32 Skin Integrity + Wound Care Flashcards
Factors that affect skin integrity
- age, amt of underlying tissues, + illness all affect resistance to injury
- nourished/hydrated body cells
- good circulation
which age groups have thin skin?
infants, kids under 2 yrs, and older adults
Wound
break or disruption of normal integrity of skin and tissues
Partial-thickness
all or portion of dermis is intact
Full-thickness
- entire dermis, sweat glands, + hair follicles are severed
- possibly exposed bone, tendon, or muscle
Unstageable
full-thickness loss where depth cannot be determined due to slough or eschar
-may involve deep tissue injury
Stages of Wound Healing
1 Hemostasis
2 Inflammatory Phase
3 Proliferation Phase
4 Maturation Phase
Hemostasis
occurs immediately after initial injury
- bld vessels CONSTRICT, clotting begins (pltlet activn + clustrng)
- bld vessels then DILATE to incr permeability (plasma + bld components leak into area, form EXUDATE)
- exudate buildup causes swelling+pain
- incr circ leads to heat + redness
Inflammatory Phase
- last 2-3 days
- WBC (leuk ingest bacteria + debri; + macrphg come later + stay longer + release growth factors)
- pain, heat, redness, swelling
- patient has incr temp, leukocytosis, + malaise
Proliferation Phase
- lasts several weeks
- GRANULATED TISSUE-new tissue built to fill the wound
- FIBROBLASTS are connectv tissue cells that synth + secrete collage + produce specialized growth factors
- –induce bld vessel formation + incr endothelial cells
- CAPILLARIES grow across the wound (bring O2 + nutrients)
- COLLAGEN synth peaks at 5-7 days
Maturation Phase
- 3 weeks after injury
- collagen is remodeled making the wound stronger + more like adjacent tissue
- scar becomes flat + thin
if 3 stages of wound healing are identified, then…
hemostasis occurs w inflammatory phase
if 3 stages of wound healing are identified, then…
hemostasis occurs w inflammatory phase
Nutrients for Wound Healing
requires adequate proteins, carbs, fat, vitamins, + minerals
- vit A C
- Zinc
Vitamins A + C for wound healing
for epithelialization + collagen synthesis
Zinc
for proliferation in cells
Zinc
for proliferation in cells
Dehiscence
partial or total separation of wound layers as a result of excessive stress on wounds that arent healed
Evisceration
most serious complication of dehiscence
-potrusion of a viscera
what to do when dehiscence occurs
cover wound area w sterile towels moistened w sterile 0.9% NaCl soln
- notify healthcare provider
- medical emergency
what to do when dehiscence occurs
cover wound area w sterile towels moistened w sterile 0.9% NaCl soln
- notify healthcare provider
- medical emergency
Pressure Injury
new term for pressure ulcer
- localized damage to skin + underlying tissue
- develop when soft tissue is compressed bw BONY prominence + external surface for prolonged period
- may occur fr soft tissue undergoes pressure w shear/friction
Risk Factors for pressure injury
- mobility + activity limitations are required conditions*
- poor skin hygiene
- diabetes mellitus
- diminished sensory perception/pain awareness
- fractures
- hx of corticoid therapy
- hx of pressure injury
- significant obesity or thinness
- term illness/dying process
- microvasc dysfunction
Stage 1 Pressure Injury
defined, localized area of intact skin w NONBLANCHABLE ERYTHEMA
- area may be painful, firm, soft, warmer, or cooler than surrounding skin
- color changes DO NOT include purple/maroon
Stage 2 Pressure Injury
involved partial-thickness loss of dermis
- presents shallow, open ulcer or ruptured/intact serum-filled blister
- fat is NOT exposed
- granulation, slough, eschar NOT present
Stage 3 Pressure Injury
full-thickness tissue loss
- subcutaneous fat may be visible
- epibole (rolled wound edges) may occur
- may have undermining, tunneling
- bone, tendon, muscle is NOT exposed
Stage 4 Pressure Injury
full-thickness tissue loss w exposed or palpable bone, cartilage, ligament, tendon, fascia, or muscle
-slough, eschar, epibole, undermining, tunneling may be present
Deep Tissue Pressure Injury
persistent non-blanchable maroon/purple color
Types of Wound Drainage
- serous drainage
- sanguineous drainage
- serosanguineous drainage
- purulent drainage
Serous Drainage
clear watery serous portion of blood fr serous membranes
Sanguineous Drainage
large number of RBC + looks like blood
bright red=fresh, darker=older
Serosanguineous Drainage
mixture of serum + RBC
-light pink to blood-tinged
Purulent Drainage
WBC, liquefied dead tissue debris, both dead + live bacteria
-thick, musty/foul odor, dark yellow to green color depending on causative agent
Open System Drains
1 Gauze
2 Penrose
Closed System Drains
1 Chest Tube
2 Hemovac
3 Jackson-Pratt
4 T-tube
Gauze
allows healing fr base of wound
-gauze dressing packed loosely so wound is allowed to drain
Penrose
drains blood + fluid
open drainage systm consisting of soft rubber tube that provides sinus tract
ex) drainage for abscess in ab surgery
Chest Tube
mediastinal placement to drain blood
- used after cardiac surgery
- different fr chest tube used in pleural space
Hemovac
neg-pressure suction device
-drains blood + fluid
Jackson-Pratt
bulb suction device to drain blood + fluid
T-tube
t shaped tube placed in the COMMON BILE DUCT
-collects bile after gallbladder surdery
open vs closed wound care
open wound
Wound Culture Collection
1 assess for pain 2 prep items, adjust bed, position 3 remove old dressing w clean gloves 4 inspect COCA 5 doff gloves + HH 6 clean wound using NONantimicrobial cleanser 7 don clean gloves 8 obtain swabs on culturette tube 9 use area that is free fr necrotic tissue, apply sufficient pressure to express fluid
