ATI skin integrity

A _____ is a disruption in the normal composition and performance of the skin and its underlying structures.

wound

____ wounds develop rapidly and typically heal in a predictable time frame, while _____ wounds fail to heal in a normal time frame and may last for weeks or months.

Acute wounds develop rapidly and typically heal in a predictable time frame, while chronic wounds fail to heal in a normal time frame and may last for weeks or months.

_______ acute wounds are those created during a surgical procedure.

Intentional

______ acute wounds develop as a result of traumatic injuries, such as burns, punctures, or gunshot wounds.

Unintentional

________ are tears in the skin caused by blunt or sharp objects and typically have an irregular or jagged shape.

Lacerations

_______ are classified as simple or complicated depending on the severity and extent of damage.

Lacerations

____ ____ are caused by mechanical forces such as removing tape from a client’s skin and are common in older adults.

Skin tears

The severity of a skin tear is defined by the _____ of skin loss.

Depth

______ wounds are acute wounds intentionally created during surgery and are classified as clean, clean-contaminated, contaminated, or dirty, depending on the level of bacterial contamination.

Surgical

_____ and ____-contaminated surgical wounds have minimal bacterial loads, while _______ and dirty wounds have higher bacterial loads that may require long-term wound management.

Clean and clean-contaminated surgical wounds have minimal bacterial loads, while contaminated and dirty wounds have higher bacterial loads that may require long-term wound management.

What are the stages of surgical wound healing?

Surgical wounds typically appear ___ (days 1–4), bright ____ (days 5–14), and pale ___ (after day 15). ___ and ____ decrease over time.

Surgical wounds typically appear red (days 1–4), bright pink (days 5–14), and pale pink (after day 15). Edema and exudate decrease over time.

______ is fluid consisting of plasma secreted by the body during the _______ phase of healing. It should progressively decrease and resolve by postoperative day 5.

Exudate is fluid consisting of plasma secreted by the body during the inflammatory phase of healing. It should progressively decrease and resolve by postoperative day 5.

MASD is a form of dermatitis caused by skin exposure to irritants like feces, urine, and wound exudates, and it can lead to pain, burning, and itching.

MASD

How does moisture-associated skin damage (MASD) affect wound healing?

MASD predisposes clients to ______ injury formation and can complicate wound ______.

MASD predisposes clients to pressure injury formation and can complicate wound healing.

What conditions contribute to chronic wounds?

Chronic wounds can result from chronic venous insufficiency, peripheral artery disease, and diabetes mellitus, as well as aging, smoking, malnutrition, immunosuppression, and infection.

What are the major categories of chronic lower extremity wounds?

venous disease wounds, arterial disease wounds, and neuropathic disease wounds.

______ Disease Wounds: Associated with poor venous return, usually on the lower legs, with shallow wounds, heavy exudate, and discolored skin.

venous

________ Disease Wounds: Caused by poor blood flow due to narrowed arteries, typically on the toes or feet, with well-defined edges, dry necrotic tissue, and pain.

Arterial

__________ Disease Wounds: Caused by nerve damage (e.g., from diabetes), often painless, with deep, punched-out wounds typically found on pressure points (feet, toes).

Neuropathic

What should be assessed during dressing changes?

During dressing changes, wounds should be assessed for manifestations of _____, ______, changes in ____, amount, and ___ of exudate.

During dressing changes, wounds should be assessed for manifestations of healing, infection, changes in color, amount, and odor of exudate.

What types of exudate may be present in wounds?

Wound exudate may be ___, _______, _____, or _____.

Wound exudate may be serous, serosanguineous, sanguineous, or purulent.

_______ exudate indicates infection and should be reported to the provider.

Purulent

Wound _________ allows for future comparisons in appearance, size, and healing progress.

Wound documentation allows for future comparisons in appearance, size, and healing progress.

Wounds should be _______according to facility policy, often using tracing the wound circumference or measuring length and width with a ruler.

measured

Using the same measurement method throughout treatment ensures ______ tracking of the progression of wound healing.

accurate

Wound ____ is measured by gently inserting a sterile, premoistened cotton tip applicator under the wound edges until resistance is felt, marking the depth on the applicator, and then measuring with a ruler.

Wound depth

_______ refers to the development of a narrow channel or passageway extending in any direction from the base of the wound.

Tunneling

_______ injuries develop due to prolonged pressure on an area of skin or a combination of pressure and shearing.

Pressure

_______ occurs when deeper tissues are pulled downward by gravity while the top layers of skin remain in contact with the surface, stretching and traumatizing blood and lymphatic vessels.

Shearing

Pressure injuries most often occur over ___ prominences but can also develop where pressure is produced by _____ devices.

bony, medical

The main factors contributing to pressure injury development are ______, _____, and ______.

pressure, shear, and friction.

What are some risk factors for developing pressure injuries?

Risk factors include ______, ______, reduced _____, altered ______, decreased level of _______, and exposure to ____, ____, ____, ___, and bruises.

Risk factors include immobility, malnutrition, reduced perfusion, altered sensation, decreased level of consciousness, and exposure to moisture, friction, tears, cuts, and bruises.

While _____doesn't directly cause pressure injuries, it increases skin and tissue trauma, raising the risk of developing a pressure injury.

friction

Tightly braided hair increases the risk of _____ _______ injuries due to constant pressure on the scalp, especially in immobile clients.

For clients with tightly braided hair, the nurse should suggest removing the braids upon admission.

occipital pressure

Why are pressure injuries a concern in healthcare settings?

Pressure injuries can be painful, have prolonged healing times, are potential sources of infection, and may significantly affect both the client’s health and healthcare facility’s finances.

Where are the areas most susceptible to pressure injury formation?

The areas most susceptible to pressure injury formation are bony prominences, including the heels, toes, sacrum, hips, elbows, shoulders, and back of the head.

____ prominences apply pressure on the deeper layers of tissue, leading to greater damage to deep tissue.

Bony

What makes tissue damage from pressure injuries difficult to assess?

The exact extent of tissue damage from pressure injuries might not be visible from the surface.

What is the first step in decreasing the risk of pressure injury development?

The first step is conducting a thorough risk assessment to identify individual client preferences and specific risk factors.

Which factors are most often assessed by nurses to determine the risk for pressure injury development?

Factors include immobility, malnutrition, reduced perfusion, and sensory loss.

______ results in consistent pressure on one area without relief, increasing the likelihood of skin breakdown.

Immobility

______ and low _____ levels weaken tissue integrity, making it more prone to breakdown.

Malnutrition and low albumin levels weaken tissue integrity, making it more prone to breakdown.

_______ is low oxygen levels in the tissues caused by poor circulation, leading to tissue breakdown.

Hypoperfusion

______ loss alters the perception of pain and pressure sensation, increasing the risk because clients may not respond to pressure buildup.

Sensory

What are the key factors a nurse should observe when staging a pressure injury?

Factors include non-blanchable erythema, the amount and depth of skin and tissue loss, tissue in the wound bed, presence of dead tissue, and tunneling.

Why is accurate staging of pressure injuries important?

Accurate staging guides the treatment plan, evaluates healing progress, and allows benchmarking against other facilities.

_________ refers to an open area extending under the skin along the edge of the wound.

Undermining

Stage __: The skin is intact, with non-blanchable erythema and possible changes in sensation.

Stage 1

Partial-thickness skin loss occurs with visible pink or red viable tissue. STAGE ___

Partial-thickness skin loss occurs with visible pink or red viable tissue. STAGE 2

There is full-thickness skin loss with visible adipose tissue.STAGE __

STAGE 3

An _______ _____ injury is one where full-thickness skin and tissue loss is obscured by slough or eschar.

An unstageable pressure injury is one where full-thickness skin and tissue loss is obscured by slough or eschar.

_______ tissue is new tissue that forms on the surface of a wound as it heals, often seen in stage __ pressure injuries.

Granulation tissue is new tissue that forms on the surface of a wound as it heals, often seen in stage 3 pressure injuries.

What characterizes a Deep Tissue Pressure Injury (DTPI)?

A ______ is characterized by non-blanchable, deep red, maroon, or purple discoloration of the skin.

DTPI ( Deep Tissue Pressure Injury )

______-_____ pressure injuries occur due to prolonged pressure from medical devices that remain in direct contact with the skin.

Device-related

A ______ refers to a pressure injury caused by the prolonged use of medical devices.

medical device-related pressure injury (MDRPI)

A ____ ______ pressure injury occurs in the lining of body cavities and cannot be staged due to the lack of skin layers.

mucosal membrane

HAPIs are pressure injuries that occur during hospitalization and can increase healthcare costs.

Hospital Acquired Pressure Injuries (HAPIs)?

Why are pressure injuries in clients with darkly pigmented skin difficult to detect?

Indicators such as _________ erythema are harder to detect. Changes in skin ______,_____ levels, and localized ___ are often the first signs.

Indicators such as non-blanchable erythema are harder to detect. Changes in skin temperature, moisture levels, and localized pain are often the first signs.

How should a nurse assess for Stage 1 or deep tissue pressure injuries in clients with dark skin?

The nurse should assess the adjacent skin area that may appear _____ than the surrounding skin.

The nurse should assess the adjacent skin area that may appear darker than the surrounding skin.

When should pressure injuries be assessed and documented?

Pressure injuries should be assessed and documented on _______, during ______ assessments, and with each _____ change.

Pressure injuries should be assessed and documented on admission, during routine assessments, and with each dressing change.

What should be included when documenting a pressure injury?

Include the location and stage of the wound, size, description of tissue, color of the wound bed, condition of surrounding tissue, appearance of wound edges, presence of undermining and tunneling, any foul odor, and characteristics of wound drainage.

Why might a nurse recommend further diagnostic testing for a pressure injury?

If a pressure injury is not healing as expected, further diagnostic testing might be recommended to guide the treatment plan.

______ _______ is the process of removing dead tissue and debris from a wound using a scalpel or scissors.

Surgical debridement

_____ _____ is used to remove surface debris and decrease bacterial levels in the wound.

Wound irrigation

_______ dressings are used for small abrasions and pressure injuries, occlude the wound, maintain moisture, and promote granulation tissue growth.

Hydrocolloid

______ dressings are used for moderate to highly exudative wounds, providing hemostasis and high absorptive abilities.

Alginate

______ dressings offer high absorbency and can stay in the wound for several days.

Hydrofiber

_____ dressings provide absorption but require more frequent changes and may produce malodorous discharge.

Foam

______ dressings promote a moist healing environment, while _____ membrane dressings are used for mildly exudative wounds.

Hydrocolloid dressings promote a moist healing environment, while polymeric membrane dressings are used for mildly exudative wounds.

_______ dressings are used for dry wounds, helping maintain moisture and provide a soothing effect.

Hydrogel

Common antimicrobial agents include ____, ____, and _____.

Common antimicrobial agents include iodine, silver, and honey.

____ and ____ are used to secure and close wounds, either absorbable or nonabsorbable.

Sutures and staples are used to secure and close wounds, either absorbable or nonabsorbable.

What are the advantages and disadvantages of staples for wound closure?

Advantages include faster placement and healing, while disadvantages can include difficulty of removal and scarring.

____ ______ are used for small, straight-edged wounds, forming a waterproof protective covering.

Skin adhesives

_______ assists wound healing by reducing edema and promoting granulation tissue formation.

NPWT

_____ ____ are used to reduce fluid accumulation, remove air, and collect wound drainage for testing.

Wound drains

_____ ____ use negative pressure to suction fluid from the wound.

Active drains

_____ ____ rely on gravity to remove fluid

Passive drains

_____ drains release fluid into the air,

Open

_____ drains send fluid to a closed containment system.

Closed

Drains are usually removed when the total wound drainage is between __ and __mL in a 24-hour period.

Drains are usually removed when the total wound drainage is between 30 and 100 mL in a 24-hour period.

What are the complications associated with wound drains?

Complications can include ___ formation at the insertion site, tissue ______, accidental _____, and _____ or _____.

Complications can include clot formation at the insertion site, tissue obstruction, accidental removal, and hematomas or seromas.

A _____ drain is a passive, flat drain that relies on gravity to remove fluids from a wound.

Penrose

A ____ ____ ____ ____ device is an active, closed system that uses negative pressure to remove fluid.

portable wound bulb suction

How is fluid measured in a large bottle drainage system?

The bottle is placed at eye level, and a line is drawn next to the fluid level to calculate drainage.

A _____ _____ ____ ____ device provides continuous low vacuum suction from the wound into a measuring cup.

circular portable wound suction

A _____-____ drain is a bulb drain with a flexible plastic bulb that creates suction to drain fluid from a wound.

Jackson-Pratt (JP) drain

A ____ ___ is used for large amounts of drainage, with a silicone drain attached to a bottle for collection.

Bottle drain

A ______ drain uses a spring mechanism to create suction, drawing out fluid from the wound.

Hemovac

What type of drainage is expected immediately after a drain placement?

The drainage initially appears sanguineous (bloody) and gradually changes to serosanguineous (pinkish).

What should the nurse document regarding drainage from a surgical drain?

The nurse should document the ___, ___, _____, and ___ of the drainage.

The nurse should document the type, amount, consistency, and odor of the drainage.

When should the provider be notified about drainage?

Notify the provider if there is a significant increase or decrease in _____, presence of blood ____, signs of _____, or accidental ______.

Notify the provider if there is a significant increase or decrease in drainage, presence of blood clots, signs of infection, or accidental removal.

What should the nurse monitor around the drain site?

The nurse should monitor for _______ (skin breakdown) around the drain site.

maceration

How should the drain site be cleaned if the client cannot shower?

Clean the drain site once a day by _______ for infection signs and ______ the dressing.

Clean the drain site once a day by inspecting for infection signs and replacing the dressing.

What are the signs of infection at the drain site?

Signs include ____, _____, ____, ___, and an _____ in body temperature.

Signs include pain, swelling, redness, pus, and an increase in body temperature.

What should be done to prevent issues with the drain tubing?

Prevent ______ of the tubing and ensure _____ is maintained.

Prevent kinking of the tubing and ensure suction is maintained.

When is a drain usually removed?

A drain is typically removed when the drainage is less than ___ -___ mL per day.

A drain is typically removed when the drainage is less than 30-100 mL per day.

What care should be given after drain removal?

Apply ___ to the site, monitor for ____, and after __ hours, leave the site __ to air for healing.

Apply gauze to the site, monitor for infection, and after 24 hours, leave the site open to air for healing.

_____ ___ ____ addresses tissue injury prevention and individual client needs.

Holistic skin care

What are the two main components of preventing pressure injuries?

The two main components are identifying clients at ____ and implementing ______to reduce risk.

The two main components are identifying clients at risk and implementing interventions to reduce risk.