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NR 224 Exam 2: Chapter 48 - Skin Integrity and Wound Care

Pressure UlcersPressure ulcers, also known as bedsores or decubitus ulcers, are localized injuries to the skin and underlying tissue typically over a bony prominence. These injuries are often caused by prolonged pressure, shear (a force parallel to the skin), friction (from dragging), and moisture. Key factors contributing to the development of pressure ulcers include ischemia (reduced blood flow), which can lead to tissue death, and the inability of skin to blanch (when red tones are absent), which is not always visible in patients with darker skin tones.

Older adults and patients with decreased levels of consciousness are particularly at high risk for developing pressure ulcers due to their immobility and inability to sense discomfort that prompts repositioning. Additionally, incontinence can lead to maceration (softening and breaking down of skin) and subsequent skin breakdown. To prevent this, the use of incontinence cleansers, keeping the skin dry, and applying moisture barrier ointments are recommended.

Types of Wounds

• Contusion: A closed wound, commonly known as a bruise, resulting from a blow to the skin that causes bleeding underneath but does not break the skin.
• Laceration: An open wound characterized by jagged, irregular edges that may occur due to trauma.

Types of Wound Drainage

• Serous: Clear, watery plasma that is often seen in the early stages of inflammation.
• Serosanguineous: A mixture of clear and red blood, indicating that the wound is healing but still contains some blood.
• Frank Blood: Fresh, red blood often seen in wounds that are actively bleeding.
• Purulent: Thick, milky drainage that typically indicates infection; it contains white blood cells, bacteria, and tissue debris.

Traction and Skeletal Support

• Skeletal Balance Suspension Traction: This type of traction is used to maintain the proper alignment of a fractured bone by applying a continuous pulling force, which helps shift the weight of the immobile patient.
• Bucks Traction: Commonly used for patients with hip fractures, this traction restricts movement to allow the bone to heal properly.
• Halo Brace: A type of brace that stabilizes the cervical spine; patients with a halo brace can often ambulate while wearing it.

Nutrition and Skin ObservationProper nutrition is essential for maintaining skin integrity and promoting wound healing. Regular observation of the skin, especially for patients who are up and walking or frequently changing positions, is crucial in identifying early signs of skin breakdown. Ensuring that the skin is kept clean, providing appropriate continence care, and lifting patients rather than dragging them to prevent friction are all important preventive measures. Additionally, elevating the heels and conducting risk assessments can help prevent pressure ulcers.

Pressure Ulcer Stages

• Stage I: Non-blanchable redness on intact skin. The skin may feel warmer or cooler than the surrounding tissue, and the patient may report pain. Important: Do not massage the reddened area as this can exacerbate the injury.
• Stage II: Partial-thickness skin loss involving the epidermis and dermis. The ulcer may appear as a shallow, open wound with a red-pink wound bed, or as an intact or ruptured blister. There is no presence of slough (dead tissue that appears yellow or white).
• Stage III: Full-thickness tissue loss involving damage or necrosis of subcutaneous tissue. Subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed. Slough may be present, and the wound may have drainage or signs of infection, such as purulent discharge.
• Stage IV: Full-thickness tissue loss with exposed bone, muscle, or tendon. Slough or eschar (black, necrotic tissue) may be present, and there is often purulent discharge. These wounds heal by scar formation, a process that can be prolonged and complex.