Skin Integrity & Wound Care Study Guide PDF

Fundamentals of Nursing Study Guide: Skin Integrity and Wound Care 1. Risk Factors for Pressure Injury Formation Elderly: Thinner skin and reduced resilience. Immobility: Inability to change positions. Palliative Care: Multiple health issues leading to increased vulnerability....

Fundamentals of Nursing Study Guide: Skin Integrity and Wound Care 1. Risk Factors for Pressure Injury Formation Elderly: Thinner skin and reduced resilience. Immobility: Inability to change positions. Palliative Care: Multiple health issues leading to increased vulnerability. Diabetes: Impaired circulation and delayed healing. Key Factors: Pressure Intensity: Strong pressure compresses blood vessels. Pressure Duration: Prolonged pressure can cause tissue damage. Tissue Tolerance: Skin condition affects its resilience. 2. Factors Promoting or Impeding Wound Healing Promoting Factors: ○ Good Nutrition: Essential nutrients (protein, vitamins A and C, zinc). ○ Moisture Balance: Keeping wounds moist enhances healing. ○ Blood Supply: Adequate circulation supports healing. Impediments to Healing: ○ Infection: Increases inflammation and delays healing. ○ Necrotic Tissue: Needs removal for healing to progress. ○ Chronic Illnesses: Conditions like diabetes slow healing. 3. Nursing Care Plan for Impaired Skin Integrity Assessment: ○ Regular skin assessments. ○ Document wound size, stage, and drainage. Nursing Interventions: ○ Repositioning: Every 1-2 hours to relieve pressure. ○ Hygiene: Maintain cleanliness with gentle cleansers. ○ Nutritional Support: Collaborate with dietitian for dietary needs.  ○ Patient Education: Teach skin care and mobility importance. 4. Critical Thinking in Patient Care Assessment: ○ Identify risk factors. ○ Prioritize care based on mobility, skin condition, and nutrition. Collaboration: ○ Work with interdisciplinary teams for comprehensive care. 5. Conditions at Risk for Impaired Skin Integrity Medical Conditions: Diabetes, vascular disease, obesity. Neurological Conditions: Impaired sensation affects pressure awareness. Incontinence: Increases moisture and risk of breakdown. Pressure Injury Staging Stage I: Non-blanchable redness. Stage II: Partial loss of skin thickness. Stage III: Full-thickness skin loss; may involve subcutaneous tissue. Stage IV: Extensive damage; muscle and bone may be exposed. Unstageable: Full thickness obscured by slough or eschar. Assessment Techniques Measure Wounds: Length, width, and depth. Signs of Infection: Look for redness, swelling, and odor. Documentation Include location, size, stage, drainage characteristics, and pain assessment. 1. Describe the Pressure Injury Staging System The pressure injury staging system is a standardized method for categorizing the severity of pressure injuries (formerly known as bedsores) based on their depth and the extent of tissue damage. The stages are as follows: Stage I: Non-blanchable erythema of intact skin. The area may be painful, firm, soft, warmer, or cooler compared to adjacent tissue. Stage II: Partial-thickness skin loss involving the epidermis and possibly the dermis. This may present as a shallow open sore with a pink or red wound bed without slough. Stage III: Full-thickness skin loss. The ulcer extends into the subcutaneous tissue and may appear as a deep crater. There may be necrotic tissue and tunneling. Stage IV: Full-thickness skin loss with extensive tissue damage, necrosis, or damage to muscle, bone, or supporting structures. Slough or eschar may be present. Unstageable: Full-thickness skin loss where the base of the ulcer is covered by slough or eschar, preventing accurate staging. 2. Describe the Process of Normal Wound Healing Normal wound healing occurs in four overlapping phases: Hemostasis: Immediately after injury, blood vessels constrict, and platelets aggregate to form a clot, providing a temporary barrier to blood loss and microbial invasion. Inflammation: This phase lasts a few days. White blood cells (neutrophils and macrophages) migrate to the site, clearing debris and bacteria while releasing growth factors that promote healing. Proliferation: This phase can last from a few days to weeks. New tissue (granulation tissue) forms, and angiogenesis (new blood vessel formation) occurs. Epithelial cells migrate to cover the wound. Maturation: The final phase can last for months to years. Collagen is remodeled, and the wound gains strength. Scar tissue forms, which may not have the same properties as normal skin. 3. Describe the Differences in Nursing Care with Acute or Chronic Wounds Acute Wounds: Usually result from trauma or surgery, heal within a predictable time frame (days to weeks), and may require basic wound care, dressings, and monitoring for signs of infection. Chronic Wounds: Often associated with underlying health conditions (e.g., diabetes, vascular issues) and fail to progress through the normal healing phases. Care may involve advanced treatment, debridement, and addressing underlying factors such as nutrition and blood flow. 4. Complete an Assessment for a Patient with Impaired Skin Integrity Inspection: Look for signs of pressure injuries, including color changes, open sores, and swelling. Palpation: Assess for temperature changes, moisture, and tenderness. Measurement: Document wound size (length, width, depth), stage, and presence of necrotic tissue or slough. Assess Surrounding Skin: Check for signs of maceration or irritation. Evaluate Drains/Sutures: Note type, amount of drainage, and any signs of infection. 5. Identify Techniques to Promote Sterility and Asepsis When Performing Skin and Wound Care Hand Hygiene: Perform handwashing or use hand sanitizer before and after patient contact. Personal Protective Equipment (PPE): Wear gloves, gowns, and masks as appropriate. Sterile Field: Prepare a sterile field for dressing changes, ensuring items are sterile. Avoid Touching Sterile Items: Do not reach over the sterile field, and avoid contact with non-sterile surfaces. 6. Demonstrate Wound Cultures, Irrigation, and Sterile Dressing Application Wound Cultures: Clean the wound with saline, use a sterile swab to collect a sample from the base of the wound, and place it in a sterile container.  Irrigation: Use saline or a prescribed solution to flush the wound gently. Ensure the solution flows from the least contaminated to the most contaminated area. Sterile Dressing Application: ○ Clean the wound, apply any prescribed topical treatments, and place a sterile dressing. Secure it with tape or a bandage, avoiding tension that could disrupt healing. 7. Discuss Various Types of Wound Drainage and the Impact on the Patient Condition Serous: Clear or straw-colored fluid; normal in healing but excessive may indicate issues. Sanguineous: Red, bloody drainage; indicates active bleeding. Serosanguineous: Pink drainage; a mix of blood and serum; typically expected in the early stages of healing. Purulent: Thick, yellow, green, or brown; indicates infection and requires assessment and intervention. 8. Discuss the Purpose and Prevention Associated with Use of the Braden Scale The Braden Scale assesses a patient's risk for developing pressure injuries based on six criteria: sensory perception, moisture, activity, mobility, nutrition, and friction/shear. Purpose: Identify patients at high risk for pressure injuries, enabling early intervention. Prevention: Regular skin assessments, repositioning, nutritional support, and use of pressure-relieving devices. 9. Identify Various Wounds and Injuries Terminology Laceration: A tear or a cut in the skin or tissue. Abrasion: A scrape or rub on the skin. Contusion: A bruise caused by trauma. Incision: A clean cut, typically from surgery. Fistula: An abnormal connection between two body parts. 10. Discuss Debridement and Its Purpose in Wound Care Debridement is the process of removing dead, damaged, or infected tissue from a wound. Purpose: ○ Promotes healing by removing barriers to healing. ○ Reduces the risk of infection. ○ Prepares the wound bed for effective closure or healing. 11. Demonstrate Appropriate Hygiene Techniques (Bed Baths) Preparation: Gather supplies (bathing basin, soap, towels, clean linens) and ensure privacy. Technique: ○ Begin with the face and work downward, cleaning each body part with a fresh cloth. ○ Pay attention to skin folds and areas that may be prone to irritation. ○ Rinse and dry thoroughly, applying moisturizer as needed. 12. Perform Sterile Dressing Change and Central Line Dressing Change Sterile Dressing Change: ○ Gather sterile supplies and perform hand hygiene. ○ Remove the old dressing carefully, assess the wound, and discard appropriately. ○ Clean the wound as per protocol and apply a new sterile dressing. Central Line Dressing Change: ○ Use sterile gloves, clean the catheter site with an antiseptic solution, and apply a sterile dressing. ○ Ensure that the dressing is secure but not too tight to restrict blood flow.