ch 33 skin integrity & wound care Flashcards
abscess
collection of infected fluid that has not been drained
biofilm
a thick grouping of microorganisms
debridement
cleaning away devitalized tissue & foreign matter from a wound
dehiscence
separation of the layers of a surgical wound; may be partial, superficial, or a complete disruption of the surgical wound
dermis
layer of the skin below the epidermis
desiccation
dehydration; the process of being rendered free from moisture
epidermis
superficial layer of the skin
epithelialization
stage of wound healing in which epithelial cells form across the surface of a wound; tissue color ranges from the color of “ground glass” to pink
erythema
redness of the skin
eschar
thick, leathery scab or dry crust that is necrotic and must be removed for adequate healing to occur
evisceration
protrusion of viscera (organs) through an incision
exudate
fluid that accumulates in wound; may contain serum, cellular debris, bacteria, & wbc
fistula
an abnorm passage from an internal organ to the skin or from one internal organ to another
friction
occurs when 2 surfaces rub against each other; the resulting injury resembles an abrasion & can also damage superficial blood vessels directly under the skin
granulation tissue
new tissue that is pink/red in color & composed of fibroblasts & small blood vessels that fill an open wound when it starts to heal
hematoma
localized mass of usually clotted blood
ischemia
deficiency of blood in a particular area
maceration
softening through liquid; overhydration
negative pressure wound therapy
NPWT
pressure injury
1) localized damage to the skin & underlying tissue that usually occurs over a bony prominence or is related to the use of a (medical or other) device
2) any lesion caused by unrelieved pressure that results in damage to underlying tissue; formerly known as pressure ulcer
purulent drainage
comprised of wbc, liquefied dead tissue debris, & both dead & live bacteria
sanguineous drainage
the initial discharge produced after an injury or an open wound where the skin is broken
scar
connective tissue that fills a wound area
serosanguineous drainage
mixture of serum & rbc
serous drainage
composed of clear, serous portion of the blood & from serous membranes
shear
when tissue layers move over the top of each other, causing blood vessels to stretch and break as they pass through the subcutaneous tissue
subcutaneous tissue
underlying layer that anchors the skin layers to the underlying tissue of the body
vasoconstriction
the narrowing (constriction) of blood vessels by small muscles in their walls
vasodilation
the dilatation of blood vessels, which decreases blood pressure
what are the functions of the skin
protection
body temp reg
psychosocial
sensation
vit d produc
immunologic
absorption
elimination
resistance to injury is affected by…
age, amt of underlying tissues; & illness
children less than 2 yo
-thinner & weaker skin
-easily injured & subj to infection, increased risk for dehydration
older adults
-circulation & collegen formation impaired
-decreased elasticity
-increased risk of tissue damaged from pressure
_____ _____ during illness causes dehydration & predisposes skin to breakdown
fluid loss
_____ causes increased risk for excoriation & open wounds
jaundice
intentional wounds
e.g. surgical incisions
unintentional
traumatic
neuropathic/vascular
occur when a patient with the poor neurological function of the peripheral nervous system has pressure points that cause ulceration through the epidermal and dermal tissue layers
pressure-related wounds
classification of wounds
-open vs closed
-acute vs chronic
-partial thickness, full thickness, or complex
contusion
bruise
abrasion
superficial injury
laceration
e.g. a cut caused by glass (no skin is missing)
puncture
a type of cut that is made when a sharp object, like a nail, goes through the skin and into the tissue underneath (e.g . bite)
penetrating
occurs when a foreign object pierces the skin and enters/remains in the body creating a wound
avulsion
a forcible tearing off of skin or another part of the body, such as an ear or a finger
irradiation
impact of energetic particles or photons
venous ulcer
leg ulcers caused by problems with blood flow (circulation) in your leg veins
arterial ulcer
a painful, deep sore or wound in the skin of the lower leg or foot due to lack of blood flow to the area
diabetic ulcer
open sore or wound that occurs in approx 15% of pts with diabetes, and is commonly located on the bottom of the foot
wound healing principles
-careful hand hygiene
-systemic process
-adequate blood supply
-wound is clean
-extent of damage and state of health
-proper nutrition
hemostasis (wound healing stage)
-immediate after injury
-blood vessels constrict and clotting begins
-exudate is formed, causes swelling & pain
-increased perfusion, causes heat & redness
-platelets stimulate other cells to migrate to injury
inflammatory phase
-lasts 2-3 days
-wbcs move to the wound, ingest debris, release growth factors to attract fibroblasts
-exudate cont to form and accumulate
-generalized body response to the injury
proliferation phase
-lasts for several weeks
-new tissue is built by fibroblasts to fill the wound space
-capillaries grow across the wound space
-thin layer of epithelial cells forms across the wound
-granulation tissue forms a foundation for scar tissue
maturation phase
-final stage (3 weeks after injury months-years)
-collagen is remodeled
-new collagen is deposited, compressing the blood vessels, which creates scar tissue
-scars do not sweat, grow hair, or tan
local factors affecting wound healing
-pressure
-desiccation (the removal of moisture from something)
-maceration (the process of skin softening and breaking down due to prolonged contact with moisture that is usually not present on the skin)
-trauma
-edema
-infection
-excessive bleeding
-necrosis
-presence of biofilm
-primary vs secondary intention
systemic factors affecting wound healing
-age
-circulation & oxygen
-nutritional status
-wound etiology
-health status
-immunosuppression
-medication use
-adherence to treatment plan
-didn’t heal acronym
wound complication
-infection
-hemorrhage (the release of blood from a broken blood vessel, either inside or outside the body)
-dehiscence
-evisceration
-fistula formation (abscess)
mechanisms in pressure injury development
-external pressure
-friction or shearing forces
-microclimate
stages of pressure injuries
stage 1: nonblanchable erythema of intact skin
stage 2: partial-thickness skin loss w exposed dermis
stage 3: full-thickness skin loss, not involving underlying fascia
stage 4: full-thickness skin & tissue loss
unstageable: obscured full-thickness skin & tissue loss, eschar
deep tissue pressure injury: persistent non-blanchable deep red, maroon, or purple discoloration
preventing pressure injuries
-assess daily
-cleanse
-protect (from excess moisture)
-minimize friction/shearing forces
-positioning, turning
-support surfaces
-nutritional supplements
-improve mobility & activity
serous
clear, thin, & watery fluid
serosanguineous
thin & watery w light red or pink hue
sanguineous
bright red, fresh blood (may be hemorragic)
purulent
thick, opaque & odorous build-up from infection
wound dressing for maintaining moisture
tegaderm transparent film
wound dressing for absorbing moisture
-hydrocolloid dressing
-alginate dressing
-foam dressing (mepilex)
wound dressing for adding moisture
hydrogels
types of wound dressings for securement
-roller bandages (kerlex, ACE wrap); should be spiral or figure-8 wrapped to avoid compression
-binders (abdominal, chest)
pressure injury drsg changes are usually a _________ procedure
sterile
remove old dressing
-assess the wound, measure
-note the drainage, type of tissue to wound bed, etc…
cleanse the wound
-new gauze for each wipe
-clean to dirty - center of wound to the outside w each wipe
-irrigation w normal saline (NS), if ordered
-dry in same manner w gauze
open systems wound drains
penrose drain (a soft, flexible rubber tube that drains fluid away from a wound)
close systems wound drains
-jackson-pratt drain (closed-suction medical device that is commonly used as a post-operative drain for collecting bodily fluids from surgical sites)
-hemovac drain (drainage tube, larger and can hold more fluid than jp drains)
-negative pressure wound therapy (wound vac)
applying heat
-dilates perpipheral blood vessels
-increases tissue metabolism
-reduces blood viscosity & increases capillary permeability
-reduces muscle tension
-helps relieve pain
applying cold
-constricts peripheral blood vessels
-reduces muscle spasms
-promotes comfort
safety of application of hot or cold treatments
-15-20 min at a time
-never apply excess pressure
-never place the body on top of material, rather place the material on top of the body area
