What is the largest organ in the body?
Skin
Skin the largest organ in the body constitutes ____% of the total adult weight.
15%
The skin is a _____ ______ against disease-causing organisms.
Protective Barrier
The skin is a sensory organ for:
Pain
Temperature
Touch
The skin synthesizes:
Vitamin D
What is the Nurses most important responsibilities regarding the skin?
1. Assessing and Monitoring Skin integrity
2. Identifying problems
3. Planning, Implementing and Evaluating Interventions to maintain skin integrity
48-3
What type of patient would you do a "skin check" on? Why?
fig 48-9
What factors contribute to "skin breakdown"?
box 48-6
Impaired skin integrity related to UNRELIEVED, PROLONGED, PRESSURE is referred to as:
PRESSURE ULCER, or pressure sore, decubitus ulcer, bedsore
What exactly is a "pressure ulcer?
Localized injury to the skin and other underlying tissue, usually over a bony prominence.
What is the nurses responsibility?
Need to assess pressure ulcers at regular intervals using systematic parameters to evaluate:
-wound healing
-plan appropriate interventions
-evaluate progress
A pressure ulcer is as a result of what?
Pressure in combination with shear and/or friction.
What would you document about a pressure ulcer?
-depth of tissue involvement (staging)
-type and approximate percentage of tissue in wound bed
-wound dimensions
-exudate description
-condition of surrounding skin
Stage 1 Pressure Ulcer:
Non blanchable Redness of Intact skin.
-Painful
-Warmer or cooler than adjacent tissue.
-Firm or soft
Stage 2 Pressure Ulcer
Partial-thickness skin loss or blister involving epidermis, dermis, or both.
-Shiny or dry shallow ulcer
Stage 3 Pressure Ulcer
Full-thickness skin loss (Fat visible) tissue loss
Stage 4 Pressure Ulcer
Full-thickness tissue loss with (Exposed bone, muscle, or Tendon.) 48-4
Unstageable Pressure Ulcer
Full thickness tissue loss where the base of the ulcer is covered by slough and/or eschar.
What is the major cause of the formation of a pressure ulcer?
- Pressure Intensity
-Pressure Duration
-Tissue Tolerance
Risks for pressure ulcers:
-Nutrition
-Impaired sensory perception
-Impaired mobility
-Alteration in the level of consciousness
-Presence of a cast
- Secondary to an illness
-Shear
-Friction
-Moisture
48-1/48-9
Prevention measures for pressure ulcers:
-Skin care
-Positioning
-Use of support surfaces
What is a wound?
A wound is a disruption of the integrity and function of tissues in the body.
No 2 (two) wounds are ___
the same
Two types of wounds:
Those with:
-Lots of Tissue
-Without Tissue
Complications regarding wounds:
-Hemorrhage: bleeding from a wound site.
-Hematoma: localized collection of blood underneath the tissues.
-Infection (second most common HAI)
-Dehiscence: partial of total separation of wound layers
-Evisceration: protrusion of visceral organs through a w
Two types of Dressings:
1. Clean
2. Sterile
Who is at risk for a pressure ulcer development?
-Any patient experiencing decreased mobility
-Decreased sensory perception
-Fecal or Urinary Incontinence
-Poor nutrition
Normal Capillary pressure rangeis between:
15 to 32 mm Hg
Tissues receive oxygen and nutrients and eliminate metabolic wastes via the ____.
Blood
Any factor that interferes with ____ flow in turn interferes with cellular metabolism and the function of life of the cells.
Blood
Prolonged, intense pressure affects cellular metabolism by decreasing or obliterating blood flow, resulting in tissue ______ and ultimately tissue death.
Ishemia
If the pressure applied over a capillary exceeds normal capillary pressure and the vessel is occluded for a prolonged period of time, what can occur?
Tissue Ischemia
If the patient has reduced sensation and cannot respond to discomfort of the ischemia, what will be the result?
Tissue ischemia & Tissue Death
After a period of tissue ischemia, if the pressure is relieved and the blood flow returns, what color does the skin turn?
Red. Hyperemia (redness)
Blanching occurs when the normal red tones of the light-skinned patient are ____.
Absent
Evaluate an area of hyperemia by pressing a finger over the affected area. If it blanches (turns lighter in color) and the erythema returns when you remove your finger....
the hyperemia is transient and is an attempt to overcome the ischemic episode, thus called blanching hyperemia
If the erythematous area does not blanch (non blanching erythema) when you apply pressure....
Deep tissue damage is probable.
Clinical implications of pressure duration include:
1. Evaluating the amount of pressure (checking skin for reactive hypermia)
2. Determining the amount of time that a patients tolerates pressure (checking to be sure after relieving pressure that the affected area blanches.)
Systemic factors such as ___ ___ ___ affect the tolerance of the tissue to externally applied tissue.
-Poor nutrition
- Hydration status
-Low BP
Shear force
is the sliding movement of skin and subcutaneous tissue while the underlying muscle and bone are stationary.
Example: _____ _____ occurs when the head of the bed is elevated and the sliding of the skeleton starts, but the skin is fixed because of friction with the bed.
Shear force
When transferring a patient from bed to stretcher and the patient's skin is pulled across the bed, this is?
Shear force
Friction
Force of two surfaces moving across one another such as the mechanical force exerted when skin is dragged across a coarse surface such as bed linens.
What is the difference between shear and friction injuries?
Friction injuries affect the epidermis or top layer of the skin, Shear do not.
The denuded skin appears red and painful and is sometimes referred to as "sheet burn.
Fritction
A friction injury usually occurs in:
-Patients who are restless
-Those whose skin is dragged rather than lifted from the bed surface during position changes.
Immobilized patients who are unable to perform their own hygiene needs depend on the nurse to?
Keep the skin dry and intact.
Skin moisture originates from:
-wound drainage
-excessive perspiration
-fecal or urinary incontinence
Can you stage an ulcer covered with necrotic tissue?
No, because the necrotic tissue is covering the depth of the ulcer. Necrotic tissue must be debrided or removed to expose the wound base to allow for assessment.
Definition for an ulcer that is unstageable/unclassified
in which the base of the wound cannot be visualized and a definition of tissue injury in which the depth of the injury is unknown.
Depth of tissue involvement is?
Staging
Granulation tissue
red, moist, tissue composed of new blood vessels.
Soft yellow of white tissue is a characteristic of
slough (stringy substance attached to wound bed)
Black or brown necrotic tissue is ____. Thick layer of dead dry tissue that covers a pressure ulcer or thermal burn.
Eschar
Measure depth of an ulcer in the wound bed with?
Cotton-tipped applicator
Acute wound
Wounds are usually easily cleaned and repaired. Wound edges are clean and intact. Sudden onset (trauma, surgery) and usually heal well.
Chronic wound
Continued exposure to insult impedes wound healing.
Either slow in onset
Or results from complications from acute wounds
Often needs to be made "acute" again to heal.
Primary intention (healing process) Like a surgical incision.
Healing occurs by epithelialization; heals quickly with minimal scar formation.
Secondary Intention (wound edges not approximated) Like pressure ulcers
Wounds heal by granulation tissue formation, would contraction, and epithelialization.
Tertiary Intention (wound left open for several days, then wound edges are approximated)
Closure of wound is delayed until risk of infection is resolved.
Wound exudate should describe:
-the amount
-color
-consistency
-odor of wound drainage
Excessive exudate indicates the presence of...
infection
Skin surround the wound asses for:
-Redness
-Warmth
-Maceration
-Edema (swelling)
*Presence of any of these factors indicates wound deterioration.
What differentiates contaminated wounds from infected wounds?
Amount of bacteria present.
A patient who is at risk for poor wound healing:
- poor nutritional status
- infection
- obesity
Risk for dehiscence
Prevent dehiscence by:
Placing a folded thin blanket or pillow over an abdominal wound when patient is coughing.
When evisceration occurs
the nurse places sterile towels soaked in sterile saline over the extruding tissues to reduce the chances of bacterial invasion and drying of the tissues. Surgical emergency.
Braden scale six subscales:
1. sensory perception
2. moisture
3. activity
4. mobility
5. nutrition
6. friction/shear
Nutrition 1500 kcal/day required for
nutritional maintenance
Physiological processes of wound healing depend on:
-protein
-vitamins (especially A & C)
-trace minerals zinc and copper
Collage is a protein formed
from amino acids acquired by fibroblasts from protein ingested in food.
Vitamins C is necessary for
synthesis of collagen
Vitamin A reduces the negative effects of ______ on wound healing.
steriods
Protein
Wound remodeling & immune function. Tissue repair and growth.
Vitamin C
Collagen synthesis, capillary wall integrity, fibroblast function, antioxidant
Vitamin A
wound closure, epithelialization, inflammatory response, angiogenesis, collagen formation. *can reverse steroid effects on skin and delayed healing.
Vitamin E
antioxidant
Zinc
Collagen formation
Protein Synthesis
Cell membrane & host defenses
Fluid
Essential fluid environment for all cell function
Calories provide the energy source needed to support....
the activity of wound healing.
When repositioning an immobile patient, the nurse notices redness over a bony prominence. What is indicated when a reddened area blanches on fingertip touch?
A) A local skin infection requiring antibiotics
B) Sensitive skin that requires special bed linen
Correct Answer(s): D
When repositioning an immobile patient, it is important to assess all bony prominences for the presence of redness, which can be the first sign of impaired skin integrity. Pressing over the area compresses the blood vessels in the are
Which type of pressure ulcer is noted to have intact skin and may include changes in one or more of the following: skin temperature (warmth or coolness), tissue consistency (firm or soft), and/or pain?
A) Stage I
B) Stage II
C) Stage III
D) Stage IV
Correct Answer(s): A
A stage I pressure ulcer does not have a break in the skin but has a redness that does not blanch. Depending on the skin color, there may be a discoloration; the area may feel warm because of the vasodilation or cool if blood is const
When obtaining a wound culture to determine the presence of a wound infection, from where should the specimen be taken?
A) Necrotic tissue
B) Wound drainage
C) Drainage on the dressing
D) Wound after it has first been cleaned with normal saline
Correct Answer(s): D
Drainage that has been present on the wound surface can contain bacteria from the skin, and the culture may not contain the true causative organisms of a wound infection.
By cleaning the area before obtaining the culture, the skin flo
After surgery the patient with a closed abdominal wound reports a sudden "pop" after coughing. When the nurse examines the surgical wound site, the sutures are open, and pieces of small bowel are noted at the bottom of the now-opened wound. Which correcti
Correct Answer(s): C
If a patient has an opening in the surgical incision and a portion of the small bowel is noted, the small bowel must be protected until an emergency surgical repair can be done. The small bowel and abdominal cavity should be maintaine
Which description best fits that of serous drainage from a wound?
A) Fresh bleeding
B) Thick and yellow
C) Clear, watery plasma
D) Beige to brown and foul smelling
Correct Answer(s): C
Serous fluid generally is serum and presents as light red, almost clear fluid.
For a patient who has a muscle sprain, localized hemorrhage, or hematoma, which wound care product helps prevent edema formation, control bleeding, and anesthetize the body part?
A) Binder
B) Ice bag
C) Elastic bandage
D) Absorptive diaper
Correct Answer(s): B
An ice bag helps to constrict excess fluid in tissues, which prevents edema. The blood vessels become constricted, help to control bleeding, and can decrease pain where the ice bag is placed.
Which skin care measures are used to manage a patient who is experiencing fecal and urinary incontinence?
A) Keeping the buttocks exposed to air at all times
B) Using a large absorbent diaper, changing when saturated
C) Using an incontinence cleaner, foll
Correct Answer(s): C
Skin that is in contact with stool and urine can become moist and soft, allowing it to become damaged. The stool contains bacteria and in some cases enzymes that can harm the skin if in contact for a prolonged period of time. The use
Which of the following describes a hydrocolloid dressing?
A) A seaweed derivative that is highly absorptive
B) Premoistened gauze placed over a granulating wound
C) A debriding enzyme that is used to remove necrotic tissue
D) A dressing that forms a gel t
Correct Answer(s): D
A hydrocolloid dressing is made of materials that are adhesive and can form a gel over the open area of the wound. Since moisture enhances wound healing, the gel that forms places the wound in the proper environment for healing.
Which of the following is an indication for a binder to be placed around a surgical patient with a new abdominal wound?
A) Collection of wound drainage
B) Reduction of abdominal swelling
C) Reduction of stress on the abdominal incision
D) Stimulation of p
Correct Answer(s): C
A binder placed over the abdomen can provide protection to the abdominal incision by offering support and decreasing stress from coughing and movement.
When is an application of a warm compress indicated? (Select all that apply.)
A) To relieve edema
B) For a patient who is shivering
C) To improve blood flow to an injured part
D) To protect bony prominences from pressure ulcers
Correct Answer(s): A, C
Warm compresses can improve circulation by dilating blood vessels, and they reduce edema. The moisture of the compress conducts heat.
What is the removal of devitalized tissue from a wound called?
A) Debridement
B) Pressure reduction
C) Negative pressure wound therapy
D) Sanitization
Correct Answer(s): A
Debridement is the removal of nonliving tissue, cleaning the wound to move toward healing.
Name the three important dimensions to consistently measure to determine wound healing.
Correct Answer(s):
Width, length and depth.
What does the Braden Scale evaluate?
A) Skin integrity at bony prominences, including any wounds
B) Risk factors that place the patient at risk for skin breakdown
C) The amount of repositioning that the patient can tolerate
D) The factors that place the p
Correct Answer(s): B
The Braden Scale measures factors in six subscales that can predict the risk of pressure ulcer development. It does not assess skin or wounds.
On assessing your patient's sacral pressure ulcer, you note that the tissue over the sacrum is dark, hard, and adherent to the wound edge. What is the correct stage for this patient's pressure ulcer?
A) Stage II
B) Stage IV
C) Unstageable
D) Suspected dee
Correct Answer(s): C
To determine the stage of a pressure ulcer you examine the depth of the tissue involvement. Since the pressure ulcer assessed was covered with necrotic tissue, the depth could not be determined. Thus this pressure ulcer cannot be stag
Name one intervention and the rationalization to use that intervention to reduce the likelihood of a shear injury to a patient.
Correct Answer(s):
A transfer device can pick up a patient and prevent his or her skin from sticking to the bed sheet as he is repositioned. A second intervention would be to position the patient with the head of the bed to be elevated at 30 degrees, whic
Exudate
A fluid rich in protein and cellular elements that oozes out of blood vessels due to inflammation and is deposited in nearby tissues. The altered permeability of blood vessels permits the passage of large molecules and solid matter through their walls.
Purulence
the condition of containing or forming pus
When is the BEST time to so a skin assessment?
During bathing
What scale is used for skin assessment?
Braden's Scale
Senile Lentigines
Aka: sun spot
A benign, localized brownish patch on the skin, often occurring in old age and usually in fair-skinned people with sun-damaged skin.
Seborrheic dermatitis
A benign, localized brownish patch on the skin, often occurring in old age and usually in fair-skinned people with sun-damaged skin. Also called age spot
Five things to look for during inspection:
Color
Vascularity
Flaking
Scaling
Odor
Plaque
a localized abnormal patch on a body part or surface and especially on the skin
Papule
A small, solid, usually inflammatory elevation of the skin that does not contain pus
Wheal
A raised, itchy (pruritic) area of skin that is sometimes an overt sign of allergy. Create a wheal under the skin when giving a TB shot.
Macule
A macule is a change in surface color, without elevation or depression
Petechiae
A minute reddish or purplish spot containing blood that appears in skin or mucous membrane as a result of localized hemorrhage.
Vesiclea
A small circumscribed elevation of the epidermis containing a serous fluid; a small blister
Purpura
A hemorrhagic disease characterized by extravasation of blood into the tissues, under the skin, and through the mucous membranes, and producing spontaneous bruises, ecchymoses, and petechiae (small hemorrhagic spots)on the skin.
Pustule
A small inflamed skin swelling that is filled with pus; a pimple or blister.
Crust
An outer layer or coating formed by the drying of a bodily exudatesuch as pus or blood; a scab.
Erosion
Superficial destruction of a surface by friction, pressure, ulceration,or trauma.
Nodule
A small mass of tissue or aggregation of cells, can be detected by touch
Tumor
An abnormal growth of tissue resulting from uncontrolled,progressive multiplication of cells and serving no physiological function; a neoplasm.
Bulla
A blister; a circumscribed, fluid-containing, elevated lesion of theskin, usually more than 5 mm in diameter.
Cyst
An abnormal closed epithelium-lined cavity in the body, containing liquid or semisolid material.
Scale
A thin flake or compacted platelike structure, as of cornified epithelialcells on the body surface.
Lichenification
Thick, leathery skin, usually the result of constant scratching and rubbing.
Keloid
A sharply elevated, irregularly shaped, progressively enlarging scar due to excessive collagen formation in the dermis during connective tissue repair.
Excoriation
An injury to a surface of the body caused by trauma, such as scratching, abrasion, or a chemical or thermal burn
Ulcer
A site of damage to the skin or mucous membrane that is characterized bythe formation of pus, death of tissue, and is frequently accompanied by aninflammatory reaction.
Patch
A patch is a large macule equal to or greater than either 5 or 10 mm
Pressure ulcer
Localized injury to the skin, usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction.
Contusions
An injury, as from a blow with a blunt instrument, inwhich the subsurface tissue is injured but the skin is not broken; bruise.
Abrasions
Scraped spot or area; the result of rubbing
Avulsions
The forcible tearing away of a body part by trauma or surgery.
Lacerations
The act of tearing. Ex: a torn, ragged, mangled wound.
Punctures
The act of piercing or penetrating with apointed object or instrument; a wound so made
In terms of skin lesions, what 3 things should you look for?
1) Anatomic location and distribution
2) Patterns and Shapes
3) Types of skin lesions
Linear
Lesions distributed along or resembling a line.
Polycyclic
merged circles
example: (psoriasis)
Serpiginous
Lesions with a wavy or serpent-like appearance.
Annular
Lesions with a ring-like configuration.
Iris/Target
A series of concentric rings. These have a dark or blistered center.
Grouped/Clustered
Lesions that cluster together.
Generalized
Covers most of body, without intervening normal skin.
Gyrate
are lesions that are coiled or twisted
Oval/Round
self explanatory..
Singular/Discrete
areas separated by normal skin
Confluent
are lesions that run together
Examples: Urticaria
Zosteriform
are arranged in a linear manner along a nerve route
Examples: herpes zoster