Wounds & Skin

Skin Assessment

100

There are a number of things to assess for when inspecting wounds. Name three.

Wound bed color, necrosis, eschar, slough, wound margins, swelling, bleeding, exudate, pain, sinus tracts/tunneling, a wound drain present

200

What are the signs and symptoms of wound infection?

Redness, warmth, swelling, pain, odor, purulent exudate

300

If you find a foreign body in a wound, especially metal (think rusty metal), what is something you should ask the patient in relation to their health history?

When was your last tetanus shot?

400

Before removing a dressing, you should inspect and assess the dressing for what? 

List two characteristics.

Drainage: Color, consistency, odor, degree of saturation (# of gauze saturated or diameter or drainage).

500

Assisting with this activity of daily living (ADL) provides a great opportunity to assess the integumentary system.

Name one nursing intervention that can be implemented during or after this ADL to maintain skin integrity.

Bed Bath

-mild cleansing agents that minimize irritation and dryness and that do not disrupt the skin’s “natural barriers.

-avoid using hot water, which increases skin dryness and irritation. 

-minimize dryness by avoiding exposure to cold and low humidity. 

-Dry skin is best treated with moisturizing lotions applied while the skin is moist after bathing. T

-skin should be kept clean and dry and free of irritation and maceration by urine, feces, sweat, or incomplete drying after a bath 

-Apply skin protection if indicated.

Skin Assessment Equity

100

What is the best lighting to use for patient's with more melanated skin tones?

•Use natural or halogen light sources when assessing for discoloration on a patient with darkly pigmented skin. Natural daylight is the best for assessment, however, strong direct lighting is another option. Avoid using fluorescent lighting because it gives a bluish tint to skin that interferes with accurate assessment of skin coloring. 

**VISUAL INSPECTION TO IDENTIFY PRESSURE INJURIES IS INEFFECTIVE IN DARKLY PIGMENTED SKIN**

200

True or False: A patient with darkly pigmented skin does not always have visible blanching

True. Patients with darkly pigmented skin cannot be assessed for pressure injury by examining only skin color 

300

Besides categories mentioned in the Braden Scale, name 3 things that can increase risk for pressure injury regardless of skin color.

• Nares: nasogastric (NG) tube, oxygen cannula

• Tongue and lips: oral airway, endotracheal tube

• Ears: oxygen cannula, pillow

• Drainage tubes

• Wound drainage

• Indwelling urinary drainage catheter

• Under orthopedic and positioning devices

400

Name at least one important indicator of early pressure damage to the skin in individuals with darker skin tones

Localized heat, edema, and changes in tissue consistency in relation to surrounding tissue (e.g., induration [hardness]), and pain are important indicators of early pressure damage to the skin in individuals with darker skin tone

500

True or False: Race influences susceptibility to skin damage 

False.

Racism is the risk factor, not race. Not all skin is equally assessed. There is evidence that stage 1 pressure injuries are UNDERDETECTED in individuals with darkly pigmented skin

Wound Terminology

100

Yellow, white tissue that adheres to the wound bed, liquefied or wet dead tissue

-AHRQ

Slough

200

Black or brown dried out dead tissue that adheres to the wound bed or edges

-AHRQ

Eschar (necrotic)

300

What is tunneling?

Tracts that extend out from the wound

--AHRQ

400

What is undermining?

A bigger area of tissue destruction than can be seen - it extended under the edge of the visible wound

-AHRQ

500

Describe the colors of serous, serosanguinous, and purulent drainage

Serous: clear to yellow, slightly thicker than water - think fluids from blisters. 

Serosanguinous - a combination of serous fluid and blood. It’s usually a light pink to red color. This is a sign that your body is healing the wound

Purulet - white, yellow or brown fluid. May have odor. Indicator of infection

Nursing Interventions

100

Name 1 nursing interventions that could address friction and sheer

• Consider applying a prophylactic dressing (e.g., polyurethane foam) to bony prominences (e.g., heels, sacrum) for the prevention of pressure injuries in areas frequently exposed to friction and shear.
• Keep skin clean and dry.
• Observe the patient’s skin for areas at risk for change in color or texture.
• Use lifting and transfer devices when available. Do not leave transfer devices under the patient after use unless the device is specifically designed for this purpose.
• For bedridden clients, shearing force can be reduced by elevating the head of the bed to no more than 30°

if this position is not contraindicated by the client’s condition. (For example, clients with respiratory disorders may find it easier to breathe in Fowler’s position.) When the head of the bed is raised, the skin and superficial fascia stick to the bed linen while the deep fascia and skeleton slide down toward the bottom of the bed. As a result, blood vessels in the sacral area become twisted, and the tissues in the area can become ischemic and necrotic.

200

Name 2 nursing interventions that could address moisture to maintain skin integrity.

• Keep skin clean and dry.
• Avoid leaving the patient on a bedpan for long periods of time.
• Create a continence management plan for the patient.
• Provide additional fluid for the patient with dehydration, elevated temperature, vomiting, profuse sweating, diarrhea, or heavily draining wounds.
• Monitor the patient for signs and symptoms of dehydration, including change in weight, skin turgor, urine output, or elevated serum sodium.
• Dispose of all soiled dressings, supplies, or single-use equipment in a waterproof bag.

300

Name three nursing interventions for a patient's skin who has decreased mobility

• Consider using a pressure-redistribution surface bed for the patient that cannot reposition self.  
  1. Consider the need for moisture and temperature control when selecting a support surface and cover.
  2. If the patient requires a pressure-redistribution surface bed, consider an appropriate pressure-redistribution surface for a bedside chair or wheelchair.
• Create a schedule for position changes.
• Avoid positioning the patient directly onto medical devices (e.g., oxygen tubes, drainage systems)
• Keep skin clean and dry.
• Observe the patient’s skin for areas at risk for change in color or texture.
• Observe the patient’s tolerance of position changes.
• Compare subsequent risk assessment scores.
• Establish turning frequency based on the characteristics of the support surface and the patient’s response.
• Report to the practitioner the need for additional consultations (e.g., wound care specialist, dietitian) for the high-risk patient.

400

Your patient has a 

NANDA of "Readiness for Enhanced Nutrition" with a 

NOC of "understanding how to diversify their intake to increase consumption of liquids and solids that promote skin growth and healing before discharge."

What is a NIC that could help the patient achieve their outcome?

How will you evaluate if the patient has met the outcome?

Patient education!

-Teach-back method

-Have patient keep a food diary and review the diary to see if intake includes a variety of liquids and solids that promote skin growth and healing.

500

There are known vitamins, minerals, nutrients, and other associated intake that promote skin health and healing. Name 2.

Fluids, protein, vitamins B and C, iron, and calories

Because an inadequate intake of calories, protein, vitamins, and iron is believed to be a risk factor for pressure injury development, nutritional supplements should be considered for nutritionally compromised clients. 

Pertinent labs: lymphocyte count, protein (especially albumin), and hemoglobin.

Pressure Injuries

100

What is a key indicator of a stage one pressure ulcer in white skin?

Non-blanchable errythema

200

Full thickness tissue loss is categorized as what stage?

Stage IV

300

When documenting a pressure injury, what dimensions of the wound do you need to measure?

Length

Width

Depth

400

Name 3 common sites where pressure injuries develop.

1. Sacrum

2. Buttocks

3. Heel

Foot

Elbow

Ischium (bottom sides of your pelvis)

Trocanter (hip joint)

Malleolus (ankle bones)

Knee

Ears

Scapula

500

There are a number of things you should inspect and palpate for when assessing skin over pressure points. Name 3.

•Inspect for skin discoloration

Tissue consistency (e.g., induration (firmness) or boggy (spongy) feel)

palpate for abnormal sensations.

•Palpate the discolored area for blanching.

•Inspect for pallor and mottling.

•Inspect for absence of superficial skin layers.

•Palpate for skin temperature differences (e.g., warmth or coolness)