question

Acute Care: Pressure Ulcer Management

answer

-Treatment Approach ----> Holistic -Close Monitoring --- q8hr -Evaluate every dressing change -Documentation of pressure ulcer leads to better decision making & outcomes -Bates-Jensen Wound Assessment Tool --- addresses 15 wound characteristics

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Methods of Debridement (removal of nonviable necrotic tissue)

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-Mechanical - Wet to dry saline gauze dressing; never use in clean, granulating wound, nonselective method -Autolytic - Synthetic dressing to allow eschar to be self digested support moisture, transparent film/hydro colloid dressing -Chemical - Topical enzyme, Dakin's solution ( NaOCl), sterile maggots Surgical - Use of scalpel, scissors, sharp instrument; quickest method; use for cellulitis or sepsis

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Do NOT use in clean, granulating wound

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-Dakin's solution (sodium hypochlorite) -Acetic Acid -Povidone-iodine -Hydrogen Peroxide

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Acute Care: Wound Management

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-Goal: Maintenance of physiological local wound environment -Use noncytotoxic cleaner (NS) {do not kill fibroblasts} -Address prevention/manage infection, wound cleaning, remove nonviable tissue, manage exudate, protection, and moisture--ENV -Irrigate with a 19 gauge, 35 mL syringe at 8 psi -Education -Nutrition status within 24 hours of admittance -Protein - 0.8 g/kg/day or 1.8 g -Hemoglobin- 12g/100mL

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Nursing Process: Skin Assessment

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-Nursing assistive personnel cannot assess skin integrity -Observe pressure points: (1) bony prominence (2) cast edges: O2 tubing, NG Tube -Gently press reddened area for blanching -Check perineal skin, skin with tape, tubing, casts, splints -Note previous areas of skin breakdown -Abnormal reactive hyperemia outline with a marker -Record findings & prevention or treatments

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Nursing Assessment Questions for Skin Integrity

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-Sensation- (1) decreased feeling in extremities or other region? (2) sensitive to cold or heat? -Mobility- (1) physical limitations, injury, paralysis that limits mobility? (2) can you change position easily? (3) movement painful? -Continence- (1) assistance to toilet? (2) how often? when? (3) involuntary? -Presence of Wound- (1) what caused? (2) when? (3) treatment? (4) last tetanus? (5) symptoms?

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WOCN Critical Thinking Model for Skin Integrity & Wound Care Assessment

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*KNOWLEDGE* ~pathogenesis ~factors contributing to formation/healing ~impact of medication ~impact of disease *EXPERIENCE* ~Caring ~Observation of wound healing *ASSESSMENT* ~Risk for: (1) Signs and Symptoms (2) Actual impairment *STANDARDS* ~Knowledge of WOCN stand for prevention & assessment of risk -Apply standards of accuracy, relevance, completeness, precision *ATTITUDES* ~Use discipline to obtain complete/correct data ~Responsibility for specimen collection

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Economic Consequences of Pressure Ulcers

answer

-56.5% of adults with a pressure ulcer age 65 and older -1.6 million patients year in acute care settings develop pressure ulcers ---> $11-$17.2 billion -Center for Medicare and Medicaid Services ---> policy Oct. 1, 2008 hospitals get 0 reimbursement for care of 8 conditions, including stage III & IV pressure ulcer during hospitalization [hospitals must improve quality of care]

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Risk Assessment for Pressure Ulcer

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-Braden Scale based on risk factors in nursing home population and composed of 6 sub scales: (1) sensory perception (2) moisture (3) activity (4) mobility (5) nutrition (6) friction/shear -Score 6-23 with 6 being highest risk; cutoff 18

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Evisceration

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-Protrusion of visceral organs through wound opening -Requires surgical repair -SMOB-D (soft, moist, occlusive, bandage or dressing) -NPO for patient -Watch for shock

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Dehiscence

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-Partial or total separation of wound layers -Occurs before collagen formation (3-11 days after injury) -Involves abdominal wounds {result of cough, sneeze, vomit, sitting up -Place folded blanket over wound when coughing to prevent occurrence

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Infection

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-2nd most common HAI -CDC - purulent drainage despite negative results -Wounds with > 100,00 organisms per gram of tissue -Greater when wound has necrotic tissue, foreign bodies in or near, blood supply -Inhibits healing -Traumatic wounds within 2-3 days -Surgical- 4th or 5th post op day

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Hematoma

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-Localized collection of blood underneath tissues -Swelling, change in color, sensation, warmth, or mass of bluish discoloration -Dangerous near major artery or vein

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Hemorrhage

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-Bleeding from wound site normal during & immediately after trauma -Bleeding after hemostasis ---> slipped surgical suture, dislodged clot, infection, erosion of blood vessel -Internal bleeding ---> distention or swelling of body part, hypovolemic shock, change in type/amount of drainage -External bleeding ---> surgical wounds ---> greatest 24-48 hrs after surgery

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Complications of Wound Healing

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-Hemorrhage -Infection -Dehiscence -Evisceration

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Remodeling

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-Maturation extends for more than a year -Healed wound have strength of tissue it replace -Scar tissue fewer pigmented cells (melanocytes)

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Proliferative Phase

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-Begins & lasts from 3-24 days -Main activities: (1) vascular bed reestablished (granulation) (2) area filled with replacement tissue (collagen, contraction, granulation tissue) (3) resurfacing (epithelialization) -Impairment results from age, anemia, hypoproteinemia, zinc deficiency

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Inflammatory Phase

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-Damaged tissue & mast cells secrete histamine -Vasodilation -Serum -White blood cells -Redness, edema, warmth, & throbbing -Primary WBC ---> neutrophil - ingests bacteria & small debris -2nd WBC ---> monocyte transforms into macrophage or "garbage cells" - clean wound by phagocytosis

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Wound Healing Process

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-Primary Intention- wound closed; surgical incision, suture, staples - heals quickly, minimal scar -Secondary Intention- wound edges not approximated (closed); pressure ulcer - heal by granulation tissue formation, wound contraction, epithelialization - scar -Tertiary Infection- wound left open several days then approximated; contaminated wounds requiring observation - closure delayed until risk of infection resolved

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Process of partial thickness wound healing

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-Inflammatory response (1st 24 hrs after wounding) -Epithelial proliferation & migration - left open to air can resurface 6-7 days -Reestablishment of epidermal layers-pink/dry -If kept moist, can resurface in 4 days - epidermal cells only migrate across moist surface

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Partial-thickness wounds

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-Shallow -Loss of epidermis -Partial loss of dermis -Heal by regeneration of epidermis -Ex: surgical wound abrasion

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Phases of healing of a full-thickness wound

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-Hemostasis - blood vessels constricting to stop bleeding - clot formation --> fibrin -Inflammatory Phase -Proliferative Phase -Remodeling

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Characteristics of Dark Skin with Impaired Integrity

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-Use natural or halogen light to prevent blue tones *Color - (1) remains unchanged with pressure (2) may be lighter than original color *Temparature - (1) warm to touch (2) inflammation --> compare surrounding skin *Appearance - (1) edema with induration, taut, shiny (2) localized area purple/blue or violet - no redness

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Collagen

answer

Tough fibrous protein made from fibroblast cells

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Skin-associated issues in older adults

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-Age reduces skin elasticity, collagen, easily torn -Wound healing affected by conc medication condition and polypharmacy -Attachment between epidermis & dermis flattens - skin tear -Diminished inflammatory response -Little subcutaneous padding over bony prominence -Malnutrition linked to decubitus

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When the skin is injured

answer

-Epidermis - resurface wound and restore barrier against invading organism -Dermis - restore structural integrity & physical properties

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Pressure Ulcer (aka pressure sore, decubitus ulcer, bed-sores)

answer

-Consistent with recommendation of guidelines written by the Wound, Ostomy & Continence Nurses Society -Localized, over body prominence -Result of pressure, shear, and or friction

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Risk factors for pressure ulcer

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-Decreased mobility -Decreased sensory perception -Fecal/urinary incontinence -Poor nutrition -Pressure (interferes with blood, oxygen, nutrition flow) -Shear (sliding movement of skin & subQ tissue while muscle & bone stationary) - elevating bed transfer -Friction -Altered level of ?

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Pressure-related factor to pressure ulcer

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*Pressure intensity normal range one a capillary 15-32 mmHg. -pressure exceeds range --> tissue ischemia -pressure relieved --> blood flow returns --> skin red -vasodilation --> hyperemia -evaluate hyperemia by pressing finger over area; look for blanching - if occurs --> overcome ischemic episode blanching hyperemia -no blanching --> deep tissue damage

question

Infection

answer

-Prolongs inflammatory phase -Delays collagen synthesis -Prevents epithelialization -Increases cytokines --> tissue destruction

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Tissue Perfusion

answer

-O2 essential to healing -Peripheral vascular disease at risk due to poor circulation -Chronic tissue hypoxia --> impaired collagen synthesis & reduced resistance to infection

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Role of Nutrients in wound healing

answer

-Calories - fuel for cell energy "protein protection" - 30-40 kcal/kg/day for positive nitrogen balance -Protein - fibroplasia, angiogenesis, collagen formation, wound remodel, immune function - 1-1.5 g/kg/day -Vitamin C - collagen synthesis, antioxidant, capillary wall integrity, fibroblast function, immune 100-1000 mg/day -Vitamin A - epithelialization, wound closure, inflammatory response, angiogenesis, collagen -Vitamin E - No known role -Zinc - collagen, protein synthesis - 15-30 mg - can inhibit Cu metabolism -Fluid - all cell function - 30-35 mL/kg/day

question

First Aid for wounds

answer

-Hemostasis - do not remove impaled object; apply pressure around object except for skill injuries; apply additional bandages on top of soaked bandages -Cleaning - abrasions, minor lacerations, small puncture wounds --> rinse with NS & cover -Protection - sterile or clean dressing

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Purposes of dressings

answer

-Protect from microorganisms -Aid in hemostasis -Absorb drainage -Debrides -Supports or splints -Protects patients from seeing wound -Thermal insulation -Moist environment

question

Pressure

answer

_____________ dressing eliminates dead space in underlying tissues. Always assess CSM's

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Three layers of surgical gauze

answer

-Contact/primary layer-covers the incision -Absorbent layer -Outer protective/secondary layer *if gauze sticks use NS to moisten for easy removal*

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Nursing Process: Pressure Ulcer Assessment

answer

*Braden Scale -Mobility -Moisture/body fluids -Nutrition - loss of 5% < 90% of ideal weight, decreases in 10 lbs signal problems -Pain/sensory perception -Activity -Friction/shear - limit head elevation to 30 degrees

question

Risk for skin breakdown from body fluids

answer

*Low Risk -saliva -serosanguineous drainage *Moderate Risk -bile -stool -urine -ascitic fluid -purulent exudate *High Risk -gastric drainage -pancreatic drainage

question

Nursing Process: Wound Assessment

answer

-Tetanus needed if injury from dirty object & patients not had one within 5 years -Consider analgesics at least 30 mins before exposing -Puncture wound dangers are internal bleeding & infection -Appears inflamed first 2-3 days -7-10 days wound resurfaces with epithelial cells -1 gram drainage = 1 mL of drainage chart frequency of dressing change

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Wound Closures

answer

-Staples, sutures, wound closures (steri-strips or derma bond) -1st 2-3 days after surgery skin edematous -Early suture removal --> decreased defect formation along suture line

question

Wound Drains

answer

*Penrose *Hemovac or Jackson-Pratt -exert constant low pressure as long as container is compressed -self-suction -if unable to maintain vacuum --> secondary system (wall suction)

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Wound Cultures

answer

-Clean wound first with NS -Aerobic organisms -- superficial wounds exposed to air -Anaerobic grow in body cavities -Gram stains -BIOPSY - GOLD STANDARD

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Nursing Diagnosis for impaired skin integrity & wounds

answer

-Risk for infection -Imbalanced nutrition: less than body requirements -Acute or chronic pain -Impaired physical mobility -Impaired skin integrity -Risk for impaired skin integrity -Ineffective peripheral tissue perfusion -Impaired tissue integrity

question

SKIN

answer

-Largest organ in the body -15% of total adult body weight -Protective barrier -Sensory organ -Synthesis Vitamin D

question

Epidermis

answer

*Top layer of skin *Has several layers that help make up this layer: (1) stratum basal (cell origination) (2) stratum spinosum (3) stratum granulosum (4) stratum lucidum (5) stratum corner (thin outermost layer) (flattened, dead, keratinized cells) (protects from dehydration & certain chemical agents)

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Suspected Deep Tissue Injury Depth Unknown

answer

-Purple or maroon localized area -Intact or blood-filled blister - damage of soft tissue -May be preceded by pain, firm, mushy, boggy, warmer, or cooler adjacent tissue -Evolution - thin, blister over clark wound bed - thin eschar

question

Dermis

answer

-Inner layer of skin provides strength, support, protection to muscles, bones & organs -Contains connective tissue & few skin cells -Collagen found here -Fibroblast cells reside -Blood vessels -Nerves -Reticular, region, papillary region, papillae

question

Unstageable/Unclassified: Full-thickness Skin or Tissue Loss-Depth Unknown

answer

-Depth obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown, black) -Will be either Stage III or Stage IV -Stable eschar on heel "natural biological cover of body" do not remove

question

Stage IV: Full-thickness tissue loss (muscle/bone visible)

answer

-Slough/eschar -Tunneling/undermining -Bone, tendon, muscle visible -Can be shallow on nose, ear, occiput & malleolus -Can extend to fascia, tendon, joint capsule --> osteomyelitis/osteitis

question

Stage II: Partial-thickness Skin Loss or Blister

answer

-Partial-thickness loss of dermis -Shallow open ulcer -Red-pink wound be without slough -Open/ruptured serum-filled or serosanguineous blister -Stage II presents as a shiny or dry shallow ulcer without slough or bruising -Do not use to describe skin tears, tape burns, incontinence-associated dermatitis

question

Assessment of Pressure Ulcer

answer

-Depth of tissue involvement (staging) -Type & % tissue in wound bed -Dimension of wound -Exudate presence -Condition of surrounding skin -Cannot stage an area with necrotic tissue

question

Stage III: Full-thickness Skin Loss (Fat Visible)

answer

-Bone, tendon, muscle, NOT exposed -Slough present -Tunneling/undermining -Nose, ear, occiput & malleolus -- no adipose but stage III can be shallow

question

Stage I: Nonblanchable Redness of Intact Skin

answer

-Nonblanchable erythema of localized area over bony prominence -Discoloration -Warmth -Edema -Hardness -Pain

question

Healing Stage III Pressure Ulcer

answer

Pressure ulcers do not progress from a stage III to stage I. Stage III demonstrating signs of healing is described as ________________________________________

question

Granulation Tissue

answer

Beefy red, bumpy, moist tissue composed of new blood vessels ---> presence indicates healing

question

Pressure Duration

answer

-Low pressure over prolonged period -High-intensity over short period -Evaluate amount of pressure (reactive hyperemia) -Determine amount of time patient tolerates pressure (check for blanching)

question

How to Measure Depth

answer

Cotton-tipped applicator in wound bed

question

Tissue Tolerance

answer

-Factors such as shear, friction, moisture make skin susceptible -Ability of underlying skin structure (blood vessels, collagen) to redistribute pressure -Poor nutrition, aging, hydration, low BP

question

Full-thickness Wound

answer

-Extend into dermis -Pressure ulcers -Scarring -Deep structures do not regenerate

question

Goal for wounds

answer

*Improvement within 2 weak period -higher % granulation tissue in wound base -no further skin breakdown -increased caloric intake by 10% *Planned according to severity, type, complicating conditions *Hemostasis, prevent infection, promote healing, maintain skin integrity, gain comfort, promote health

question

Priorities for Risk of Pressure ulcer

answer

*TOP/HIGH PRIORITY* -Skin care practice -Elimination of shear -Positioning *OTHER* -Patient preference -Daily activities -Family

question

Implementation: Prevention of Pressure Ulcers

answer

*Assess risk 1st *3 major areas of intervention -skin care/management of incontinence -mechanical loading & support devices - proper positioning; use of therapeutic surfaces -education

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Home Care for Wound/Ulcer

answer

-Assessment/document weekly -Assess patient resources - successful treatment requires adequate caregiver & equip. -Evaluate caregivers ability comprehend/implement -Level of strength/endurance -Economic factors -Clean dressings for home -"No touch" dressing change - grasp dressings at corners or pinch in center

question

Topical Skin Care and Incontinence Management

answer

-Frequent skin assessment once a day or every shift -Avoid soap & hot water -Use nonionic surfactants -Clean skin, dry, apply moisturizer -Incontinence use moisture barrier - protect from excessive moisture & bacteria -Bladder & habit training - timed voiding - behavioral technique

question

Positioning

answer

-30 degree lateral turn & no more that 30 degree head elevation -Prevent direct positioning over bony prominence -Limit sitting to 2 or less hrs - shift weight every 15 mins to reduce pressure on ischial tuberosities -Sit on foam, gel, or air cushion -Reposition every 2 hrs -Reassess patient skin -NEVER massage reddened areas -- increased breaks in capillary

question

Support Surfaces (Therapeutic Beds & Mattresses)

answer

*Common errors: (1) wrong side of sys. against patient (2) not plugging sys into power outlet (3) not turning it on (4) improper inflating (5) patient sinks to bed frame

question

Choosing Appropriate Support Surface

answer

*Stage I or II: -Foam or non powered -Avoid prolonged head of bed elevation -Limit chair sitting to 3x a day/60 mins *Stage III, IV, Unstageable: -Avoid prolonged head of be elevation -Low-air-loss-->flow of air -Alternating pressure -Air-fluidized-->press. redistribution via fluid like medium

question

Wet-to-dry

answer

_______________________ dressings are only for deriding wounds. Never use in a clean, granulating wound

question

Gauze Sponge

answer

______________________ oldest and most common dressing that are useful to wick away wound exudate. Most common size is 4x4.

question

Types of Dressings

answer

-Gauze Sponge -Tefla-shiny, non adherent -Transparent film - self adhesive, traps moisture; small superficial wound; partial-thickness, high risk skin -Hydrocolloid - adhesive with colloids, elastomeric -Hydrogel - water or glycerin based amorphous gel gauze

question

Transparent/Secondary Dressing Advantages

answer

-Adheres to undamaged skin -Barrier to external fluids & bacteria but allows wound to breathe -Moist ENV -Removed without damaging underlying tissue -Permits viewing -Does not require secondary dressing

question

Hydrocolloid Dressing

answer

-Wound contact layer forms a gel as fluid is absorbed -Supports healing in clean wound & autolytically derbies -Impermeable to bacteria -Self adhesive & molds well -Preventive dressing for high risk infection area -Useful on shallow to moderately deep dermal ulcers -Can be left 3-5 days -May leave confusing residue - purulent drainage

question

Hydrogel Dressing

answer

-Used for Stage II, III, & IV deep wound without exudate, burns, necrotic & radiation-damage -Require secondary dressing on top -Soothing & reduces pain -Moist ENV -Debrides -Easy to remove

question

Hydrocolloid

answer

Stage I, II, &III can all us ________________ dressing.

question

Calcium Alginate

answer

-Used in Stage III & IV without exudate -Made from seaweed -Not to be used in dry wounds

question

Order for Changing a Dressing

answer

The physician's ______________________ will include dressing type, frequency of changing, and any solutions or ointments to be applied. Adding dressings without removing original is common right after surgery.

question

1st Step in Packing a Wound

answer

-Assess size, depth, and shape ----> useful in determining size & type of dressing

question

Negative Pressure

answer

(V.A.C) Vacuum-assisted closure & NPWT - wound therapy to draw edges of wound together, fluid removal, edema reduction, granulation formation

question

NPWT

answer

-Used for treating acute & chronic wounds -Wear time for dressing 24 hrs - 5 days -Used in skin grafts to prevent shifting

question

Tape Width & Uses

answer

-Available as 1.3, 2.5, 5 and 7.5 cm (1/2, 1, 2, 3 inch) -7.5 cm stabilize large dressing *do not tape over irritated or broken skin; use Montgomery ties (2 sets)

question

Therapeutic Effects of Heat

answer

-Vasodilation - promote delivery of nutrients -Reduced viscosity (thins blood for leukocyte to go to wound) -Reduced muscle tension -Increased tissue metabolism -Increased capillary permeability

question

Therapeutic Effects of Cold

answer

-Vasoconstriction - decreases edema/inflammation in sprains, fractures, puncture/laceration -Local anesthesia -Decreases cell metabolism - less O2 needs -Increases blood viscosity - coagulates -Decreases muscle tension - relieves pain

question

Advantages of Dry & Moist Applications *disadvantages will be opposite effect"

answer

*MOIST/DRY (opposite) -Decreases drying of skin -Softens exudates -Conform well to body -Penetrates deep tissue -Doesn't promote sweating/fluid loss *DRY/MOIST (opposite) - no evaporation

Nursing Fundamentals: Skin Integrity and Wound Care – Flashcards

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