Wounds and hygiene NCLEX

What’s the integumentary system?

The skin’s LARGEST organ, it is the body’s first line of defense against microorganisms, environmental factors, regulating temperature, and sensing pain and pressure.

Pressure injuries

localized damage to the skin and/or underlying tissue caused by prolonged pressure, friction, and/or shear.

Prolonged pressure leads to

Tissue ischemia and necrosis

Risk factors that cause pressure injuries include

Impaired mobility, frequent moisture exposure, and decreased sensory perception.

RISK FACTORS FOR PRESSURE INJURIES (SORES) EXAMPLES

• Sensory perception (neuropathy, paralysis)

• Mobility (paraplegia, stroke)

• Friction and shear

• Moisture exposure (incontinence)

• Nutrition

• Perfusion (peripheral vascular disease, diabetes mellitus.

When do you preform skin assessments?

FIRST upon admission

then on regular intervals

What scale do you use to assess pressure injuries?

Braden Scale

What’s the score range on the Braden scale for a skin assessment?

6-23

On the Braden scale score range when the number more than ___ indicates that the patient is at risk for a pressure injury?

<18 (more than 18)

What are 5 pressure point areas on the body for pressure injuries?

1. Head

2. Shoulder blades

3. Elbows

4. Sacrum

5. Heels

If the patient slides down or is pulled down the skin might

Shear (tear)

For clients with darker skin, assess for pressure injuries by comparing….

Temperature and blanching (condition where the skin may appear pale or white) of affected area to that of the surrounding skin.

What should you NOT to an area that it affected by a pressure injury?

Reddened or affected areas of the skin should not be massaged, it could cause further tissue injury.

What do you have to DOCUMENT when your patient has a pressure injury?

• Wound location

• Size

• Color

• Tissue involvement

• Drainage characteristics

Serous drainage

Clear, watery

Serosanguineous drainage

Pink or red-tinged

Sanguineous drainage

• Bright red which is a sign of ACTIVE BLEEDING.

Purulent Drainage

Thick, yellow, green indicates INFECTION

What are the signs of infection of a wound?

• Purulent

• Foul smelling drainage

• Edema (swelling)

• Fever

• Warmth

• Excessive/ high amount of drainage.

Stage 1

Intact skin with non-blanchable redness

Stage 2

Partial-thickness loss with shallow wound or blister

Stage 3

Full-thickness loss with visible subcutaneous tissue

Stage 4

Full-thickness loss with exposed muscle, tendon, or bone

Unstageable

Full-thickness loss; slough and/or eschar obstruct wound visualization.

Unstageable “Slough”

Stringy yellow or white tissue.

Unstageable “Eschar”

Black, brown, or tan necrotic tissue.

What should the nurse do when an unstageable pressure injury has “slough” or “eschar”

Slough and eschar must be removed (debrided) to visualize and stage the wound bed.

Deep tissue pressure injury

Non-blanchable, dark discoloration (red or purple) that feels spongy or boggy

Nursing Intervention #1 for pressure injury

Repositioning and offloading pressure

Nursing intervention #2 for pressure injuries

Protecting skin

Nursing intervention #3 for pressure injuries

Promoting nutrition and hydration

Every ___hours a patient should be turned

Every 2 hours

Lateral tilt the bed ___ degrees to lower risk of pressure injuries risk on bony prominences.

30 degrees

Head of bead (HOB) should be elevated to ___

30

What can you use to aleviate the body for pressure injuries

pillows, wedges, heel protectors, mattress overlay

DO NOT USE ___when seated

donut cushions because it decreases perfusion to the affected area

What are lifting devices that can be used to “boost” the patient

draw sheet, mechanical sheet

When a wound is healing what does it need?

A moist environment, removing any excess drainage.

Wound dressing depends on

Wound characteristics

(for draining, wounds, moist dressings for dry wounds)

Before beginning a wound dressing or wound change you first

Premedicate with oral analgesics 30-45 minutes prior,

Before beginning a wound dressing or wound change you second

Don appropriate PPE; wear gown, mask, and goggles when there is a risk of splash (wound irrigation).

When wound dressing or wound change you third

Remove old dressing by pulling tape toward the center of the wound.

When wound dressing or wound change you fourth

Don clean gloves, cleanse wound with sterile saline, and clean from center to edges (least to most contaminated)

• Do not use povidone-iodine or hydrogen peroxide (cytotoxic).

• Perform wound irrigation as needed using sterile technique.

• Gently flush wound from top to bottom until fluid runs clear.

After wound care you report

Signs of infection (e.g., foul odor, purulent drainage) and anticipate:

• Wound culture: Irrigate or clean wound before

• Collecting culture directly from the wound base.

• Antibiotics as prescribed

• Maintain wound drains to remove drainage from surgical wounds

Transparent film (dressing)

Protects wound and allows

visualization

Moist (dressing)

Maintains moisture for

autolytic debridement

• Hydrocolloid, hydrogel

Absorbent (dressing)

Absorbs excessive drainage

• Foam, gauze, alginate

Antimicrobial (dressing)

Accelerate healing

• Contains silver

sulfadiazine, chlorhexidine

Dry, superficial

wounds (stage 1

pressure injuries), what type of dressing do you use?

Transparent film

Minimal drainage or

dry wounds (necrotic, granulating

wounds) what type of dressing do you use?

Moist

Deep wounds with

heavy drainage, what type of dressing do you use?

Absorbent

Infected wounds and burns, what type of dressing do you use?

Antimicrobial

Wound drains: Jackson-Pratt and Hemovac

• Compress drain reservoir before sealing to maintain suction.

• Record output and notify HCP for changes in drainage characteristics or amount.

To clean skin (or around affected area) you should always use ___ soap and ___ water

mild soap and warm water NOT HOT

Clients with incontinence make sure they have

absorbent pads and barrier creams to keep skin dry. AWLAYS immediately change soiled linens.

Apply ___ to prevent skin from cracking

Moisturizer

Gently flush wounds from ___ to ___ until fluids run ___

1. Top

2. Bottom

3. Clear

Wash body from ___ to ___

1. Head

2. Toes

you should always pat the skin dry but especially between the fold (what are examples of these folds)

under breasts and axillae

Do NOT apply lotion where?

in between toes, increases risk of infection

perineal care for women

Separate labia and clean front to back to prevent UTIs.

perineal care for men

Clean in a circular motion from urethra to glans (from center outward).

• Uncircumcised: Retract, clean, and return

  foreskin to prevent constriction.

What should you take IMPORTANT consideration when trimming nails?

1. Specialized foot care should be preformed on a patient with Diabetes Mellitus or peripheral vascular disease, due to foot injury or infection. These clients are prone to infection and wounds are difficult to heal which can lead to complications.

2. Trim nails straight across to prevent ingrown nails.

3. YOU NEED HCP ORDER BEFORE CUTTING OR TRIMMING NAILS.

For oral care what should the head of the bed be raised by?

Semi-Flowlers to prevent aspiration.

Patients with high bleeding risks (taking anti-coagulants) use

soft bristle toothbrush

Clients on ventilators, how to you provide oral care?

Provide oral care with chlorhexidine to decrease risk of ventilator-associated pneumonia.

clients going through radiation and chemotherapy treatment (oral care)

Provide frequent oral care and monitor for signs of mucositis (inflammation of the mouth, redness, mouth pain)

Clients with dentures

Clean daily and store in water in a labeled container to prevent accidental disposal.

Oral precaution for children

Do not let children take milk or juice to bed, as it can increase risk for dental caries.

Post-mortem Care

• Provide emotional support to the client’s family and allow them time to view the body.

• Respect religious and cultural preferences and ask

  family if they wish to participate in postmortem care.

• Report death to the appropriate organ donation

  agency or staff, if applicable.

What position should the patient be in during postmortem care

Position patient in supine with head on a pillow to prevent skin discoloration.

Postmortem cleaning

• Remove medical equipment per agency policy.

• Gently clean the body, close eyes, brush hair,

• Insert dentures (if applicable), and cover with a sheet.

What should the deceased patient have before transportation

Apply identification tags before transporting the body.