!! Ch. 32: Skin Integrity Flashcards
What are the 7 functions of the skin?
Protection body temperature regulation Psychosocial- appearance of the skin. Ex; goosebumps Sensation Vitamin d production Immunologic Absorption Elimination
What’re some factors about the skin that can affect it?
- Unbroken/healthy skin and mucous membrane
- Resistance to injury
- nourishment and hydration
- Adequate circulation
What are some developmental considerations?
- In children<2 years, the skin is thinner and weaker than it is in adults
- An infant’s skin and mucous membranes are easily injured and subject to infection -As a person ages; the maturation of epidermal cells is prolonged, leading to thin, easily damaged skin.
- Circulation collagen formation is impaired
What’re some causes of skin alterations?
- Very thin and very obese people are more susceptible to skin injury
- excessive perspiration during illness predisposes skin breakdown
- jaundice
- diseases can cause lesions
What are the 4 categories for types of wounds?
- intentional or unintentional
- open or closed
- acute or chronic
- partial, full, or complex thickness
What are the 3 different types of wound thickness?
- Partial thickness: not all the way through to the bone
- Full thickness: all the way through the subcutaneous tissue to the bone
- Complex: varying different levels of thickness
What are 5 types of wounds?
Contusion: caused by a blunt instrument and may result in bruising or hematoma.
Abrasion: the rubbing or scraping of epidermal layers of skin.
Laceration: the tearing of skin and tissue with a blunt or irregular instrument.
Avulsion: the tearing of a structure from normal anatomic position
Incision: well-approximated edges and no signs of infection
What are the wound healing types? (3 intentions)
- Primary intention: The edges of the surgical incision are closed together with stitches or clips until the cut edges merge.
- Secondary intention: The healing of an open wound, from the base upwards, by laying down new tissue
- Tertiary intention: Occurs when a wound is initially left open after debridement of all nonviable tissue.
What are the principles of wound healing?
- Intact skin
- hand hygiene
- body responds systematically
- adequate blood supply
- normal healing when wound is free of bacteria
- extent of damage
- person’s health
- response to wound
What are the 4 phases of wound healing?
Hemostasis
Inflammatory
Proliferation
Maturation
What is the hemostasis phase?
- Occurs immediately after initial injury.
- The process of the wound being closed by clotting.
- liquid plasma is formed causing swelling and pain
- platelets stimulate other cells to go to injury site
- cant heal unless it stops bleeding
What is the Inflammatory phase?
- lasts about 2-3 days
- WBC’s move to the wound site.
- Macrophages enter the wound area and ingest debris/release growth factors that attract fibroblasts to fill in the wound.
- Damaged cells, pathogens, and bacteria are removed from the wound area.
- Wound is red, hot, and swollen.
What is the Proliferation phase?
- Lasts for several weeks
- a thin line of epidermal cells form across the surface of the wound in a process called epithelialization.
- Wound is rebuilt with new tissue that was made by fibroblasts
- capillaries grow across the wound
What is the Maturation phase?
- Final stage of healing
- beings 3 weeks after injury, continuing for months or years
- “Remodeling stage”
- When collagen is remodeled from type III to type I and the wound fully closes.
- scar becomes a flat, thin, white line
What are the 9 factors affecting wound healing?
Pressure Desiccation (dehydration) Maceration (overhydration) Trauma Edema Infection Excessive bleeding Necrosis Presence of biofilm (thick grouping of microorganisms)
