Skin Integrity/Wound Care
Terms
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- Name some age related changes that happen to skin.
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- decrease in skin elasticity
- decrease in collagen
- attachment b/w epidermis and dermis is flattened
- impaired immune response
- decrease in hypodermis
- decrease nutritional intake - What is capillary closing presuure?
- it is the minimal amount of pressure required to collapse a capillary.
- Name 2 considerations with regard to the duration of pressure.
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- low pressure over prolonged period of time causes tissure damage.
- high-intensity pressure over a short period of time causes tissue damage. - What is the best light for checking the skin?
- natural/ halogen light
- What is the difference between shear and friction?
- shear causes deep tissue necrosis and friction affects only the epidermis.
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describe the wound classifications by color.
black, yellow, and red. -
black- eschar- necrotic tissue
yellow- slough
red- granulation tissue- healing - what is the difference between healing by primary intention and secondary intention.
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primary is like with surgery- risk of infection is low
secondary takes longer to heal and filled with scar tissue. - 3 components in the healing process of PARTIAL THICKNESS wound.
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-inflammatory phase
-proliferative phase (regeneration)
-maturation (remodeling) - what is dehiscence and evisceration?
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dehiscence- partial or total separation of wound layers. obese clients are at high risk. shows an increase in serosanguineous drainage.
-evisceration- is protrusion of visceral organs. - nutrition plays are role in wound healing. Name some things to be considered.
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need vitamin a and c, zinc, copper, and collagen suffient calories.
people with low albumin levels are at greater risk for pressure ulcers. - why should soap and hot water be avoided in topical skin care for prevention of ulcers?
- they cause alkaline residue that discourages growth of normal skin bateria- therefore promoting growth of opportunistic bacteria to enter an open wound.
- what should be used as a dry lubricant to help reduce friction?
- cornstarch
- what is the best positon to prevent pressure ulcers?
- a 30 degree lateral position
- why are donut shaped cushions avoided for sitting?
- they reduce blood supply to the area, resulting in wider areas of ischemia.
- why is massaging avoided in reddened areas?
- it increases breaks in capillaries in the underlying tissue and increases the risk of injury to underlying tissue and pressure ulcer formation.
- what is the difference between pressue relieving devices and pressure reducing devices?
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-pressure relieving devices relieve interface pressure below 32 mm hg (capillary closing pressure)
-pressure reducing reduce the interface pressure, but not necessarily below the capillary closing pressure. - which bed is used for a person who has burns, stage III or stage IV ulcers?
- air-fluidized beds
- which bed is used for a person who has atelectasis and/or pneumonia?
- kinetic therapy bed
- name 3 other beds used for high risk clients.
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-low air loss system- pressure relief device
- foam- only reduces pressure
- static air filled overlays- pressure relief device or reduction (depends) - name some commonly used solutions that are cytotoxic (kill cells) that should NEVER be used to clean granulating wounds.
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- Dakin's soln
- acetic acid
- povidone-iodine
- hydrogen peroxide - what is the optimum method to ensure adequate removal of bacteria by irrigation?
- use a 19-gauge needle or an angiocatheter and a 35 ml syringe that delivers saline to a pressure ulcer at 8 psi.
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what measurement adequately represents tissue loss at a stage I and II?
What measurement represents tissue loss at a stage III and IV? -
-for stage I and II surface area represents tissue loss.
- for stage III and IV volume represents tissue loss. - enzyme ointment is used on what area of an ulcer?
- only on necrotic areas!
- any eschar ulcer has to be debrided except...
- a dry necrotic heal ulcer.
- name the methods of debridement.
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-mechanical- examples are wet to dry, irrigation, and whirpools.
-autolytic- examples are transparent dressings, hydrocolloid dressing.
-chemical- examples are Dakins soln and sterile maggots. require a dr order.
- sharp/ surgical- removing devitalized tissue which is the quickest way. - 2 nursing interventions that relate to nutritional status in the treatment of pressure ulcers.
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- increase protein intake- it helps rebuild epidermal tissue.
- keep hemglobin levels normal- low hemoglobin leads to futher tissue ischemia. - a puncture wound is allowed to bleed. why?
- to remove dirt and other contaminates, like saliva from a dog bite.
- a penetrating object should not be removed. why?
- removal could cause massive uncontrolled bleeding.
- the best dressing for a painful wound is?
- hydrogel dressing
- what is "dead space"?
- it is a cavity remaining in a wound. it should be eliminated by loosely filling all the wound cavity.
- what is the wound V.A.C?
- it applies localized negative pressure to draw the edges of a wound together.
- when using a V.A.C what types of foam can be used and what are they good for?
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- black polyurethane foam stimulates granulation tissue and wound contraction.
- white polyvinyl alcohol soft foam is used to prevent granualtion tissue growth. - irrigation of an open wound requires ________ technique.
- sterile
- what type of suture is best used for a client with a small laceration of the face?
- dacron (polyester)- they minimize scar formation.
- why is irrigation soln used at body temperature?
- it increases comfort and reduces vascular constriction response in tissues.
- what is a sling. what does it support?
- slings support arms with muscular sprains or fractures.
- when are warm applications contraindicated?
- when the client has an acute, localized inflammation. like appendicitis b/c the heat could cause the appendix to rupture.
- when are cold applications contraindicated?
- when the site of injury is already edematous. Also if the client has neuropathy b/c they cannot percieve temperature change. Also if client is shivering it can increase body temp.
- what type of therapy is used for a client that had a episiotomy, painful hemorrhoids, or vaginal inflammation?
- sitz bath
- what is an aquathermia pad used for?
- used to treat muscle sprains and areas of mild inflammtion. only use it for 20 to 30 min.