8:3 Skin Integrity And Wound Care

Front 1

Skin

Back 1

Largest organ in the body

Front 2

Intentional trauma

Back 2

Occur during therapy ex. operations, orvenipunctures

Front 3

Unintentional wounds

Back 3

are accidental. Ex. fracture from auto accident

Front 4

Incision

Back 4

sharp instrument (knife) open wound deep or shallow

Front 5

Contusion

Back 5

Blow from blunt instrument, closed and ecchymotic (bruised)

Front 6

Abrasion

Back 6

surface scrape, intentional, or unintentional : open wound

Front 7

Puncture

Back 7

penetration of the skin underlying tissues by sharp instrument can be intentional or unintentional open wound

Front 8

Laceration

Back 8

tissues torn apart, often from accident, open wound with jagged edges

Front 9

Penetrating

Back 9

penetrates the skin and underlying tissues (bullet) open to wound

Front 10

Pressure Ulcers

Back 10

decubitus ulcer, pressure sores, or bedsores they are due to localized ischemia a deficiency in the blood supply to to the issue

Front 11

Friction

Back 11

is a force acting parallel to the skin surface (sheets against skin)

Front 12

Shearing force

Back 12

is a combination of friction and pressure. Ex. sliding across bed sheets when sitting (sacrum pushing down)

Front 13

Risk Factors contributing to pressure ulcers

Back 13

- immobility
-Inadequate Nutrition
-Fecal and Urinary Incontinence
-Decreased mental Status
-Diminished sensation from paralysis or stroke or neurologic disease
-Excessive body heat
-Elevated body temperature (increasing metabolic rate)
-Chronic medical conditions Ex. diabetes and cardiovascular disease by delayed healing

Front 14

Hypoprotienemia

Back 14

low protein content in the blood predsposes pt to edema

check albumin!

Front 15

Skin maceration

Back 15

softened by prolonged wetting or soaking

Front 16

Excoriation

Back 16

area of loss of the superficial layers of the skin also known as denuded area

Front 17

Stages of pressure ulcers

Stage I

Back 17

non blanchable erythemia signaling potential ulceration

Front 18

Stages of pressure ulcers

Stage II

Back 18

partial thickness skin loss involving the epidermisand possibly the dermis (abrasion, blister)

Front 19

Stages of pressure ulcers

Stage III

Back 19

full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend to fascia ( deep crater without undermining of adjacent tissue

Front 20

Stages of pressure ulcers

Stage IV

Back 20

full thickness skin loss involving damage or necrosis to muscle or bone or supporting structures, tendon or joint, undermining sinus tract to be present

Front 21

Healing

Back 21

quality of living tissue, it is also referred to as regeneration (renewal of tissue)

Front 22

Types of healing

Back 22

having to do with caregivers decision on whether to allow the wound to seal itself or purposely close the wound

Front 23

Phases of Healing

Back 23

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

Front 24

Rate of Healing

Back 24

depends on factors such as type of healing, the location and sizeof the wound and health of the client

Front 25

Primary Intention

Back 25

where the tissue surface have been approximated (closed) and there is minimal tissue loss, it is characterized by the formation of minimal granulation tissue and scarring Ex. surgical incision closed with sutures

Front 26

Secondary Healing

Back 26

A wound that is extensive and involves considerable tissue loss heals by secondary healing. Ex. A pressure ulcer repair time is longer scarring is greater, and susceptibility to infection is greater with second intention healing

Front 27

Inflammatory process
( essential to healing)

Back 27

innitiated immediately after injury and last 3-6 days. Two major processes occur durting this phase: hemostasis and phagocycotisis

Front 28

Hemastaisis

Back 28

cessation of bleeding
results from vasoconstriction of blood vessels
scab forms on surface

Front 29

proliferative disease

Back 29

2nd phase in healing extends 3 or 4 extends to about day 21 into healing after the healing

Front 30

Fibroblasts

Back 30

connective tissue cells

Front 31

granulation tissue

Back 31

beefy looking, fragile and red looking

Front 32

The maturation phase

Back 32

begins day 21 and extends 1-2 years after the injury

Front 33

Keloid

Back 33

abnormal amount of collegen is laid down called hypertrophy keloid

Front 34

Exudate

Back 34

material such as fluid and cells that have escaped from blood vessels during the inflammatory process

Front 35

3 Major Types of Exudate

Serous

Back 35

SEROUS exudate consitently of serum ( clear portion of the blood) It looks watery and has few cells (blister)

Front 36

3 Major Types of Exudate

Purulent

Back 36

PURULENT thicker because of the presence of pus, which consists of leudocytes, liquified dead tissue debris and dead and living bacteria. This varries in color, blue, green, and yellow. The color may depend on the causitive organism

Front 37

3 Major Types of Exudate

Sanguineous

Back 37

SANGUINEOUS ((hemorraphigic) exudate consists of large amounts of red blood cells indicating damage to capillaries. Seen in open wounds

Front 38

Hemorrhage

Back 38

massive bleeding, hemorrhage emergency the nurse should apply pressure dressings to the area and monitor vital signs

Front 39

Colonization

Back 39

contamination of wound surface with micro-organaisms, colonizing they would multiply excessively or invade the tissue, infection occurs

Front 40

Severe wound infection

Back 40

fever,and elevated WBC

Front 41

Dehiscence

Back 41

partial opr total rupturing of a sutured wound ( sterile dressing, normal saline

Front 42

Evisceration

Back 42

is the protusion of the internal viscera through the incision
viscera-coli of intestine

Front 43

Braden Scale

Back 43

Predicting pressure sore risks. This scale consists of 6 subscales
1. sory perception
2. moisture
3. activity
4. mobility
5. nutrition
6. friction and shear
A total of 23 points is possible

Front 44

Braden Scale

Back 44

15-18 At Risk
10-12 High Risk
9 or less very high risk

Front 45

Undermining

Back 45

Sometimes the wound reaches under the skin surfaces

Front 46

Planning

Back 46

Major goal of clients at risk for imapaired skin integrity
(pressure ulcer development) are to maintain skin integrity and avoid potential associated risks

Front 47

Nutrition and Fluids

Back 47

Patients should take in atleast 2,500ml a day. Ensure patients recieve adequate amounts of protein, vitamins and minerals, C, A, B1, B5, and Zinc

Front 48

Labs:

Back 48

lymphocyte count
protein (especially albumin)
hemoglobin

Front 49

Skin barriers

Back 49

Skin Prep

Front 50

Clients confined to bed

Back 50

Overlay mattress
Replacement Mattress
Specialty beds can be used as support surfaces

Front 51

To guide wound care the nurse can use the RYB code of wounds

Back 51

This concept is based on the color of an open wound -red- yellow-black -rather than size of a wound. The goals of wound care are to protect (cover) red, cleanse yellow, debride black

Front 52

Red wounds

Back 52

Stage I
usually in the late regeneration phase of tissue repair (developing granulation tissue). They need to be protected to avoid disturbance to regenerating tissue
Do not cleanse

Front 53

Yellow Wounds

Back 53

are characterized by liquid to nsemiliquid "slough" that is often accompanied by purulent drainage
Cleanse yellow wounds

Front 54

Black Wounds

Back 54

covered with thick necrotic tissue or eschar, when eschar removed wound is treated as yellow then red
- when more than one color is treated first black, then red.