Chapter 48 Skin Integrity and Wound Care

Identify these principles that are important to cleaning an incision:

1) Cleanse in a direction of the least contaminated area to the surrounding skin 2) Use gentle friction when applying solutions locally to the skin 3) When irrigating, allow the solution to flow from the least to the most contaminated area

Explain how protection is included in first aid of wounds:

Applying sterile or clean dressing and immobilizing the body part

Summarize the principles of packing a wound:

Assess the size, depth, and shape of the wound; dressing (moist) needs to be flexible and in contact with all of the wound surface; do not pack tightly ( over packing causes pressure); do not overlap the wound edges (maceration of the tissue)

Define eschar related to wound healing:

Black or brown necrotic tissue

Define exudate related to wound healing:

Describes the amount, color, consistency, and the odor of wound drainage

Explain the rationale for cold soaks:

Immersing a body part for 20 minutes

Explain the rationale for warm, moist compresses:

Improve circulation, relieve edema, and promote consolidation of pus and drainage.

Dermis

Inner layer of the skin that provides tensile strength and mechanical support

Blanching

Normal red tones of light-skinned patients are absent

Drains:

Observe the security of the drain and its location with respect to the wound and the character of the drainage; measure the amount

Explain the purpose from drainage evacuation:

Portable units that connect tubular drains lying within a wound bed and exert a safe, constant low-pressure vacuum to remove and collect drainage

Explain the rationale for warm soaks:

Promotes circulation, lessens edema, increases muscle relaxation, and provides a means to debride wounds and apply medication solutions.

Define slough related to wound healing:

Stringy substance attached to a wound bed that is soft, yellow, or white tissue

Wound closures:

Surgical wounds are closed with staples, sutures, or wound closures. Looks for irritation around staple or suture sites and note whether the closures are intact.

Explain the rationale for sitz baths:

The pelvic area is immersed in warm fluid, causing wide vasodilation.

Explain the rationale for ice bags or collars:

Used for muscle sprain, localized hemorrhage, or hematoma

Pressure Ulcer

localized injury to the skin and underlying tissue over a body prominence

Collagen

tough, fibrous protein

Staging systems for pressure ulcers are based on the depth of tissue destroyed. Briefly describe each stage.

1) Stage I-Intact skin with nonblanchable redness of a localized area over a bony prominence 2) Stage II-Partial-thickness skin loss involving epidermis, dermis, or both 3) Stage III-full thickness with tissue loss 4) Stage IV-full thickness with tissue loss with exposed exposed bone, tendon, or muscle

List the questions to ask if the identified outcomes were not met:

1) Was the etiology of the skin impairment addressed? 2) Was the wound healing supported by providing wound base with a moist, protected environment? 3) Were issues such as nutrition assessed and a plan of care developed?

List the factors that influence heat and cold tolerance:

1) a person is better able to tolerate short exposure to temperature extremities 2) more sensitive to temperature variations: neck, inner aspect of the wrist and forearm, and perineal region 3) the body responds best to minor temperature adjustments 4) a person has less tolerance to temperature changes in which a large area of the body is exposed 5) tolerance to temperature variations changes with age 6) physical conditions that reduce the reception or perception of sensory stimuli 7) uneven temperature distribution suggests that the equipment is functioning improperly

Identify the following types of emergency setting wounds:

1) abrasion-is superficial with little bleeding and is considered a partial thickness wound 2) laceration-sometimes bleeds more profusely depending on depth and location 3) puncture-bleeds in relation to the depth and the size, with a high risk of internal bleeding and infection

List the functions of hydrocolloid dressings:

1) absorbs drainage through the use of exudate absorbers 2) maintain wound moisture 3) slowly liquefies necrotic debris 4) impermeable to bacteria 5) self-adhesive and molds well 6) acts as a preventive dressing for high-risk friction areas 7) may be left in place for three to five days, minimizing skin trauma and disruption of healing

List the advantages of transparent film dressing:

1) adheres to undamaged skin 2) Serves as a barrier to external fluids and bacteria but allows a wound surface to breath 3) Promotes a moist environment 4) Can be removed without damaging underlying tissues 5) Permits viewing 6) Does not require a secondary dressing

List the guidelines to following during a dressing change procedure:

1) assessment of the skin beneath the tape 2) performing thorough hang hygiene before and after wound care 3) wear sterile gloves 4) removing or changing dressing over close wounds when they become wet or if the patient has signs and symptoms of infection

Describe the physiological responses to heat and cold applications:

1) heat applications-improves blood flow to an injured part; if apples for more then one hour the body reduces blood flow by reflex vasoconstriction to control heat loss from the area 2) cold applications-diminishes swelling and pain, prolonged results in reflex vasodilation

List the nursing responsibilities when applying a bandage or binder:

1) inspecting the skin for abrasions, edema, discoloration, or exposed wound edges 2) covering exposed wounds or open abrasions with a sterile dressing 3) assessing the condition of underlying dressings and changing if soiled 4) Assessing the skin for underlying areas that will be distal to the bandage for sign of circulatory impairment

Identify the methods of debridement:

1) mechanical 2) autolytic 3) chemical 4) sharp or surgical

Explain the following factors that place a patient at risk for a pressure ulcer:

1) mobility-potential effects of impaired mobility; muscle tone and strength 2) nutritional status-malnutrition is a major risk factor, a loss of 5% usual body weight, weight less then 90% of ideal body weight, or a decrease of 10lbs in a brief period 3) Body fluids- continuous exposure of the skin to body fluids, especially gastric and pancreatic drainage, increases the risk for breakdown 4) pain-adequate pain control and patient comfort will increase mobility, which in turn reduces risk

List the potential or actual nursing diagnoses related to impaired skin integrity:

1) risk for infection 2) Imbalanced nutrition: less then bodys requirements 3) Acute or chronic pain 4) Impaired skin integrity 5) impaired physical mobility 6) Risk for impaired skin integrity 7) Ineffective tissue perfusion 8) Impaired tissue integrity

Identify the three major areas of nursing interventions for preventing pressure ulcers:

1) skin care and management of incontinence 2) Mechanical loading and support devices 3) Education

Darkly pigmented skin

does not blanch

Epidermis

top layer of skin

List the advantages of the hydrogel dressing:

1) Soothing and reduces pain 2) Provides a moist environment 3) Debrides the wound 4) Does not adhere to the wound base and is easy to remove

Explain the benefits of binders and bandages:

1) Creating pressure over a body part 2) immobilizing a body part 3) Supporting a wound 4) Reducing or preventing edema 5) Securing a splint 6) Securing dressings

Briefly explain each complication of wound healing:

1) Hemorrhage-bleeding from a wound site that occurs after hemostasis indicates a slipped surgical suture, a dislodged clot, infection, or erosion of blood vessel by a foreign object. 2) Hematoma-localized collection of blood underneath the tissue 3) Health care-associated infection-Second most common nosocomial infection; purulent material drains from the wound (yellow, green. or brown, depending on the organism) 4) Dehiscence-A partial or total separation of wound layers; risks are poor nutritional status, infection, or obesity 5) Evisceration-Total separation of wound layers with protrusion of visceral organs through a wound opening surgical repair

Explain the four phases involved in the healing process of a full-thickness wound:

1) Hemostasis-Injured blood vessels constrict, and platelets gather to stop bleeding; clots for from a fibrin matrix for cellular repair 2) Inflammatory phase-damaged tissues and mast cells secrete histamine(vasodilates) with exudation of serum and WBC into damaged tissues 3) Proliferative phase-With the appearance of new nlood vessels as reconstruction progresses, the proliferative phase begins and lasts from 3 to 24 days. The main activities during this phase are the filling of the wound with granulation tissue, contraction of the wound, and resurfacing of the wound by epithelialization. 4) Maturation-The final stage, may take up to one year; the collagen scar continues to reorganize and gain strength for several months.

List the possible goals to achieve wound improvement:

1) Higher percentage of granulation tissue in the wound base 2) No further skin breakdown in any body location 3) An increase in the caloric intake by 10%

Identify the risk factors that predispose a patient to pressure ulcer formation:

1) Impaired sensory perception 2) Impaired mobility 3) Alteration in level of consciousness 4) Shear 5) Friction 6) Moisture

Identify the three components involved in the healing process of a partial-thickness wound

1) Inflammatory response 2) Epithelial proliferation (reproduction) 3) Migration with reestablishment of the epidermal layers

List the factors that influence pressure ulcer formation:

1) Nutrition 2) Tissue perfusion 3) Infection 4) Age 5) Psychosocial impact of wounds

Identify the pressure factors that contribute to pressure ulcer development:

1) Pressure intensity 2) Pressure duration 3) Tissue tolerance

List the principles to address to maintain a healthy wound environment:

1) Prevent and manage infection 2) Cleanse the wound 3) Remove nonviable tissue 4) maintain the wound in moist environment 5) eliminate dead space 6) control odor 7) eliminate or minimize pain 8) protect the wound

List the purposes of dressings:

1) Protects a wound from microorganisms contamination 2) Aids in hemostasis 3) Promotes healing by absorbing drainage and debriding a wound 4) Supports or splints the wound site 5) Promotes thermal insulation of the wound surface 6) Provides a moist environment

The Braden Scale was developed for assessing pressure ulcer risks. Identify the subscales of this tool:

1) Sensory perception 2) Moisture 3) Activity 4) Mobility 5) Nutrition 6) Friction or shear

How does the nurse assess character of wound drainage?

Amount, color, odor, and consistency of drainage which depends on the location and the extent of the wound.

Briefly describe how the wound vacuum-assisted closure device works( wound VAC):

Applies localized negative pressure to draw the edges of a wound together by evacuating wound fluids and simulating granulation tissue formation, reduces the bacterial burden of a wound, and maintains a moist environment

Explain how hemostasis is included in first aid of wounds:

Control bleeding by applying direct pressure in the wound site with a sterile or clean dressing, usually after trauma.

Explain the rationale for commercial hot packs:

Disposable hot packs that apply warm, dry heat to an area

Explain how cleansing is included in first aid of wounds:

Gentle cleansing rather than vigorous cleansing with NS (physiological and will not harm tissue)

Describe how primary intention is a physiological process involved in wound healing:

Wound that is closed by epithelialization with minimal scar formation

Define granulation tissue related to wound healing:

Red, moist tissue composed of new blood vessels, which indicate wound healing

Explain the rationale for cold, moist, and dry compresses:

Relieves inflammation and swelling

Explain the rationale for debriding a wound:

Remove nonviable necrotic tissue to rid the ulcer of a source of infection, enable visualization of the wound bed, provide a clean base necessary for healing.

Summarize the principles of wound irrigation:

Use an irrigating syringe to flush the area with a constant low-pressure flow of solution of exudates and debris. Never occlude a wound opening with a syringe.

How does the nurse assess wound appearance?

Whether the wound edges are closed, the condition of tissue at the wound base; look for complications and skin coloration

Describe how secondary intention is a physiological process involved in wound healing:

Wound is left open until it becomes filled by scar tissue; chance of infection is greater