Podcast
Questions and Answers
A patient with decreased sensation is at risk for tissue death due to ischemia. What physiological response is the patient unable to perceive, leading to this increased risk?
A patient with decreased sensation is at risk for tissue death due to ischemia. What physiological response is the patient unable to perceive, leading to this increased risk?
- The increase in blood flow to the affected area.
- The change in skin temperature around the affected area.
- The visible blanching of the skin when pressure is applied.
- The discomfort caused by prolonged pressure on the tissue. (correct)
In assessing a patient with darkly pigmented skin for pressure injury risk, what limitation should a healthcare provider be aware of when examining skin color?
In assessing a patient with darkly pigmented skin for pressure injury risk, what limitation should a healthcare provider be aware of when examining skin color?
- Standard pressure injury risk assessment scales are not validated for use in darkly pigmented skin.
- Changes in skin color may be subtle and difficult to detect in darkly pigmented skin. (correct)
- Darkly pigmented skin is naturally more resistant to pressure injuries.
- Darkly pigmented skin is more prone to blanching, making hyperemia assessment unreliable.
What is the primary function of the epidermis in wound healing after a skin injury?
What is the primary function of the epidermis in wound healing after a skin injury?
- To resurface the wound and act as a barrier against infection. (correct)
- To provide a matrix for new blood vessel growth.
- To initiate the inflammatory response and attract immune cells.
- To restore the skin's structural integrity through collagen production.
A nurse assesses a patient's sacral area and observes non-blanchable erythema. What does this finding indicate?
A nurse assesses a patient's sacral area and observes non-blanchable erythema. What does this finding indicate?
Hospitals are no longer reimbursed by The Centers for Medicare and Medicaid Services for care related to certain pressure injuries. Which stages of pressure injuries are included in this policy?
Hospitals are no longer reimbursed by The Centers for Medicare and Medicaid Services for care related to certain pressure injuries. Which stages of pressure injuries are included in this policy?
Which characteristic differentiates a Stage 2 pressure injury from a Stage 3 pressure injury?
Which characteristic differentiates a Stage 2 pressure injury from a Stage 3 pressure injury?
What is the primary obstacle in accurately staging an unstageable pressure injury?
What is the primary obstacle in accurately staging an unstageable pressure injury?
A patient presents with intact skin but a localized area of non-blanchable deep maroon discoloration. Which type of injury is MOST likely?
A patient presents with intact skin but a localized area of non-blanchable deep maroon discoloration. Which type of injury is MOST likely?
Which anatomical structure is exposed or directly palpable in a Stage 4 pressure injury?
Which anatomical structure is exposed or directly palpable in a Stage 4 pressure injury?
Which of the following is NOT appropriate to classify as a Stage 2 pressure injury?
Which of the following is NOT appropriate to classify as a Stage 2 pressure injury?
What is the MOST important step to take after debridement of an unstageable pressure injury?
What is the MOST important step to take after debridement of an unstageable pressure injury?
A critically ill patient has a pressure injury on their face caused by an oxygen mask. What type of injury is this MOST likely to be classified as?
A critically ill patient has a pressure injury on their face caused by an oxygen mask. What type of injury is this MOST likely to be classified as?
Following the removal of a medical adhesive, a nurse observes persistent skin integrity compromise lasting longer than 30 minutes. How should this be classified?
Following the removal of a medical adhesive, a nurse observes persistent skin integrity compromise lasting longer than 30 minutes. How should this be classified?
When assessing dark-skinned individuals for pressure injuries, which factor requires particularly close examination due to its subtle presentation?
When assessing dark-skinned individuals for pressure injuries, which factor requires particularly close examination due to its subtle presentation?
Extrinsic factors significantly affect the skin's ability to tolerate pressure. How do shear forces contribute to pressure injury development?
Extrinsic factors significantly affect the skin's ability to tolerate pressure. How do shear forces contribute to pressure injury development?
Which systemic factor would most significantly reduce tissue tolerance to externally applied pressure?
Which systemic factor would most significantly reduce tissue tolerance to externally applied pressure?
A patient with impaired mobility is at high risk for pressure injuries. What is the primary reason that immobility increases this risk?
A patient with impaired mobility is at high risk for pressure injuries. What is the primary reason that immobility increases this risk?
How does shear force contribute to pressure injury development when the head of the bed is elevated?
How does shear force contribute to pressure injury development when the head of the bed is elevated?
Friction is described as the force of two surfaces moving across one another. How does friction primarily affect the skin, and what visible damage is typically observed?
Friction is described as the force of two surfaces moving across one another. How does friction primarily affect the skin, and what visible damage is typically observed?
What is Moisture-Associated Skin Damage (MASD), and which bodily fluids are common culprits in its development?
What is Moisture-Associated Skin Damage (MASD), and which bodily fluids are common culprits in its development?
The goal in preventing pressure injuries involves early identification of at-risk clients and implementation of prevention strategies. Which of the following scenarios indicates the MOST immediate need for implementing pressure injury prevention strategies?
The goal in preventing pressure injuries involves early identification of at-risk clients and implementation of prevention strategies. Which of the following scenarios indicates the MOST immediate need for implementing pressure injury prevention strategies?
Which of the following assessment findings would be most concerning when evaluating a patient's wound healing process?
Which of the following assessment findings would be most concerning when evaluating a patient's wound healing process?
A patient is transferred from acute care to a rehabilitation center. What is the primary reason for assessing the patient's skin integrity upon arrival at the rehabilitation center?
A patient is transferred from acute care to a rehabilitation center. What is the primary reason for assessing the patient's skin integrity upon arrival at the rehabilitation center?
A nurse notes black, dry tissue in a pressure injury. Which intervention is most appropriate based on this finding?
A nurse notes black, dry tissue in a pressure injury. Which intervention is most appropriate based on this finding?
Which aspect of wound exudate provides the most comprehensive information about a potential infection?
Which aspect of wound exudate provides the most comprehensive information about a potential infection?
A patient at high risk for pressure injuries is prescribed frequent turning and position changes. What additional environmental consideration is most important for this patient?
A patient at high risk for pressure injuries is prescribed frequent turning and position changes. What additional environmental consideration is most important for this patient?
What is the primary risk associated with packing a wound too tightly?
What is the primary risk associated with packing a wound too tightly?
A patient has a wound with copious exudate requiring a highly absorbent dressing. Which type of dressing is MOST appropriate for this wound?
A patient has a wound with copious exudate requiring a highly absorbent dressing. Which type of dressing is MOST appropriate for this wound?
Which of the following is the MOST LIKELY reason a wound may require a Vacuum-Assisted Closure (VAC) device?
Which of the following is the MOST LIKELY reason a wound may require a Vacuum-Assisted Closure (VAC) device?
What is the primary mechanism by which hyperbaric oxygen therapy (HBOT) is thought to promote wound healing?
What is the primary mechanism by which hyperbaric oxygen therapy (HBOT) is thought to promote wound healing?
A patient has a clean, granulating wound. Which type of dressing would BEST support healing and autolytic debridement?
A patient has a clean, granulating wound. Which type of dressing would BEST support healing and autolytic debridement?
A patient who underwent abdominal surgery reports a sudden sensation of something 'giving way' at their incision site. Upon examination, there is a partial separation of the wound edges, but no organs are protruding. What immediate action should the nurse take?
A patient who underwent abdominal surgery reports a sudden sensation of something 'giving way' at their incision site. Upon examination, there is a partial separation of the wound edges, but no organs are protruding. What immediate action should the nurse take?
Which of the following assessment findings in a post-operative patient would MOST strongly suggest a surgical site infection (SSI)?
Which of the following assessment findings in a post-operative patient would MOST strongly suggest a surgical site infection (SSI)?
An elderly patient is recovering from a hip replacement surgery. The nurse recognizes that age-related physiological changes can affect wound healing. Which of the following is a common age-related factor that may impair wound healing?
An elderly patient is recovering from a hip replacement surgery. The nurse recognizes that age-related physiological changes can affect wound healing. Which of the following is a common age-related factor that may impair wound healing?
A patient develops evisceration of an abdominal wound. After covering the protruding organs with sterile saline-soaked gauze, what is the next MOST important nursing intervention?
A patient develops evisceration of an abdominal wound. After covering the protruding organs with sterile saline-soaked gauze, what is the next MOST important nursing intervention?
Which of the following nutritional deficiencies is MOST likely to impair collagen synthesis during wound healing?
Which of the following nutritional deficiencies is MOST likely to impair collagen synthesis during wound healing?
A patient with a chronic wound has a consistently high white blood cell count. How does a chronic wound infection typically affect the healing process?
A patient with a chronic wound has a consistently high white blood cell count. How does a chronic wound infection typically affect the healing process?
An obese patient is at a higher risk for wound dehiscence due to which of the following factors?
An obese patient is at a higher risk for wound dehiscence due to which of the following factors?
A patient's wound is showing signs of hemorrhage. A surgical drain has been placed. What is the primary purpose of the surgical drain in this situation?
A patient's wound is showing signs of hemorrhage. A surgical drain has been placed. What is the primary purpose of the surgical drain in this situation?
A patient undergoing wound care has a history of poor tissue perfusion due to peripheral vascular disease. What is the MOST significant impact of poor tissue perfusion on wound healing?
A patient undergoing wound care has a history of poor tissue perfusion due to peripheral vascular disease. What is the MOST significant impact of poor tissue perfusion on wound healing?
Following surgery, a patient is prescribed a diet high in protein, vitamin C, and trace minerals. What is the primary rationale for this dietary intervention in the context of wound healing?
Following surgery, a patient is prescribed a diet high in protein, vitamin C, and trace minerals. What is the primary rationale for this dietary intervention in the context of wound healing?
Flashcards
Epidermis
Epidermis
The top layer of skin that resurfaces wounds and restores the barrier against infections.
Dermis
Dermis
The inner layer of skin containing collagen, blood vessels, and nerves; restores structural integrity after injury.
Pressure Injury
Pressure Injury
Also known as pressure ulcer or bed sore; caused by prolonged pressure leading to tissue ischemia and potential death.
Tissue Ischemia
Tissue Ischemia
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Blanchable Hyperemia
Blanchable Hyperemia
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Risk Factors for Pressure Ulcers
Risk Factors for Pressure Ulcers
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Impaired Sensory Perception
Impaired Sensory Perception
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Impaired Mobility
Impaired Mobility
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Shear
Shear
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Friction
Friction
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Moisture-associated Skin Damage (MASDI)
Moisture-associated Skin Damage (MASDI)
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Tissue Tolerance
Tissue Tolerance
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Extrinsic Factors
Extrinsic Factors
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Hemorrhage
Hemorrhage
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Infection
Infection
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Surgical Site Infections (SSIs)
Surgical Site Infections (SSIs)
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Local Signs of Infection
Local Signs of Infection
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Dehiscence
Dehiscence
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Evisceration
Evisceration
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Nutrition in Wound Healing
Nutrition in Wound Healing
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Tissue Perfusion
Tissue Perfusion
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Age and Wound Healing
Age and Wound Healing
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Proinflammatory Cytokines
Proinflammatory Cytokines
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Stage 1 Pressure Injury
Stage 1 Pressure Injury
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Stage 2 Pressure Injury
Stage 2 Pressure Injury
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Stage 3 Pressure Injury
Stage 3 Pressure Injury
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Stage 4 Pressure Injury
Stage 4 Pressure Injury
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Unstageable Pressure Injury
Unstageable Pressure Injury
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Deep-Tissue Pressure Injury
Deep-Tissue Pressure Injury
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Medical Device-Related Pressure Injury
Medical Device-Related Pressure Injury
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Medical Adhesive-Related Injury
Medical Adhesive-Related Injury
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Wound Assessment
Wound Assessment
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Slough
Slough
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Eschar
Eschar
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Induration
Induration
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Exudate
Exudate
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Irrigation
Irrigation
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Vacuum Assisted Closure (VAC)
Vacuum Assisted Closure (VAC)
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Types of Dressings
Types of Dressings
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Hyperbaric Oxygen Therapy (HBOT)
Hyperbaric Oxygen Therapy (HBOT)
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Packing a Wound
Packing a Wound
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Study Notes
- Skin integrity and wound care is a critical topic for week 4.
- The epidermis is the top layer of skin. It functions to resurface wounds and restore the barrier against invading organisms when injured.
- The dermis is the inner skin layer, containing collagen, blood vessels, and nerves. It responds to injury by restoring the structural integrity and physical properties of the skin.
- Dermal-epidermal junction separates the dermis and epidermis.
- Pressure injuries are costly to healthcare systems, and profoundly affect patient well-being. More than 1.6 million patients develop pressure injuries annually in acute settings.
- Factors influencing psychosocial impact of wounds include wound location and presence of scars, stitches, drains (often needed for weeks/months), and odor from drainage, or temporary/permanent prosthetic devices.
- Pressure injuries (pressure ulcers, decubitus ulcers, bed sores) occur due to pressure intensity (amount of pressure needed to collapse a capillary). Tissue ischemia occurs when vessels occlude, and if sensation is compromised, tissue death may result.
- Blanching: Place a finger over the affected area; if it whitens (blanches), and turns back to red when removed, it is a blanchable/reversible erythema. Non-blanchable erythema indicates deep tissue damage.
- Assess dark skin for changes in temperature, moisture, pain, discoloration, previous pressure injuries, edema, and discomfort (e.g., bony prominences, under medical devices). This is due to cultural aspects of care where dark pigmentation could mask any early signs of pressure ulcers.
- Extrinsic factors (shear, friction, moisture) affect the skin's tolerance to pressure. Tissue tolerance depends on tissue and supporting structural integrity. Systemic factors also affect tissue tolerance concerning externally applied pressure.
- Risk factors for pressure ulcer development include impaired sensory perception, impaired mobility, alteration in level of consciousness (LOC), shear, friction, and moisture.
- Identifying at-risk patients and implementing preventive strategies are critical.
- Understanding "shear" and "friction" is essential, as these cause pressure injury. Shear involves sliding of skin/subcutaneous tissue, while friction is two surfaces moving against one another.
- Moisture-associated skin damage (MASD) results from prolonged moisture exposure (wound drainage, urine/stool, perspiration, mucus, saliva). Prolonged moisture softens skin, making it more vulnerable to damage.
- Pressure injuries are classified into stages (1-4) based on the depth of tissue involvement. Stage 1 involves non-blanchable erythema; stage 2 is partial-thickness skin loss; stage 3 is full-thickness skin loss, with adipose tissue visible; stage 4 involves extensive full-thickness loss, exposing deeper tissue.
- Unstageable pressure injuries are obscured by slough or eschar, making visual assessment of depth impossible. Deep-tissue pressure injuries are present as dark discoloration or epidermal separation, with potential blood-filled blisters.
- Medical device-related injuries occur when tissues sustain sustained pressure or shear from medical devices (e.g., masks, oxygen tubing). Medical adhesive-related injuries occur when adhesive removal causes persistent skin damage.
- Wound types include closed (e.g., hematomas, contusions, stage 1 pressure injuries), and open (skin is split, incised, or cracked, exposing underlying tissue).
- Wound healing classifications include acute (trauma, surgical incision) and chronic (fails to heal orderly, resulting in anatomical and functional issues).
- Three types of wound healing processes are recognized: primary intention (surgical closure with stitches); secondary intention (healing by granulation tissue, wound contraction, and epithelialization, used when substantial tissue loss); tertiary intention (delayed primary intention closure, allowing for healing).
- Wound repair involves partial or full-thickness wound repair, incorporating inflammation and epithelial proliferation, reestablishment of epidermal layers, and tissue remodeling.
- Hemostasis, inflammation, and proliferation are three phases of normal wound repair; remodeling and maturation are additional phases.
- Common wound healing complications include hemorrhage, infection, dehiscence (surgical incision fails to heal), evisceration (separation of layers, organs extruding).
- Local signs of infection include increased erythema (redness), wound drainage changes, peri-wound warmth, pain, edema, and an increase in white blood cell counts.
- Assessing skin on admission and at transfer of care involves evaluating sensation, mobility, nutrition, continence, environment, assessing skin (at least start of care, and at each shift), and inspecting for breakdown in high-risk areas (sacrum, heels).
- Using proper aseptic technique, regularly inspecting skin, and assessing previous damage/chronic diseases are safety guidelines to prevent pressure injuries.
- Adequate nutrition, prompt treatment of infection, and considering patient age are critical factors for optimal wound healing.
- Proper critical thinking in wound assessment requires normal integument/musculoskeletal physiology knowledge. Examining how healing occurs helps recognition of abnormal occurrences.
- A variety of wound dressings are available. Wound care involves appropriate use of drainage reservoirs (e.g., Jackson-Pratt), and treatments like hyperbaric oxygen therapy.
- Heat and cold therapy may be used for wound care. Assess patient preferences and the potential presence of family caregivers. Consider collaborating with wound care teams and healthcare providers.
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Description
This lesson covers the risk factors, identification, & staging of pressure injuries. It highlights the challenges in assessing darkly pigmented skin and staging unstageable injuries. Focus is on the physiological responses associated with them.
