NURM-102 Skin Integrity and Wound Care Exam Review

Dehiscence

Separating apart

Eschar

Leathery, dark, dead tissue

Fistula

Tunnel from one organ/cavity to another

Hematoma

Collection of blood pocketing under the skin

• As it collects, there’s less blood in the rest of the body —> Lightheadedness, hypotension, pallor and increased HR

What illnesses affect skin?

• Malnutrition

• Dehydration (Turgor)

• Diaphoresis

• Jaundice (itchy and yellow)

• Skin diseases

• Reduced sensation/paralysis

How can therapeutic measures affect skin integrity?

Some measures (like bedrest and casts) have to be prioritized over skin integrity

Contusion

Bruising, skin is intact

Abrasion

Friction/rubbing/scraping

• Top epidermal layer abraded

Avulsion

Tearing a structure from normal anatomical position

• Can indicate vascular, nervous or other damage

Chronic wounds

Takes months to heal

How often should patients be repositioned?

At least q2h

How to avoid maceration?

Only moisten the exposed mucous membranes of wounds, NOT intact skin surrounding

Edema

Impedes blood flow by pressing on blood circulation

Circulation and oxygenation

Needed for proper wound healing

Pressure ulcer

Soft tissue surfaces compressed between bony prominence for prolonged period

Pressure Ulcer Factors

• External pressure against blood vessels

• Friction/shearing damaging superficial vessels under skin

• Inactivity/Immobility

• Malnutrition

• Diaphoresis

• Incontinence

• Vascular disease

• Localized edema

• Dehydration

• Steroids

Braden Scale

6 different scales adding up to a total score for risk level and treatment protocol

• Higher score is better

Pre-Ulcer

Area of reactive hyperemia that is blanchable, should fade within 60-90 minutes if repositioned

Suspected Deep Tissue Injury

Localized purple/maroon discolored area with intact skin

• Painful, firm, mushy, boggy, different temperature

• Allegedly like mashed potatoes

Stage 1 Pressure Ulcer

Non-blanchable erythema

Stage 2 Pressure Ulcer

Partial thickness skin loss of epidermis or dermis

• Superficial and pink or clear fluid-filled blister

• NO slough

Stage 3 Pressure Ulcer

Full thickness skin loss involving damage/necrosis of subcut

• Potential slough or tunneling

Stage 4 Pressure Ulcer

• Full thickness skin loss, exposed muscle/tendons/bone

• Eschar/slough likely present, undermining/tunneling common

Unstageable pressure ulcer

Full thickness ulcer obscured by slough and/or eschar in wound bed

SKIN-E Pressure Ulcer Prevention

• Surface

• Keep Moving

• Incontinence

• Nutrition

• Education

Surface SKINE

Redistribute pressure with devices

• PAD BONEY PROMINENCES

• Ambulate prn

PRIMARY intention

Clean wound edges with minimal tissue loss

SECONDARY intention

Unapproximated wound edges, deeper wound with more tissue loss

• Heals by contraction

TERTIARY intention

Wound opened for surgery and closed

When is wound care performed?

• Doctor’s orders

• Performing drainage

• Post-surgery - SURGEON DOES INITIAL POST OP DRESSING

• Packing the wound

• Debridement

Packing a wound

Not with too much pressure to allow granulation tissue formation

Why are doctor’s orders needed for wound care?

To charge supplies used to patient

Gauze

Dry dressings

Non-adherent dressings

Doesn’t tear skin off when removed

• Adaptic, xeroform

Transparent film

Allows you to see wound

• Tegaderm, biocluse

Hydrocolloid

Maintains moisture for wounds with little exudate

• Promotes autolytic debridement

• Nu-gel, aquasorb

Alginate

Absorbs drainage

• Aquacel (Calcium vs. silver)

Wound documentation

• Location, size, stage (if pressure ulcer)

• Drainage present

• Character (color, infectious seeming, malodorous, improving)

  • Tunneling described based on clockwise location

• Dressings

• Pressure-relieving devices used

Bandage principles

• Elevated and supported

• Wrap distal to proximal

• Avoid gaps between each turn

• Equal, not excessive tension

• Assess after 30 minutes

Friction

External skin breakdown

Shearing

Internal skin breakdown

• Outer skin stays in place but inner is slowly shifting off

What days does the INFLAMMATION phase occur?

Days 1-6

What days does the PROLIFERATION phase occur?

Days 7-21