!! 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)
What are some of the Systemic Factors Affecting Wound Healing?
- age
- circulation and oxygenation
- nutritional status
- wound etiology
- health status
- Immunosuppression
- medication use
- adherence to treatment plan
What are the 4 types of wound complications?
- infection
- hemorrhage
- dehiscence and evisceration
- fistula formation
What are some Psychological Effects of Wounds?
- pain
- anxiety
- fear
- Impact on ADL’s
- change in body image
What are the 8 Factors Affecting Pressure?
Aging skin Chronic illnesses Immobility Malnutrition Fecal and urinary incontinence Altered level of consciousness Spinal cord and brain injuries Neuromuscular disorders
What’re the 2 Mechanisms in Pressure Injury Development?
External pressure compressing blood vessels
Friction or shearing forces tearing or injuring blood vessels
What are the stages of pressure ulcers?
Stage 1: red, no skin missing
Stage 2: blister, layer of skin missing
Stage 3: deep, red and full-thickness skin loss
Stage 4: can see bone. full-thickness skin, tunneling and undermining is present.
Unstageable: obscured full-thickness skin and tissue loss. more problematic.
What is a Deep tissue pressure injury?
persistent nonblanchable deep red, maroon, or purple discoloration. example is a hematoma.
What is eschar?
characterized by dark, crusty tissue at either the bottom or the top of a wound.
What is slough?
necrotic tissue that needs to be removed from the wound for healing to take place
How do you measure a pressure injury?
- size of wound
- depth of wound
- presence of undermining, tuning or sinus tract
- use a clock to say where it is
How do you clean a pressure injury/wound?
- clean with each dressing change
- use new gauze to clean form top to bottom
- use 0.9% saline solution
- dry area with gauze after cleaned
- report drainage or necrotic tissue
What are the 4 types of wound drainage?
- Serous: clear and watery
- Sanguineous: red blood cells, fresh blood
- Serosanguineous: combo of serous and sanguineous. light pink.
- Purulent: prescience of infection. White blood cells, dead tissue, musty and foul odor, can be from dark yellow to green color
How do you perform a wound assessment?
- Inspect for sight and smell; describe the colors
- Palpate for appearance, drainage, and pain
- Note drainage and what it looks like
- See if there’s any sutures, drains or tubes, and manifestation of complications
What are 3 types of wound dressings?
Telfa; waterproof, doesn’t stick to wound
Gauze dressings
Transparent dressings; can see wound through it
What are the two types of drainage systems?
Open: ex; Penrose drain
Closed: ex; Jackson-pratt drain and hemovac drain
What do you assess in a pressure injury assessment?
- risk assessment
- mobility
- nutritional status
- moisture and incontinence
- appearance of existing pressure injury
- pain assessment
Effects of applying heat:
- Heat increases inflammatory response
- Dilates peripheral blood vessels
- Increases tissue metabolism
- Reduces blood viscosity and increases capillary permeability
- Reduces muscle tension
- Helps relieve pain
Effects of applying cold:
- Constricts peripheral blood vessels
- Reduces muscle spasms
- Promotes comfort
- Decreases edema
- Helps relieve pain
- Cold decreases inflammatory response
- Has a level of non pharmacological pain relief
