skin integrity & wound care ch 48:

Inflammatory response

-causing redness and swelling to the area with moderate amount of serous exudate.

Stage 2

2 layers of damage (epi and derm) wound bed is red/pink,shiny,dry.

STAGING SYSTEMS FOR PRESSURE INJURIES ARE BASED ON:

THE DEPTH OF TISSUE DESTROYED.

PROTECTION

applying sterile or clean dressings and immobilizing the body part.

ESCHAR

black or brown necrotic tissue

EXPLAIN THE RATIONALE FOR DEBRIDING A WOUND

it enables visualization of the wound bed,and provide a clean base necessary for healing.

BLANCHING

normal red tones of light-skinned patients are present.

Purulent drainage

thick yellow,green,tan or brown.

Stage 1

1 layer of damage(epidermis) red skin that is NON blanchable and not broken.

Stage 3

3 layers of damage(epi,derm,sub) full thickness skin loss into subcutaneous fat wound may tunnel under the edges of the wound bed.

Stage 4

4 layers of damage that extends all the way down into the muscle,bone,or tendon.

Primary intention

Surgical closure of a wound with sutures, staples, tapes, surgical glue. Low risk for infection

IMPAIRED MOBILITY

UNABLE TO CHANGE POSITIONS.

IDENTIFY THE FOLLOWING TYPES OF EMERGENCY SETTING WOUNDS

abrasion,laceration,puncture.

Sanguineous drainage

bright red, active bleeding.

FIRST AID FOR WOUNDS INCLUDES THE FOLLOWING

hemostasis,cleansing,protection.

IDENTIFY FOUR METHODS OF DEBRIDEMENT

mechanical,Autolytic-removal of dead tissue via lysis of necrotic tissue by the WBCs and natural enzymes of the body.,Chemical-topical enzymes preparation such as sterile maggots,Sharp or surgical.

COLLAGEN

tough,fibrous protien

You're working on a medical surgical floor. You have the following patients below. Select all the patients below that are at risk for a pressure injury

A 19 year old female who is a quadriplegic. A 45 year old with a Braden Scale score of 7. A 35 year old male with a BMI of 13.6 that is incontinent of stool and has a right leg splint.

The nurse is providing patient teaching about prevention of pressure injuries. Which statement by the patient would indicate that the teaching was successful?

Because I have dry skin, I need to moisturize.

Tertiary intention

Delayed primary intention closure.Planned period where superficial layers are left open (closed later by primary intention (surgically)

DTI pressure ulcer

Discolored purple or maroon on intact skin.

The nurse recognizes that the pts limited mobility can have adverse effects on the skin. What other information would the nurse need to gather to establish priorities for the plan of care? (Select all that apply.)

Fall risk, nutritional status, smoking history, hygiene status/practices,circulation status.

Induration

Formation of thickened or hardened edges around the wound.

STAGE IV(4)PRESSURE INJURY:

Full-thickness tissue loss with exposed bone, tendon, or muscle.

STAGE III PRESSURE INJURY:

Full-thickness with tissue loss

LIST POSSIBLE GOALS TO ACHIEVE WOUND IMPROVEMENT

Increase in the percentage of granulation tissue in the wound base,No wound erythema or redness to palpation,No further skin breakdown,An increase in the caloric intake by 10%.

STAGE I PRESSURE INURY:

Intact skin with nonblanchable redness of a localized area over a bony prominence.

IDENTIFY THE PRESSURE FACTORS THAT CONTRIBUTE TO PRESSURE INJURY DEVELOPMENT

PRESSURE INTENSITY,PRESSURE DURATION, TISSUE TOLERANCE

STAGE II PRESSURE INJURY:

Partial-thickness skin loss involving epidermis,dermis, or both.

LIST PRINCIPALES TO ADDRESS TO MAINTAIN A HEALTHY WOUND ENVIRONMENT

Prevent and manage infection,Cleanse the wound,Remove nonviable tissue,Maintain the wound in moist environment,Eliminate dead space,Control odor,Eliminate or minimize pain,Protect the wound.

LIST THE PURPOSE OF DRESSINGS

Protects a wound from microorganism contamination,Aids in hemostasis,promotes healing by absorbing drainage and debriding a wound,supports or splints the wound site,promotes thermal insulation of the wound surface,provides a moist environment.

IDENTIFY THE THREE MAJOR AREAS OF NURSING INTERVENTIONS FOR PREVENTING PRESSURE INJURIES

Skin care and management of incontinence,Mechanical loading and support devices,education.

staging of stage 2 pressure injury

The skin is visibly damaged and NOT intact with PARTIAL loss of the dermis. No subq (fatty tissue) is visible. These wounds may be opened with a superficial red/pink ulcer or may have the formation of an opened or closed blister.

You're educating a group of nursing students about the different stages of a pressure injury. Which statement is correct about a stage 3 pressure injury?

The skin will not be intact and there will be full loss of skin tissue that can extend to the subcutaneous tissue.

IMPAIRED SENSORY PERCEPTION

UNABLE TO FEEL WHEN A PART OF THEIR BODY UNDERGOES INCREASED,PROLONGED PRESSURE OR PAIN.

unstageable pressure ulcer

Unable to determine depth obscured by necrotic tissue.

The nurse is inspecting pts skin. To which areas should the nurse pay close attention while performing a physical assessment? (Select all that apply.)

Under breast, groin, arms and legs,sacrum.

The nurse is providing education to Josephine Morrow on how to prevent additional venous stasis ulcers from developing. Which statement(s) would be appropriate to include in the teaching plan? (Select all that apply.)

Wear support stockings to help prevent ulcers and heal existing ones.', 'Watch for signs and symptoms of new ulcers.'

DEHISCENCE

a partial or total separation of wound layers the risks are poor nutritional status infection or obesity.

Dehiscence

a surgical incision fails to heal properly, the layers of skin and tissue separate.

Secondary intention

a wound involving loss of tissue, such as a burn, Stage 2 PI, severe laceration.Not closed surgically due to unable to bring the tissues together safely from tissue loss.

CHARACTER OF WOUND DRAINAGE

amount,color,odor,consistency of drainage, depend on location and the extent of the wound.

CLEANSING

appropriate cleansing solution and using a mechanical means of delivering the solution w/o causing injury to healing wound tissue.

Eschar(esCHARCOAL)

black/brown dead necrotic tissue.

HEMORRHAGE

bleeding from a wound site that occurs after hemostasis indicated a slipped surgical suture, a dislodged clot,infection or erosion of a blood vessel.

PUNCTURE

bleeds in relation to the depth and size, with a high risk of internal bleeding and infection.

Epithelial proliferation (reproduction)

cells begin to regenerate providing new cells to replace the lost cells.

Serous drainage

clear, watery plasma.

HEMOSTASIS

control bleeding by applying direct pressure in the wound site with a sterile or clean dressing.

INFLAMMATORY PHASE

damaged tissues and mast cells secrete histamine (vasodilates) with exudation of serum and WBC into damaged tissues.

EXUDATE

describes the amount,color,consistency,odor of wound drainage,excessive drainage indicates infection.

DARKLY PIGMENTED SKIN

does not blanch.

An 86 year old female patient is immobile and is in the right lateral recumbent position. As the nurse you know that which sites below are at most risk for pressure injury in this position?

ear, hip,shoulder.

Unstageable

eschar(black/brown)dead necrotic tissue, slough(yellow,stringy).

DEEP TISSUE INJURY

fatty tissue is injured below the skin (dark purple,sometimes open wound.

BRIEFLY EXPLAIN THE FOLLOWING COMPLICATION OF WOUND HEALING

hemorrhage,hematoma,wound infection,dehiscence,evisceration.

EXPLAIN THE FOUR PHASES INVOLVED IN THE HEALING PROCESS OF A FULL-THICKNESS WOUND

hemostasis, inflammatory phase, proliferative phase,remodeling maturation.

Non-blanchable erythema

if skin does not blanch when pressure is applied to skin and possible tissue damage is probable.

IDENTIFY AND EXPLAIN THE RISK FACTORS THAT PREDISPOSE A PATIENT TO PRESSURE INJURY FORMATION

impaired sensory perception,impaired mobility,altered level of consciousness, shear, friction, moisture.

Wound VAC therapy

improves the possibility of primary closure of wounds and reduces the need for reconstructive procedures.

IDENTIFY THE THREE COMPONENTS INVOLVED IN THE HEALING PROCESS OF A PARTIAL THICKNESS WOUND

inflammatory response, epithelial proliferation, migration.

HEMOSTASIS

injured blood vessels constrict, and platelets gather to stop bleeding,clots form a fibrin matrix for cellular repair.

DERMIS

inner layer of the skin that provides tensile strength and mechanical support.

EXPLAIN WHAT A DEEP TISSUE PRESSURE INJURY IS

intact or nonintact skin with localized area of persistent nonblanchable deep red,maroon,purple discolorization or epidermal separation revealing a dark wound bed or blood filled blister.

ABRASION

is a superficial with little bleeding and is considered a partial-thickness wound

PALPATATION OF A WOUND INCLUDES

lightly press the wound edges,detecting localized areas of tenderness or drainage collection.

HEMATOMA

localized collection of blood underneath the tissue.

PRESSURE INJURY

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

Most common areas for pressure injuries

lower back,buttocks (sacrum &coccyx), heels,ankles,hip bones,shoulders,elbows.

REMODELING MATURATION

maturation, the final stage, may take up to 1 year, the collagen scar continues to reorganize and gain strength for several months.

EXPLAIN THE FOLLOWING FACTORS THAT PLACE A PATIENT AT RISK FOR PRESSURE INJURY DEVELOPMENT

mobility, nutritional status, body fluids,pain.

LIST AND EXPLAIN THE FACTORS THAT INFLUENCE PRESSURE INJURY FORMATION AND WOUND HEALING

nutrition,tissue perfusion,infection,age,psychosocial impacts.

A NURSES RESPONSIBILITY WITH ASSESSING DRAINS IS

observe the security of the drain and its location with respect to the wound and the character of the drainage,measure the amount.

shear

occurs when HOB is elevated and the sliding of the skeleton starts but the skin is fixed bc of friction with the bed.

Serosanguineous drainage

pale,pink,watery mixture of clear and red fluid.

Blanchable hyperemia

placing finger over affected area, if the skin turns lighter in color and erythema returns.

Process of wound healing

primary intention,secondary intention,tertiary intention.

Nutrition for wound healing

protein,vitamin C,trace minerals,zinc,copper. Chicken breast,Orange,Broccoli,Milk

Evisceration

protrusion of visceral organs through a wound opening.The condition is an emergency that requires surgical repair .

GRANULATION TISSUE

red, moist tissue composed of new blood vessels,which indicates wound healing

moisture

reduces the resistance of the skin to other physical factors.

LIST THE POTENTIAL OR ACTUAL NURSING DIAGNOSES RELATED TO IMPARED SKIN INTEGRITY

risk for infection,acute or chronic pain,impaired mobility,Impaired peripheral tissue perfusion.

WOUND INFECTION

second most common health care associated infection

THE BRADEN SCALE WAS DEVELOPED FOR ASSESSING PRESSURE INJURY RISKS. IDENTIFY THE SUBSCALES OF THIS TOOL

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

Exudate

should describe the amount, color, consistency, and odor of wound drainage.

friction

skin is dragged across a coarse surface affecting the epidermis layer.

LACERATION

sometimes bleeds more profusely depending on the depth and location (> 5cm or 2.5 cm in depth).

The nurse is assessing a shallow, open ulcer with a red-pink wound bed that is located on a patient's sacrum. How would the nurse document this wound?

stage II.

SLOUGH

stringy substance attached to wound bed that is soft,yellow, or white tissue.

TYPES OF SURGICAL WOUND CLOSURES ARE

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

EPIDERMIS

top layer of the skin

EVISCERATION

total separation of wound layers with protrusion of visceral organs through a wound opening requiring surgical repair.

WOUND APPEARANCE

whether the wound edges are closed, the condition of tissue at the wound base;look for complication and skin coloration.

Migration

with reestablishment of the epidermal layers.

PROLIFERATIVE PHASE

with the appearance of new blood vessels as reconstruction progresses, the proliferation phase begins and lasts from 3 to 24 days. Filling of the wound with granulation tissue.

SECONDARY INTENTION

wound is left open until it becomes filled by scar tissue,chance of infection is greater,healing takes longer. involved in wound healing.

PRIMARY INTENTION

wound that is closed by epithelialization with minimal scar formation as long as infection and secondary breakdown are prevented. involved in wound healing.

Slough

yellow stringy, think skin of cicken.