Fundamentals Chapter 48 Skin Integrity and Wound Care

Hematoma

a solid swelling of clotted blood within the tissues.

sanguineous

bloody drainage

secondary intention wound

large wound with considerable tissue loss; can't be closed with suturing, repair time is longer and scarring is greater (chance of infection is greater

pressure injury

localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device

Dehiscence

partial or total separation of wound layers

Braden Scale

A tool for predicting pressure ulcer risk

List the advantages of a transparent film dressing

A. Serves as a barrier to external fluids and bacteria b. Ideal for small wounds c. Promote a moist environment d. Can be removed without damaging underlying tissues e. Permits viewing f. Does not require a secondary dressing

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

*Stage I:* Intact skin with non-blanchable redness *Stage II:* Partial-thickness skin loss involving epidermis, dermis, or both *Stage III:* Full thickness tissue loss with visible fat *Stage IV:* Full-thickness tissue loss with exposed bone, muscle, or tendon *Unstageable/Unclassified:* Full-thickness Skin or Tissue Loss (Depth Unknown) *Suspected Deep-Tissue Injury* (Depth Unknown)

List the factors that influence heat and cold tolerance

- A person is better able to tolerate short exposure to temperature extremes. - More sensitive to temperature variations: neck, inner aspect of the wrist and forearm, and perineal region. - The body responds best to minor temperature adjustments - A person has less tolerance to temperature changes to which a large area of the body is exposed. - Tolerance to temperature variations changes with age. - Physical conditions that reduce the reception or perception of sensory stimuli - Uneven temperature distribution suggests that the equipment is functioning improperly.

List the functions of hydrocolloid dressings

- Absorbs drainage through the use of exudate absorbers - Maintains wound moisture - Slowly liquifies necrotic debris - Impermeable to bacteria - Self-adhesive and molds well - Acts as a preventive dressing for high-risk friction areas - May be left in place for 3-5 days, minimizing skin trauma and disruption of healing

Explain the benefits of binders and bandages

- Creating pressure over a body part - Immobilizing a body part - Supporting a wound - Reducing or preventing edema - Securing a splint - Securing dressings

List the advantages of hydrogel dressing

- Soothing and reduces pain - Provides a moist environment - Debrides the wound - Does not adhere to the wound base and is easy to remove

List the guidelines to follow during a dressing change procedure

-Know the type of dressing, the presence of underlying drains or tubing and type of supplies needed -Use of medical aseptic technique -Education on changing dressing in preparation for home care

recommended protein intake

0.8 grams per kilogram of body weight for healing and 0.5 grams per kilogram for adults

Place the following steps in correct order for performing a wound irrigation 1. Use slow continuous pressure to irrigate the wound 2. Attach 19-gauge angiocatheter to syringe 3. Fill syringe with irrigation fluid 4. Assess wound 5. Position amgiocatheter over wound

4, 3, 2, 5, 1

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

1. Risk for infection 2. Acute or chronic pain 3. Impaired physical mobility 4. Impaired peripheral tissue perfusion

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

Evisceration

The displacement of organs outside of the body.

Explain the rationale for debriding a wound

Removal of nonviable necrotic tissue to rid the ulcer of a source of infection, enable visualization of the wound bed, and provide a clean base necksary for healing

A nurses responsibility with assessing drains is

Security of the drain Location with respect to the wound Character of the drainage Measure the amount

Summarize the principles of wound irrigation

Use of 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.

Ice bags or collars

Used for muscle sprain, localized hemorrhage, or hematoma

Wound appearance

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

Serosanguineous

Pale, red, watery: mixture of clear and red fluid

Explain the purpose for 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.

Warm Soaks

Promotes circulation, lessens edema, increases muscle relaxation, and provides a means to apply medicated solution

Nursing Interventions for wound care management

Provide Adequate hydration and meet protein and calorie needs Perform wound cleansing and irrigation Remove sutures and staples Administer analsegic Administer anti microbial Document

Treatment for Stage 1 + DTI (Deep Tissue Injury)

Relieve Pressure Turn Frequently Use Pressure Relieving devices (Air fluidized bed) Implement pressure relduction surfaces Keep client dry, clean, well nourished and hydrated

Cold, moist, and dry compresses

Relieves inflammation and swelling

Treatment for Stage 4

Clean and/or debride with the following -Prescribed dressing -Surgical interventions -Proteolytic Enzymes Perform non adherent dressing changes every 12 hours Treatment can include skin grafts or specialized therapy Provide nutritional supplements Administer analgesics Administer anti microbial (topical and/or systematic)

Treatment for Stage 3

Clean and/or debride with the following -Prescribed dressing -Surgical interventions -Proteolytic enzymes Provide nutritional supplements Administer Analgesics Administer anti microbial (topical and/or systemic)

Collagen

Fibrous protein that gives the skin form and strength

Cold soaks

Immersing a body part for 20 minutes

Dermis

Inner layer of skin

Which of the following is not a sub scale on the Braden Scale for predicting pressure ulcer risk?

1. Age 2. Activity 3. Moisture 4. Sensory Perception 1.Age is not a subscale

Explain what a deep tissue pressure injury (dtpi) is

Intact or non intact skin with localized area of persistent non blanchable deep red maroon purple discoloration or epidermal separation revealing a dark wound bed or blood-filled blister. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface.

Palpation of a wound includes

Lightly press the wounds edges Detecting localized areas of tenderness or drainage collection

Treatment for stage 2

Maintain moist healing environment (saline or occlusive dressing) Apply hydrocolloid dressing Promote natural healing while preventing the formation of scar tissue Provide nutritional supplements Administer Analgestics

Explain the factors that place a patient at risk of pressure injury development

Malnutrition Impaired Mobility Exposure of skin to body fluids (gastric or pancreatic drainage) Adequate pain control and comfort will help to increase mobility

List possible goals to achieve wound improvement:

a. Higher percentage of granulation tissue in the wound base b. No further skin breakdown in any body location c. An increase in the caloric intake by 10%

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

a. Inflammatory response- causing redness and swelling to the area with moderate amount of serous exudate b. Epithelial proliferation (reproduction)- cells begin to regenerate c. Migration with reestablishment of the epidermal layers

List the principles to address to maintain a healthy wound environment

a. Manage infection. b. Cleanse the wound. c. Remove nonviable tissue. d. Manage exudates. e. Maintain the wound in moist environment. f. Protect the wound. g. Eliminate dead space h. Eliminate or minimize pain

List the purposes of dressings

a. Protects a wound from microorganism contamination b. Aids in hemostasis c. Promote healing by absorbing drainage and debriding a wound d. Support or splints the wound site e. Protects the patient from seeing the wound f. Promote thermal insulation of the wound surface g. Provides a moist environment

List the clinical guidelines to use when selecting the appropriate dressing.

a. Use a dressing that will continuously provide a moist environment. b. Perform wound care using topical dressings as determined by assessment. c. Choose a dressing that keep the surrounding skin dry. d. Choose a dressing that controls exudates. e. Consider caregiver time, availability, and cost. f. Eliminate wound dead space by loosely filling all cavities with dressing material. g. Clean wound with each dressing change h. Dressing may change overtime as pressure heals

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

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

Identify three principles that are important when cleaning an incision

a. Cleanse in a direction from the least contaminated area to the surrounding skin. b. Use gentle friction when applying solutions locally to the skin. c. When irrigating, allow the solution to flow from the least to the most contaminated area.

Identify the pressure factors that contribute to pressure ulcer development. (3)

1. pressure intensity 2. pressure duration 3. tissue tolerance

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

hemostasis- injured blood vessels constrict and platelets gather to stop bleeding inflammatory- damaged tissues and mast cells secrete histamine with exudation of serum and WBC into the damaged tissues proliferative- Begins and lasts from 3-24 days. Filling of the wound with granulation tissue, contraction of the wound, and resurfacing of the wound by epithelial toon maturation- Final Stage (May take up to 1 year) collagen scar continues to reorganize and gain strength

serous

clear, watery plasma

granulation tissue

new tissue that is pink/red in color and composed of fibroblasts and small blood vessels that fill an open wound when it starts to heal

Blanching

occurs when the normal red tones of the light-skinned patient are absent

eschar

dead matter that is sloughed off from the surface of the skin, especially after a burn (black or brown + necrotic)

darkly pigmented skin

does not blanch

purulent

producing or containing pus

Sitz Baths

provide warm moist heat to the perineal and rectal area

Braden Scale Subscales

sensory perception moisture activity mobility nutrition friction shear

slough

string substance attached to wound bed (yellow or white) - has to be removed before wound can heal properly

primary intention wound

wound edges are closed, well-approximated and there is little tissue loss and little scarring (no infection and secondary breakdown)

List and explain the factors that influence pressure ulcer formation and wound healing

Nutrition- deficiencies in any of the nutrients result in impaired or delayed healing Tissue Perfusion - the ability to perfuse the tissues with adequate amounts of oxygenated blood is critical to wound healing Infection - Prolongs the inflammatory phase, delays collagen synthesis, prevents epithelial action, and increases the production of pro inflammatory cytokines Age - increased age causes a decrease in the functioning of macrophages Psychosocial Impact of Wounds - stress on a patient's adaptive mechanisms

Mr. Post is in a Fowler position to improve his oxygenation status. The nurse notes that he frequently slides down in the bed and needs to be repositioned. Mr. Post is at risk for developing a pressure ulcer on his coccyx because of

3. Shearing Force: His body is sliding down pushing him downs

Identify the following types of emergency setting wounds

Abrasion - superficial with little bleeding (partial thickness wound) Laceration - Sometimes bleeds more profusely depending on depth and location (>5 cm or 2.5 cm in depth) Puncture - Bleeds in relation to depth and size. High risk of internal bleeding and infection

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

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

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 (overpacking causes pressure) do not overlap the wound edges (maceration of the tissue).

Exudate

Description of fluid that accumulates in a wound; may contain serum, cellular debris, bacteria, and white blood cells (amount, color, consistency and odor)

Commercial hot packs

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

hemorrhage

Excessive or profuse bleeding

Character of wound drainage

Note the amount, color, odor, and consistency of drainage

Wound infection

Second most common health care associated infection

Types of surgical wound closures are

Staples Sutures Wounds Closures

Epidermis

top layer of skin

Identify the four methods of debridement

1. Mechanical 2. Autolytic - Use of lysis 3. Chemical - Topical enzyme preparation (Dakin's solution or sterile maggots) 4. Sharp or Surgical

List the nursing responsibilities when applying a bandage or binder

- Inspecting the skin for abrasions, edema, discoloration, or exposed wound edges. - Covering exposed wounds or open abrasions with a sterile dressing - Assessing the condition of underlying dressings and changing if soiled - Assessing the skin for underlying areas that will be distal to the bandage for signs of circulatory impairment

Describe the physiological responses to the following

- Heat application: Improves blood flow to an injured part; if applied for more than 1 hour, the body reduces blood flow by reflex vasoconstriction to control heat loss from the area - Cold application: Diminishes swelling and pain, prolonged results in reflex vasodilation

You are taking care of a patient who is experiencing frequent fecal and urinary incontinence. What specific nursing interventions could you institute to help manage this patient?

Checking on the patient often and consistently assessing the skin and perineal areas, incontinence cleanser, skin barrier, ointment + more frequent help to toilet

Warm, moist compresses

Improve circulation, relieve edema, and promote consolidation of purulent drainage