42 terms

Skin Integrity and Wound Care

Risk Factors for Pressure Ulcers
Friction and Shearing
Inadequate Nutrition
Fecal and urinary incontinence
Decr. mental status
Diminished sensation
Excessive body heat
Risk Assessment Tools for Pressure Ulcers
Braden Scale for Predicting Pressure Sore Risk
Norton's Pressure Area Risk Assessment Form Scale

*Need consistency for trending and measuring
2 Layers: The Epidermis and Dermis
Pressure Ulcer (PU) Stage I
nonblanchable erythema
PU Stage II
Partial thickness skin loss
PU Stage III
Full thickness skin loss involving damage/necrosis to subcutaneous tissue
PU Stage IV
Full thickness skin loss + damage/necrosis to muscle, bone, or supporting structures
Reactive Hyperemia
A bright red flush on the skin occurring after pressure is relieved (illustrates blood is still flowing to this area - no ischemia)
Partial Thickness
Confined to teh skin, that is, the dermis and epidermis; heal by regeneration
Full Thickness
Involving the dermis, epidermis, and subcutaneous tissue, and possibly muscle and bone; require connective tissue repair.
Primary Intention Healing
Tissue surface approximated
Secondary Intention Healing
(inside -> out)
Edges cannot be approximated
Large tissue loss
Scarring is greater
Takes longer
Higher susceptibility to infection (open wound)
Tertiary Intention Healing
(Delayed primary intention)

Initially left open 3-5 days
Normally to to drainage or infection
Phases of Wound Healing
Proliferative (collagen synth and granulation tissue formation)
Maturation (organization/remodeling, scar stronger)
Wound Exudate
Serous (watery)
Purulent (yellow, pus)
Sanguineous (bloody)
Mixed Exudate
Serosanguineous (watery + blood)
Purosanguineous (pus + blood)
How to measure Pressure Ulcer Depth
Parallel swabs used to measure wound depth
Obtain Wound Specimen from...
From base of the wound
*think in class they said, irrigate, then obtain specimen from inside granulated tissue
Preventing Pressure Ulcers
Reassess clients risk for all clients DAILY
Semi Fowlers preferred 45-60
Turn q.2h
Skin Cleansing Agents
Use "Mild" agents
Treating Pressure Ulcer
Never use alcohol or hydrogen peroxide
These are cytotoxic (they kill cells)
ROM exercise
Provide devices to minimize pressure areas
RYB Color Guide Wound Care
Red = protect and cover
Yellow = cleanse
Black = Debride (remove the dead black necrotic flesh.. yum)
Gallant Salute
Peter Wesson
Wound Dressing for Pressure Ulcers
Transparent Film
Impregnated Nonadherent
Clear absorbent acrylic
Polyurethane foam
Montgomery Straps
Tie Tapes - used to secure large dressing that require frequent changing - the tape has ties on it, so you don't have to remove and reapply tape a bunch (risk tearing the skin)
Incr. capillary permeability
Incr. cellular metabolism
Incr. inflammation
Sedative effect
Use Heat For...
Joint stiffness from arthritis
Low back pain
Decr. capillary permeability
Decr. cellular metabolism
Slows bacterial growth
Decr. inflammation
Local anesthetic effect
Use Cold for...
Post-injury swelling and bleeding (contusions?)
Rebound Phenomenon
Heat: 30-30 min (more = bad)
Cold: only until 15 degrees Celsius (60F)
When cleaning a drain (e.g., penrose)
Use circular movements.
Start around the drain and work your way out.
Precut gauze goes on afterwards
Hydrocolloid dressings protect shallow ulcers and maintain an appropriate healing environment
are used for wounds with significant drainage
Braden Scale
Total of 23 Points.
Below 18 points is at risk.
Nortons Scale
Total of 24 Points.
15 or 16 are scores that indicate risk.
Granulation Tissue
As the capillary network develops, the tissue becomes a translucent red color. The tissue, called granulation tissue, is fragile and bleeds easily.
Cleaning sutures
Clean midpoint to outwards. Top to bottom. (book)
Partial or total rupturing of a sutured wound
The protrusion of the internal viscera through an incision
Anti-embolic Hose
Compression hose.
designed to increase blood circulation
Tighter at ankle, push blood back to the heart.
Delegation of Wound Care
You don't delegate wound care? Correct me on fb if this is wrong pls.
Care of contusions