technique for performing a wound culture includes which action? A. Cleansing the wound prior to obtaining the specimen. B. Swabbing for the specimen in the area with the largest collection of drainage. C. Removing crusts or scabs with sterile forceps and then culturing the site beneath. D. Waiting 8 hours following a dose of antibiotic to obtain the specimen.

A. Rationale: Wound culture specimens should be obtained from a cleaned area of the wound. Microbes responsible for the infection are more likely to be found in viable tissue. Collected drainage contains old and mixed organisms. An appropriate specimen can be obtained without causing the client the discomfort of debriding. The nurse does not generally debride the wound to obtain a specimen. Once systemic antibiotics have been begun, the interval following a dose will not significantly affect the concentration of wound organisms

Select all that apply. Which of the following medications are known to cause sensitivity to the sun? A. Tetracycline B. Acetaminophen C. Doxycycline D. Methotrexate E. Tricyclic Antidepressants

A. Tetracycline C. Doxycycline D. Methotrexate E. Tricyclic Antidepressants

Bandages and binders serve various purposes

A. supporting a wound (fractured bone) B. Immobilizing a wound (strained shoulder) C. Applying pressure (elastic bandages on the lower extremities to improve blood flow) D. Securing a dressing (extensive abdominal surgical wound) E. Retaining warmth (flannel bandage on a rheumatoid joint)

The types of dressings used depends on

A. the location, the size, the types of wound, B. the amount of exudate, C. whether the wound requires debridement or is infected, D. such considerations as frequency of dressing change, ease or difficulty of dressing application and cost

A nurse is preparing a discharge plan for a client with a risk of skin breakdown. What would the nurse include in the discharge ​plan? Select all that apply. A. If persistent redness occurs, apply lotion to the area B. Position to prevent pressure on bony prominences C. Diet should be adequate in fluids, protein, vitamin B and C, iron, and calories D. Turn and reposition every 2 hours E. Massage the bony prominences

B, C, D. Rationale To have healthy​ skin, it is important to have a diet that includes vitamins B and C as well as iron. Preventing pressure on bony prominences decreases the chance of pressure ulcers. Moving the client​'s position prevents prolonged​ pressure, which can lead to tissue damage. Massaging bony prominences is contraindicated and damages the skin. Any persistent redness should be reported to the health care provider. Redness that does not blanch is a stage I pressure ulcer.

A client is complaining of stiffness and arthritic pain in the hands. Which application should the nurse expect to be included in the treatment​ plan? A. Cool, moist compress B. Heat pack C. Cold pack D. Ice glove

B. Rationale Although​ cool, moist​ compresses, ice​ gloves, and cold packs decrease inflammation and provide anesthetic​ effects, the application of heat through a heat pack is recommended to treat joint stiffness and inflammation. This would be the appropriate application to be included in the client's treatment plan.

The nurse is explaining the stages of pressure ulcers to a group of new RNs. Which area of the body is most likely to develop a stage III​ ulcer? A. Patella B. Buttocks C. Sacrum D. Ankle

B. Rationale Areas with more adipose tissue are more likely to develop stage III ulcers. Examples of areas with larger amounts of adipose tissue are​ hips, thighs,​ buttocks, and abdomen. The sacral area is not an area that is plentiful in subcutaneous​ fat, which increases the risk for stage III ulcers. The sternum is a​ high-pressure area and is prone to pressure ulcers in general. The patella and the ankle have little adipose tissue and do not have an increased risk of stage III ulcers.

The nurse is assessing the extent of tunneling of a pressure ulcer on a client admitted to the wound care unit. Which assessment technique is​ appropriate? A. Rotate a tongue blade into the tunneled area until resistance is met B. Insert a sterile cotton tipped applicator to measure the involved area C. Apply sterile gloves and insert a gloved index finger until the full extent of the tunneling is reached D. Use a ruler to measure the glossy appearance of the skin area involved.

B. Rationale The proper technique of determining the extent of a pressure ulcer is to use a sterile​ cotton-tipped applicator for assessment of the tunneling. Stage II ulcers can appear shiny and dry with deep tissue​ damage, but tunneling extent cannot be measured on the outer skin surface. Finger insertion is not the proper technique for measuring tunneling extension and may cause unnecessary pain for the client. The use of a tongue blade to measure tunneling could introduce​ germs, cause tissue​ damage, and cause unnecessary pain for the client.

The nurse is caring for an emaciated older adult client who is immobile and is experiencing frequent watery stools. Which technique would the nurse use to protect the client​'s skin​ integrity? A. Wipe the soiled skin firmly with a towel B. Use a gel and foam combination mattress C. Use a firm, circular motion to cleanse the sacral area D. Place the client in the Fowler's position in the bed

B. Rationale The use of a pressure relieving​ device, such as a gel and foam combination​ mattress, helps ensure proper circulation and relief of pressure to areas with bony prominences. Wiping the soiled skin firmly with a towel or using a​ firm, circular motion to cleanse the area could cause redness and irritation of the tissues and break the integrity of the skin due to the older client​'s thinning​ epidermis, decreased skin​ elasticity, decreased oil​ production, decreased venous and arterial blood​ flow, and decreased pain sensation. Shearing​ (the force on the skin that combines friction and​ pressure) usually occurs when the client is in a sitting position in bed. The shearing force damages the blood vessels and tissues in the sacral region.

The client has a Braden scale score of 17. The appropriate nursing action is A. Assess the client again in 24 hours; the score is within normal limits. B. Implement a turning schedule; the client is at increased risk of skin breakdown. C. Apply a transparent wound barrier to major pressure sites; the client is at moderate risk of skin breakdown. D. Request an order for a special low-air-loss bed; the client is at very high risk of skin breakdown.

B. Rationale: A score ranging from 15 to 18 is considered at risk and a turning schedule is appropriate. Option 1 requires a score above 18 (normal and ongoing assessment is indicated). Option 3, moderate risk, for which a transparent barrier would be appropriate, is applied to persons with scores of 13 to 14. Option 4, very high risk, is assigned for those with a score of 9 or less.

Which technique indicates proper use of a triangle arm sling? A. The elbow is kept flexed at 90 degrees or more. B. The knot is placed on either side of the vertebrae of the neck. C. The sling extends to just proximal of the hand. D. Remove the sling every 2 hours to check for circulation and skin integrity.

B. Rationale: The knot of the triangle sling must be kept off the spinal processes because this would be uncomfortable and put unnecessary pressure on the vertebrae. The elbow should be flexed slightly less than 80 degrees (not >90 as in option 1) so the hand is above the elbow to prevent dependent swelling. The sling must extend past the wrist in order to support the hand. Although the sling must be removed to check for circulation and skin integrity, every 2 hours (option 4) is unnecessarily frequent and impractical

An appropriate nursing diagnosis for a client with large areas of skin excoriation resulting from scratching an allergic rash is a. Risk for Impaired Skin Integrity b. Impaired Skin Integrity c. Impaired Tissue Integrity d. Risk for Infection

B. Rationale: This client has an actual impairment of the integrity of the skin due to the rash and the scratching so is no longer "at risk". Because the damage is at the skin level, it is not impaired tissue integrity (Option 3) since that would involve deeper tissues. Surface excoriation is also not prone to becoming infected.

Do insurance companies pay for health care associated pressure ulcers?

Because pressure ulcers are preventable, public health insurance and some private insurance companies will no longer reimburse health care agencies for the cost of treating health care associated pressure ulcers.

The nurse is evaluating why a wound is not healing. Which​ medication, taken by the​ client, can delay wound​ healing? A. Esomeprazole​ (Nexium) B. Nebivolol​ (Bystolic) C. Dexamethasone​ (Decadron) D. Digoxin​ (Lanoxin)

C. Rationale Corticosteroid agents interfere with wound healing. Digoxin increases the contractility of the heart but has no direct relationship with wound healing. Nebivolol is a beta blocker with no effect on wound healing. Esomeprazole is a proton pump inhibitor not associated with wound healing.

A client sustained a​ right-wrist strain following a fall. Prior to applying the order ACE​ wrap, the nurse notes a superficial abrasion. Which nursing assessment should be completed prior to applying the ACE​ wrap? A. Pain on a scale from 1 to 10 B. Adequacy of the circulation in the right arm C. Wound drainage D. Client​'s ability to reapply the dressing

C. Rationale: Before applying the​ bandage, the client​'s limb should be inspected for the presence of wound drainage. If drainage is​ present, a dressing is required before applying the bandage. Adequacy of circulation in the limb would be assessed after the dressing has been applied. Pain assessment can be done at any time prior to the application of the bandage. The client​'s ability to reapply the bandage is not a priority to be assessed before applying the bandage.

A client has a pressure ulcer with a shallow, partial skin thickness, eroded area but no necrotic areas. The nurse would treat the area with which dressing? A. Alginate B. Dry gauze C. Hydrocolloid D. No dressing is indicated

C. Rationale: Hydrocolloid dressings protect shallow ulcers and maintain an appropriate healing environment. Alginates (option 1) are used for wounds with significant drainage; dry gauze (option 2) will stick to new granulation tissue, causing more damage. A dressing is needed to protect the wound and enhance healing.

The NANDA international nursing diagnoses that relate to clients who have skin wounds or are at risk for skin breakdown are as follows:

Risk for pressure ulcers, risk for impaired skin integrity, impaired skin integrity, impaired tissue integrity

consists of large amounts of red blood cells, indicating damage to capillaries that is severe enough to allow the escape of red blood cells from plasma. Frequently seen in open wounds.

Sanguineous exudate

is healing by granulation or indirect union (due to considerable tissue loss, and in which the edges cannot or should not be approximated or closed) Granulation tissue (newly formed vascular and connective tissue produced in the early stages of wound healing) is formed to fill the gap between the edges of the wound with a thin layer of fibrinous (the 3rd and final stage of blood clotting) exudate. Granulation tissue also excludes bacteria from the wound and brings new blood vessels to the injured part. This type of healing takes longer. Ex: pressure ulcer

Secondary intention healing or Healing by second intention

True or False? Chronic illnesses and their treatments affect skin integrity.

True

has to do with the primary care providers decision on whether to allow the wound to heal itself or to purposefully close the wound and is influenced by the amount of tissue loss.

Types of healing

Assessment of wounds: theses wounds are usually seen shortly after an injury (Ex: at the scene of an accident or in an emergency center)

Untreated wound

A process in which extra blood flows to the area to compensate for the preceding period of impending blood flow.

Vasodilation

What causes the flush experienced with reactive hyperemia?

Vasodilation

consists chiefly of serum (the clear portion of the blood) derived from blood and the serous membranes of the body such as the peritoneum. Ex: is the fluid in a blister from a burn

Serous exudate

A combination of friction and pressure that occurs commonly when a client assumes a sitting position in bed. The skin and superficial tissues are this relatively unmoving in relation the bed surface, whereas deeper tissues are attached to the skeleton and move downward.

Shearing force

What are the systemic effects of cold?

Since cold causes vasoconstriction it can cause the BP to rise because blood is shunted from the cutaneous circulation to the internal blood vessels. Shivering is a generalized effect of prolonged cold and is a normal response of the body trying to warm itself.

used to soak a clients perineal or rectal area. The temperature should be from 104-110 degrees F unless the client can't tolerate heat and should last 20 minutes

Sitz bath

What collected data should the nurse to evaluate if the outcomes were met?

Skin status over bony prominences, nutritional and fluid intake, mental status, signs of healing if an ulcer is present.

anchor the bandage with two circular turns and bring the bandage upward at 30 degree angle, place the thumb of your free hand on the upper edge of the bandage so it can fold on itself, unroll and then turn your hand so that the bandage falls over itself, continue wrapping, terminate the bandage with two circular turns, and secure the end

Spiral reverse turns

Make two circular turns to anchor the bandage, Continue spiral turns at about a 30 degree angle, terminate the bandage with two circular tunes, and secure the as described for circular terms.

Spiral turns

A purosanguineous discharge consisting of pus and blood, is often seen in

a new wound that is infected

How do you confirm or deny the presence of infection?

a wound culture

Penetration of the skin and the underlying tissues, usually unintentional (e.g. from a bullet or metal fragments); open wound

Penetrating Wound

During migration leukocytes (especially neutrophils) move into the interstitial space. These are replaced about 24 hours after injury by macrophages. These macrophages engulf microorganisms and cellular debris by this process.

Phagocytosis

refers to the steps in the body's natural processes of tissue repair.

Phases of healing

What does a hemoglobin level below the normal range indicate?

Poor oxygen delivery to the tissues

One method of documenting the progress of healing in pressure ulcers is to use the

Pressure Ulcer Scale for Healing (PUSH)

Consists of injury to the skin and or underlying tissue, usually over a bony prominence, as a result of force alone or in combination with movement.

Pressure ulcer

What is the etiology of pressure ulcers?

Pressure ulcers are due to localized ischemia. If the tissue is compressed between a bed or a chair the blood cannot reach the tissue. When that happens the cells are deprived of oxygen and nutrients, the waste products of metabolism accumulate in the cells, and the tissue dies.

Occurs where the tissue surfaces have been approximated (closed) and there is minimal or no tissue loss; it is characterized by the formation of minimal granulation tissue and scarring. There is little or no inflammatory reaction and in such a manner that little or no scar is left to reveal the site of injury. Ex: a closed surgical incision

Primary Intention Healing or Healing by First Intention

This phase of healing extends from day 3 or 4 to about day 21 post injury. Fibroblasts (connective tissue cells), which migrate into the wound starting about 24 hours after injury, begin to synthesize collagen, a whitish protein substance that adds tensile strength to the wound. As the capillary network develops the tissue becomes translucent red color. This tissue is called granulation tissue and is fragile and bleeds easily. If the wound does not close by epithelialization it forms eschar.

Proliferative Phase

Wounds that are left open for 3 to 5 days to allow edema or infection to resolve or exudate to drain and are then closed with sutures, staples, or adhesive skin closures heal by this type of healing. This delayed type of healing that occurs in the base of ulcerated or cavitary wounds, especially those that have become infected, fills very slowly with granulation tissue and often forms a large scar. Often wound revision surgery is needed

Tertiary Intention or delayed primary intention

Penetration of the skin and often the underlying tissues by a sharp instrument, either intentional or unintentional. Open wound.

Puncture wound

thicker than serous exudate due to the presence of pus, which consists of leukocytes, liquefied dead tissue debris, and dead and living bacteria. The process of pus formation is referred to as suppuration. It varies in color, some acquiring tinges of blue, green, or yellow. The color depends on the causative organism.

Purulent exudate

How does advanced aging cause pressure ulcers?

The aging process brings about several changes in the skin and its supporting structures, making the older person more prone to impaired skin integrity.

How often are these risk assessment scales conducted in long term facility settings?

The braden or norton scale is conducted on admission and then on a regular basis usually weekly. This increases awareness of specific risk factors and serves as assessment data from which to plan goals and interventions to either maintain or improve skin integrity.

Which statement, if made by the client or family member, would indicate the need for further teaching? A. If a skin area gets red but then the red goes away after turning, I should report it to the nurse. B. Putting foam pads under the heels or other bony areas can help decrease pressure. C. If a person cannot turn himself or herself in bed, someone should help the person change position every 4 hours. D. The skin should be washed with only warm water (not hot) and lotion put on while it is still a little wet.

Rationale: Immobile and dependent persons should be repositioned at least every 2 hours, not every 4, so this client or family member requires further teaching. Warm water and moisturizing damp skin are correct techniques for skin care. Red areas that do not return to normal skin color should be reported. It would also be correct to use a foam pad to help relieve pressure.

Anchor the bandage with two circular turns, fold the bandage back on itself and bring it over the distal end to be bandaged, bring the bandage back over the end to the right, bring the bandage back on the left, continue this pattern of alternating right and left, terminate with two circular turns and secure the end.

Recurrent Turn

Hold the bandage in your dominant hand, apply the bandage to the part of the body to be bandaged, encircle the body part a few times, the bandage should be firm, but not tight, and secure the end with tape or clips

Circular turn

Uninfected wounds in which there is minimal inflammation and the respiratory, gastrointestinal, genital, and urinary tracts are not entered. They are primarily closed wounds.

Clean wounds

surgical wounds in which the respiratory, gastrointestinal, genital, or urinary tract has been entered. Such wounds show no evidence of infection.

Clean-contaminated wounds

In regard to thermal tolerance what type of clients have peripheral vascular disease, diabetes, congestive heart failure and lack the normal ability to dissipate heat via blood circulation>

Clients with impaired circulation

In regard to thermal tolerance what type of clients are unable to perceive that heat is damaging the tissues and are at more risk for burns or are unable to perceive discomfort from cold and prevent injury

Clients with neurosensory impairment

Includes open, fresh, accidental, wounds and surgical wounds involving a major break in sterile technique or a large amount of spillage from the gastrointestinal tract. These wounds show evidence of inflammation.

Contaminated wounds

Caused from a blow from a blunt instrument, closed wound, skin appears ecchymotic (bruised) because of damage blood vessels.

Contusion wound

The client has been taught nutrition needs for healthy skin. Which client diet selection best indicates to the nurse that understanding has taken​ place? A. A bowl of chili, crackers, and baked potato B. A Caesar salad, broth, and chocolate chip cookie C. Hamburger patty, green leafy salad with dressing, and steamed broccoli D. Boiled potatoes, steamed green beans, baked chicken, and fruit

D. Rationale Protein, carbohydrates, and vitamin C are included in​ potatoes, green​ beans, baked​ chicken, and fruit. This is a well balanced diet that will promote skin integrity. Meals consisting of a hamburger​ patty, green leafy salad with​ dressing, and steamed broccoli or​ chili, crackers, and a potato are lacking in vitamin​ C, which makes them less well balanced than a meal with fruit. Protein and vitamin C are lacking from a selection of Caesar​ salad, broth, and a chocolate chip cookie.

the partial or total rupturing of a sutured wound. Usually involves an abdominal wound in which the layers below the skin also separates.

Dehiscence

Wounds, excluding pressure ulcers and burns, are classified by _____________.

Depth

What factor affecting wound healing is: healthy kids and adults often heal more quickly than older adults, who are more likely to have chronic diseases that hinder healing

Developmental considerations

Factors affecting wound healing are:

Developmental considerations Nutrition Lifestyle Medications

Includes wounds containing dead tissue and wounds with evidence of a clinical infection, such as purulent damage.

Dirty or infected wounds

Nursing History and Physical Assessment of Skin Integrity

During the review of systems as part of the nursing history, the nurse gathers information regarding skin diseases, previous bruising, general skin condition, skin lesions, and usual healing of sores. Inspection and palpation of the skin focus on determination of sen color distribution, skin turgor, presence of edema, and characteristics of any lesions present.

How does excessive body heat increase the development of pressure ulcers?

Elevated body temps increases the metabolic rate, thus increasing the cells need for oxygen. This increased need is particularly severe in the cells of an area under pressure, which are already oxygen deficient. Severe infections with accompanying elevated body temperatures may affect the body's ability to deal with the effects of tissue compression.

the protrusion of the internal viscera through an incision.

Evisceration

Area loss of the superficial layers of the skin aka denuded area

Excoriation

material such as fluid and cells, that has escaped from blood vessels during the inflammatory process and is deposited in tissue or on tissue surfaces.

Exudate.

Anchor the bandage with two circular turns, carry the bandage about the joint, around it, and then below it, making a figure 8, continue above and below the joint overlapping the previous, terminate the bandage above the joint with two circular turns, and then secure the end appropriately.

Figure 8 turns

A force acting parallel to the skin surface. For example sheets rubbing against the skin that can abrade the skin or remove the superficial layers, making it more susceptible to break down.

Friction

List some factors that contribute to pressure ulcer formation?

Friction and shearing, Immobility, Inadequate nutrition, fecal and urinary incontinence, decreased mental status, diminished sensation, excessive body heat, advanced age and the presence of certain chronic conditions.

What internal factors influences the appearance of skin and skin integrity?

Genetics, age, and the underlying health of the individual.

the cessation of bleeding results from the vasoconstriction of the large blood vessels in the affected area, retraction or drawing back of injured blood vessels, the deposition of fibrin (connective tissue), and the formation of blood clots in the area.

Hemostasis

Abnormally low protein content in the blood.

Hypoproteinemia

Refers to a reduction in the amount and control of movement a person has. However, paralysis, extreme weakness, pain, or any cause of decreased activity can hinder a person's ability to change positions independently and relieve the pressure even if they can feel the pressure.

Immobility

This causes weight loss, muscle atrophy, and the loss of subcutaneous tissue. All of these three conditions reduce the amount of padding between the skin and the bones, this creating an increased risk for pressure ulcers.

Inadequate nutrition

Caused by a sharp instrument, is an open wound that can be deep or shallow, once the edges have been sealed together as a part of treatment or healing it is considered a closed wound.

Incision wound

How does moisture from incontinence promote skin breakdown?

Incontinence promotes maceration which makes the epidermis more easily eroded and susceptible to injury.

How does decreased mental status increase the risk for pressure ulcers?

Individuals with a reduced level of awareness like patients that are unconscious, sedated, or dementia are at risk because they are less able to recognize and respond to the pain associated with prolonged pressure

this phase is initiated immediately after injury and lasts 3-6 days. It has two major processes that occur during this phase. One is hemostasis and the other is phagocytosis.

Inflammatory phase

This type of wound occurs during therapy (examples are operations)

Intentional

How should a nurse handle a hemorrhage?

It should be treated as an emergency. The nurse should apply pressure dressings to the wound and monitor the clients vital signs.

Tissues torn apart, often from accidents (e.g. with machinery). Open wound; edges are often jagged.

Laceration wound

What factor affecting wound healing is: people who exercise regularly tend to have good circulation and because blood brings oxygen and nourishment to the wound, they are more likely to heal quickly. Smoking reduces the amount of functional hemoglobin in the blood, thus limiting the oxygen-carrying capacity of the blood, and constrict arterioles.

Lifestyle

Tissue softened by prolonged wetting or soaking

Maceration

This phase begins on about day 21 and can extend to 1 or 2 years after the injury. Fibroblasts continue to synthesize collagen. The collagen fibers themselves, which were initially laid in a haphazard fashion, reorganize into a more orderly structure. The wound is remodeled and contracted. In some individuals particularly dark skinned, and abnormal amount of collagen is laid down. This can cause a hypertrophic scar or keloid

Maturation Phase

A strip of cloth used to wrap some part of the body

bandage

a type of bandage designed for a specific body part that are used to support large areas of the body

binder

Wounds that are _____________ are covered with thick necrotic tissue, or eschar and require debridement. This must be done before the wound can heal.

black

How is a moist cold applied?

by compress or cooling sponge bath

How is moist heat applied?

by compress, hot pack, soak, or sits bath.

How is a dry cold normally applied?

by means of a cold pack, ice bag, ice collar, ice glove, in addition cryotherapy can be provided like a aquathermia pad.

What external factors influence the appearance and skin integrity?

activity

Wound irrigation and packing:

an irrigation or lavage is the washing or flushing out of an area. Sterile technique is required for a wound irrigation.

Sensitivity studies are helpful in the selection of

appropriate antibiotic therapy

Infection suggested by a change in wound color, pain, odor, or drainage is confirmed by performing a culture of the wound. Severe infection causes

fever and elevated white blood cell counts

Describe Stage IV pressure ulcers.

full thickness skin loss with tissue necrosis or damage to muscle, bone, or supporting structures such as a tendon or joint capsule.

_____________ packing using the damp to damp technique has been used to pack wounds that require debridement

gauze

What are the local effects of heat

heat causes vasodilation and increases blood flow to the affected area, bringing oxygen, nutrients, antibodies, and leukocytes. It promotes soft tissue healing and increases suppuration.

drainage that overflows the dressing prior to scheduled changes

heavy drainage

a localized collection of blood underneath the skin that may appear as a reddish blue swelling (bruise). Large ones may be dangerous in that it places pressure on blood vessels and other structures and can this obstruct flow

hematoma

Massive bleeding

hemorrhage

What are some examples of complications of wound healing?

hemorrhage, infection, and dehiscence and evisceration

What is heat often used for?

clients with musculoskeletal problems such as joint stiffness from arthritis, contractors, and low back pain.

Describe a wound that is classified as partial thickness.

confined to the dermis and epidermis and heals by regeneration

How would a patient taking a corticosteroid have impaired skin integrity?

corticosteroids cause thinning of the skin, which allows it to be harmed easily.

What data is important for nurses to use when they are determining what patients are at risk for pressure ulcers?

immobility, incontinence, nutrition, and level of consciousness.

damage to mucous membrane, cornea, integumentary system, muscular fascia, muscle, tendon, bone, cartilage, joint capsule, and or ligament

impaired tissue integrity

Do wounds heal more rapidly in infants, children, adults, or elderly?

infants and children.

Due to the disadvantages of hydrocolloid dressings they shouldn't be used for what types of wounds?

infected wounds or those with deep tracts

Contamination of a wound surface with microorganisms (colonization) is an inevitable result because the surface cannot be permanently protected from contact with unsterile objects. Because the colonizing organisms compete with new cells for oxygen and nutrition, and because their by-products can interfere with a healthy surface condition, the presence of contamination can impair wound healing and lead to _______________.

infection

Body wounds are either _______________ or _________________.

intentional or unintentional

Hyper-coagulability can lead to

intravascular clotting and result in a deficient blood supply to the wound area.

What are the systemic effects of heat?

it can cause excessive peripheral vasodilation, which causes a drop in BP. A significant drop could cause fainting. Clients with heart or pulmonary disease and who have circulatory disturbances like arteriosclerosis are more prone to this.

In regards to thermal tolerance why shouldn't cold be used on an open wound?

it decreases blood flow to the wound and prohibits healing

How is dry heat applied?

locally by means of a hot water bottle, aquathermia pad, or electric pad

When pressure ulcers are being assessed the nurse includes the following:

location, size in centimeter, presence of undermining or sinus tracts, stage of ulcer, color of the wound bed and location of necrosis (dead tissue) or eschar, condition of the wound margins, integrity of surrounding skin, clinical signs of infection like redness, warmth, swelling, pain, odor, and exudate.

What are some types of examples of skin changes that come along with aging?

loss of lean body mass, generalized thinning of the epidermis, decreased strength and elasticity of the skin due to changes in the collagen fibers of the dermis, increased dryness due to a decrease in the amount of oil produced by the sebaceous glands, diminished pain perception due to a reduction in the number of cutaneous end organs responsible for the sensation of pressure and light touch, diminished venous and arterial flow due to aging vascular walls.

What are the local effects of cold?

lowers the temperature of the skin causing vasoconstriction, which reduces blood flow to the affected area and this reduces the supply of oxygen and metabolites, decreases the removal of wastes, and produces skin palor and coolness.

When it comes to skin integrity, what are some important nursing functions?

maintaining skin integrity and promoting wound healing

What factor affecting wound healing is: Anti-inflammatory drugs (steroids and aspirin) and anti-neoplastic agents interfere with healing. Prolonged use of antibiotics may make a person susceptible to wound infection by resistant organisms.

medications

drainage that saturates the dressing without leakage prior to scheduled dressing changes

moderate drainage

the dressing and frequency of change should support moist wound bed conditions. Wound beds that are too dry or disturbed too often fail to heal

moist wound healing

Supportive wound healing offers four major areas in which nurses can help clients develop optimal conditions for wound healing what are they?

moist wound healing nutrition and fluids preventing infection positioning

Describe Stage I pressure ulcers.

nonblanchable erythema signaling potential ulceration

Poor ______________ alone can interfere with the appearance and function of normal skin.

nutrition

Albumin is an important indicator of

nutritional status

Assessment of a treated wound involves:

observation of its appearance, size, drainage, and the presence of swelling, pain, and status of drains or tubes.

Describe Stage II pressure ulcers.

partial thickness skin loss (abrasion, blister, or shallow crater) involving the epidermis and possibly the dermis.

To promote wound healing, clients must be positioned off the pressure wound (sometimes referred to as off-loading) Changes of positions and transfers can be accomplished without shear or friction damage. The client should also be encouraged to be as mobile and independent as possible

positioning

Cleaning wounds involves the removal of:

debris (such as foreign materials, excess slough, necrotic tissue, bacteria, and other microorganisms.

What are other names for pressure ulcers?

decubitus ulcers, pressure sores, or bedsores.

What are the effects of a decreased leukocyte count?

delay healing and increase the possibility of infection

Clients with impaired skin integrity need goals to

demonstrate progressive wound healing and regain intact skin within a specified time frame

What are the contributors to skin excoriation?

digestive enzymes in fece, urea in urine, and gastric tube drainage. Any accumulation of secretions or excretions is irritating to the skin, harbors microorganisms, and makes an individual prone to skin breakdown and infection.

Heat can be applied to the body in what forms?

dry and moist

Prolonged coagulation times can result in

excessive blood loss and prolonged color absorption

There are two main aspects to controlling wound infection : prevention the microorganisms form entering the wound and preventing the transmission of blood borne pathogens to or from the client to others.

preventing infection

When and if the pressure is relieved, the skin takes on a bright red flush called...

reactive hyperemia

Wounds that are __________ are usually in the late regeneration phase of tissue repair (developing granulation tissue) They need to be protected to avoid disturbance to regeneration tissue

red

Healing is a quality of living tissue; it is also referred to as __________________ which means renewal of tissues.

regeneration

Gauze is used to

retain dressings on wounds and to bandage the fingers, hands, toes, and feet.

What are the additional nursing diagnoses for those with existing impaired skin or tissue integrity

risk for infection: if the skin impairment is severe, the client is immunosuppressed, or the wound is cause by trauma acute pain: related to nerve involvement within the tissue impairment or as a consequence of procedures used to treat the wound

What are the six subscales of The Braden Scale for Predicting Pressure Sore Risks?

sensory perception, moisture, activity, mobility, nutrition, and friction and shear.

What are the three major types of exudate?

serous, purulent, and sanguineous

refers to immersing a body part in a solution or wrapping a part in gauze dressings and then saturating the dressing with the solution

soaks

What is cold most often used for?

sports injuries like sprains, strains, fractures, to limit post injury swelling or bleeding

When dehiscence or evisceration occurs, the wound should be quickly supported by large sterile dressings soaked in

sterile normal saline

What are the frequently used irrigation solutions?

sterile normal saline, lactated ringers solution, and antibiotic solutions

Nursing interventions for maintaining skin integrity and wound care involve:

supporting wound healing, preventing pressure ulcers, treating pressure ulcers, dressing and cleaning wounds, supporting and immobilizing wounds, and applying heat and cold

A serosanguineous exudate consisting of both clear and blood tinged drainage, is commonly seen in

surgical incisions

Some clients will have an internal hemorrhaging that may be detected by:

swelling or distention in the area of the wound and possibly by sanguineous drainage for a surgical drain.

Serum protein analysis provides and indication of

the bodys nutritional reserves for rebuilding cells

For all hot or cold applications what should the nurse check before applying?

the clients ability to tolerate the therapy, contraindications of treatment, explain the application to the patient, assess the skin of the area to which the treatment will be applied, ask the client to report any discomfort, check every 15 minutes, after removal check the skin again

Assessment of Skin Integrity

the nurse conducts an examination of the integument as part of routine assessment and during regular care. Removing barriers to assessment is very important. Antiembolic stockings, braces, or devices must be removed to assess the skin condition underneath.

What happens if the outcomes aren't met?

the nurse should figure out why like did the patients condition change, was everything done properly with the correct technique, etc

What is the largest organ of the body?

the skin

How does age influence skin integrity?

the young and very old have more fragile skin and are more susceptible to injury than an adult.

What happens if you leave heat longer than the max of 30 minutes?

tissue congestion and blood vessels constrict and the client is at risk for burns

What is the purpose of a cooling sponge bath?

to reduce a clients fever by promoting heat loss through conduction and vaporization.

what do you do if more than one color is present?

treat black then yellow then red

Assessment of wounds: these wounds are usually assessed to determine the progress of healing. They may be inspected during the changing of dressings. If they wound itself cannot be directly inspected the dressing is inspected and other data regarding the wound.

treated wounds or sutured wounds

Sometimes the wound reaches under the skin surface called

undermining

This type of wound is accidental for example a person my fracture an arm in a car accident.

unintentional

The inflammatory phase also involves _______________ and _______________ responses intended to remove any foreign substances and dead or dying tissues.

vascular and cellular

What happens if the skin goes below 60 degrees F during a cold application?

vasodilation will begin to prevent freezing of body tissues and a continued alternation of constriction and dilation called Lewis Hunting effect will occur.

Wounds that are _______________ are characterized primarily by liquid to semiliquid slough that is often accompanied by purulent drainage or previous infection. these wounds are cleaned

yellow

When the eschar is removed, the wound is treated as ____________ then ___________

yellow then red.

What are the conditions for temperatures of a hot water bag?

~Normal adult and child over 2 years 115-125 degrees F; ~Debilitated or unconscious adult or child under 2 years 105-115 degrees F

Another tool that can be used for risk assessment for pressure ulcers that includes the categories of general physical condition, mental state, activity, mobility, and incontinence is

Norton's Pressure Area Risk Assessment Scoring System.

What factor affecting wound healing is: wound healing places additional demands on the body. They should have a diet rich in protein, carbs, lipids, vitamins A and C, and minerals such as zinc, iron, and copper. Obese people have a slower healing because of adipose tissue has a minimal blood supply.

Nutrition

The risk of hemorrhage is the greatest within the first ____ hours after surgery

48

Surface scrape, either unintentional (e.g. scraped knee from a fall) or intentional (dermal abrasion to remove pockmarks). Open wound involving the skin

Abrasion wound

All of the following people are at risk for skin integrity EXCEPT: A. an elderly patient B. a healthy person C. a patient with restricted mobility D. a patient with chronic illness or trauma. E. a patient undergoing an invasive health care procedure

B. A healthy person

In regard to thermal tolerance what type of clients are confused or have an altered LOC need monitoring during applications to ensure safety

Clients with impaired mental status

This can be either hot or cold, and is a moist gauze dressing applied to a wound

Compress

Describe Stage III pressure ulcers.

Full thickness skin loss involving damage or necrosis undermining of adjacent tissue

How can you determine if tissue has been damaged from the pressure ulcer?

If the redness goes away then no damage has occurred. If the redness does not go away then the tissue has been damaged.

What are the three phases of wound healing?

Inflammatory phase, Proliferative phase, Maturation phase

______________ refers to the presence of normal skin and skin layers un-interrupted by wounds

Intact skin

How does edema cause pressure ulcers?

It increases the distance between the capillaries and the cells, thereby slowing the diffusion of oxygen to the tissue cells and of metabolites away from the cells.***

How does diminished sensation increase the risk for pressure ulcers?

Paralysis, stroke, or other neurologic diseases may cause loss of sensation in a body area. Loss of sensation reduces a person ability to respond to trauma , to injurious heat or cold, and to the tingling that signals loss of circulation. Sensory loss also impairs against the bodys ability to recognize and provide healing mechanisms for a wound

vulnerable to alteration in epidermis and or dermis which may compromise health.

Risk for impaired skin integrity

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

Risk for pressure ulcers

Wound care that is provided in the home rather than a health care facility

Planning for home care

Preventing pressure ulcers employs a variety of prevention measures by the nurse to maintain skin integrity:

Providing nutrition, maintaining skin hygiene, avoiding skin trauma, providing supportive devices

What aspects of a person's skin is determined by genetics and heredity?

Skin color, sensitivity to sunlight, and allergies.

To guide wound care, the nurse can use the _______ color code of wounds. This concept is based on the color of an open wound (red, yellow, or black) rather than the depth or size of a wound. The goals of wound care in this plan is to cover the red, cleanse the yellow, and debride the black

They RYB color code

Transparent dressings are often applied to wounds including ulcerated or burned skin areas, They offer several advantages like:

They act as temporary skin, they are nonporous, nonabsorbent, self adhesive dressings that don't require changing like others, the wound can be assessed through them because they are transparent, they are semi occlusive so the wound remains moist and reduces the risk of infection, they can be placed over a joint since they are elastic, they adhere to the skin not the wound, the client can bathe without removing it.

What are the disadvantages to hydrocolloid dressings?

They are occlusive, opaque, and obscure wound visibility, they have a limited absorption capacity, They can facilitate anaerobic bacterial growth, They can soften and wrinkle at the edges with wear and movement, They can be difficult to remove and may leave residue on the skin.

Hydrocolloid dressings are frequently used over pressure ulcers. These dressings offer several advantages:

They last 3 to 7 days, They do not need a cover dressing and are water resistant so the clients can shower, They can be molded to uneven body surfaces, They act as a temporary skin, They decrease pain and thus reduce the need for pain meds, They absorb moderate drainage and be used on slow draining wounds, They contain wound odor.

Certain chronic medical conditions such as diabetes and cardiovascular disease are risk factors for skin breakdown and delayed healing. Explain why?

These conditions compromise oxygen delivery to tissues by poor perfusion and this cause poor and delayed healing and increase the risk of pressure ulcers.

Clients should be assisted to take in a t least 2500 mL of fluids a day unless the conditions are contraindicated.

fluid and nutrition

The use of ____________ can be extremely effective in the cleansing of chronic wounds (while leaving the healthy tissue untouched), eat bacteria, and decrease bacterial growth through the rise in surface pH that results from their presence

fly larvae (maggots)