Skin Integrity and Wound Care Study Guide, Study notes of Health sciences

Download Skin Integrity and Wound Care Study Guide and more Study notes Health sciences in PDF only on Docsity! 1 | P a g e Fundamentals of Nursing Study guide Exam 3 Chapter 36 Skin Integrity and Wound Care 1. When pressure is relieved, the skin takes on a bright red flush, called Reactive Hyperemia. 2. Reactive hyperemia usually last one half to three quarters as long as the duration of impeded blood flow to the area. If the redness disappears in that time, no tissue damage is anticipated. 3. Friction is a force acting parallel to the skin surface. 4. Shearing force- is a combination of friction and pressure. 5. Immobility- refers to a reduction in the amount and control of movement a person has. 6. 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 the person can. Perceive the pressure. 7. Prolonged inadequate nutrition causes weight loss, muscle atrophy, and the loss of subcutaneous tissue. These conditions reduce the amount of padding between skin and the bones, thus increasing the risk of pressure ulcer development. 8. Edema (the presence of excess interstitial fluid) makes skin more prone to injury by decreasing its elasticity, resilience, and vitality. Edema 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. 9. Maceration- tissue softened by prolonged wetting and soaking. 10.Digestive enzyme in feces, urea in urine, and gastric tube drainage also contribute to skin excoriation (area of loss of the superficial layers of the skin; also known as denuded area). 11. Unconscious, heavily sedated, or have dementia, are at risk for pressure ulcers because they are less able to recognize and respond to pain associated with prolonged pressure. 12.Pressure Ulcer: • Stage I: Non-blanchable erythema signaling potential ulceration • Stage II: Partial thickness of skin loss (abrasion, blister, or shallow crater) involving the epidermis and possibly the dermis. • Stage III: Full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down, to but not through, underlying fascia. The ulcer presents clinically as deep crater with or without undermining of adjacent tissue. Stage IV: Full-thickness skin loss with tissue necrosis or damage to muscle bone, or supporting structures, such as a tendon or joint capsule. Undermining and sinus tracts may also be present. • Unstageable/unclassified: Full-thickness skin or tissue loss- depth unknown, actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed. • Suspected deep tissue injury: Depth unknown, purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. 13.Braden scale: • A total of 23 points is possible and an adult who scores below 18 points is considered at risk, nurses should be trained in proper use of scale. • Sensory perception, Moisture, Activity, Mobility, nutrition, Friction and shear. 14.Norton’s Pressure area risk assessment scoring system: • Possible score 24. Score of 15 or 16 should be viewed as indicators, not predictors, of risk. 15.Assessing common pressure sites: • Supine position: Heels, Sacrum, Elbows (Olecranon process), Scapulae, and back of head (Occipital bone). • Lateral position: Malleolus (Medial and lateral condyles), greater trochanter, llium, Shoulder (acromial process), and Ear, Side of head (Parietal and temporal bones) • Prone position: Toes (Phalanges), knees (Patella), Genitalia (men), Breasts (Women), shoulder (acromial process), and cheek and ear (Zygomatic bone). • Fowlers position: Heels (calcaneus), Pelvic (ischial tuberosity), sacrum, and vertebrae (spinal processes). 16.Types of wound healing: • Primary intention- 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 scaring. Examples- Closed surgical • Blood coagulation studies are also significant. • Hypercoagulability can lead to intravascular clotting, and result in deficient blood supply to the wound area. • Serum protein- analysis provides an indication of the body’s nutritional reserves for rebuilding cells. • Albumin- is an important indicator of nutritional status. 23.Aerobic- growing in the presence of oxygen 24.Anaerobic- growing only in the absence of oxygen. 25.Supporting wound healing, provide sufficient nutrition and hydration, preventing wound infections, and proper positioning. Moist wound healing • Nutrition- client should be assisted to take in at least 2,500mL of fluids a day, Vitamins C, A, B1 and B5, B12, Zinc. Obtaining a registered dietitian consultation for wound healing nutrition is helpful for ensuring that correct supplementation needs are met. • Preventing infection • Positioning- if the client cannot move independently, range-of-motion exercises and a turning schedule are implemented. • Preventing pressure ulcers are implemented. • Preventing pressure ulcers- specifically, the nurse conducts a pressure ulcer admission assessment for all clients and reassesses risk for all hospitalized clients daily. For client at risk, the nurse also optimizes nutrition and hydration, inspects skin daily, minimizes pressure, and manages moisture by keeping the client dry and moisturizing skin. • Providing nutrition • Maintaining skin hygiene- Avoid using hot water, which increases ski dryness and irrigation. Nurses can minimize dryness by avoiding exposure to cold and low humidity. Dimethicone-based creams or alcohol-free barrier films are available in liquid, spray, and moist wipe format and very effective in preventing moisture or drainage from collecting on the skin. In most cases, the nurse can apply these without a primary care provider’s order. • Avoiding skin trauma- are never used as friction or moisture prevention. These powders create harmful abrasive grit that is damaging to tissues and they are considered a respiratory hazard when airborne. Instead, use moisturizing creams and protective films, such as transparent dressings and alcohol-free barrier films. Even when a special support mattress is used should be repositioned at least every 2 hours. In addition, massage over bony prominences should be avoided. Scientific evidence does not support this belief. In fact, vigorous massage may lead to deep tissue trauma. • Providing supportive devices 26.The RYB color code: • The goals of wound care are to protect (cover) red, cleanse yellow, and debride black. • Wounds that are red are usually in the late regeneration phase of tissue repair (developing granulation tissue). • They need to protect to avoid disturbance to regenerating tissue. The nurse protects red wounds by a gentle cleansing, protecting peri-wound skin with alcohol free barrier film, filling dead space with hydrogel or alginate, covering with an appropriate dressing such as transparent film, hydrocolloid dressing, or clear absorbent acrylic dressing, changing the dressing as infrequently as possible. • Yellow wound (semiliquid “slough”) cleanse • Black wounds are covered with thick necrotic tissue, or eschar. Black wounds require debridement (removal of the necrotic material). Removal of nonviable tissue from a wound must occur before the wound can be staged or heal. Debridement may be achieved in four different ways: sharp, mechanical, chemical, and autolytic. In sharp debridement, scalpel or scissors is used to separate and remove dead tisseue. • Mechanical debridement is accomplished through scrubbing force or damp to damp dressings. • Chemical debridement is more selective than sharp or machinal techniques. • Autolytic debridement, dressing such as hydrocolloid and clear absorbent acrylic dressings trap the wound drainage against the eschar, it is the most selective and therefore causes the least damage to healthy surrounding and healing tissues. • Maggots secrete enzymes that break down necrotic tissue (while healing tissue untouched), eat bacteria, and decrease bacterial growth through the rise in surface pH that results from their presence. • When eschar is removed, the wound is treated as yellow, then red. When more than one color is present, the nurse treats the most serious color first, that is, black, then yellow, then red. • Dressing wounds protects mechanical injury, microbial contamination, keeps it moist, thermal insulation, absorb drainage and debride, prevent hemorrhage, and to splint or immobilize the wound site. 27.Irrigating a wound: • Assist the client to a position in which the irrigating solution will flow by gravity from the upper end of the wound to the lower end and then into the basin. • Sterile Syringe 30-60mL syringe (size 18 & 19) • Clean the wound from the cleanest area toward the least clean. If the wound be from the center of the wound outward. For a linear wound, cleanse from top to bottom, beginning in the middle and moving progressively laterally. • Dry the area around the wound. Wounds have been shown to heal twice as quickly with advanced dressings compared to gauze. 28.Bandaging: • Whenever possible, bandage the part in its normal position, with joint slightly flexed. • Always bandage body parts by working from the distal to the proximal end. • Bandage with even pressure. • Whenever possible, leave the end of the body part exposed (toes). • Cover dressings with bandages at least 5 cm beyond the edges of the dressing. • Inspects for the presence of and status of wounds (open wounds will require a dressing before a bandage or binder is applied) • Circular turns usually are not applied directly over a wound because of the discomfort the bandage would cause. • Spiral turns are used to bandage parts of the body that are fairly uniform in circumference, for example, the lower leg or forearm. • Recurrent turns are used to cover distal parts of the body, for example, the end of a finger, the skull, or the stump of an amputation. • Figure eight turns are used to bandage an elbow, knee, or ankle, because they permit some movement after application. 29.Straight abdominal binder: