Ch 35- Skin Integrity & Wound Healing Flashcards
Maceration
softening and breaking down of skin resulting from prolonged exposure to moisture
Dehiscence
splitting or bursting open of a pod or wound (no organs coming out)
- Separation of one or more layers of wound tissue
Evisceration
uncontrolled exteriorization of intraabdominal contents through the dehisced surgical wound outside of the abdominal cavity.
(Organs coming out of wound)
Integumentary system
- largest organ of the body
- protects internal organs
- Helps maintain health and wellness
Braden scale -
The results guide plan of care to prevent skin breakdown
- focused assessment
- targets high risk clients
- assigned risk score based on
- sensory perception
- moisture
- activity
- mobility
- nutrition
- friction
- shear
Common interventions for wound prevention
- keeping skin free of irritants
- keeping skin clean
- optimizing nutrition and hydration
- repositioning
- massaging
Existing wound assessment
they have an existing wound
Document:
-Location (in anatomical terms)
- size (length, width, depth)
- appearance (Open or closed, sutures, wound color, condition of wound bed, skin around wound)
- drainage (Color, consistency, amounts, odor)
- patient responses (pain, discomfort, itching)
Eschar
is a collection of dead tissue within the wound that is flush with skin surface. Thick, hard, and black and brown
Aka
unstageable pressure injury
Slough
Tan, Yellow, gray, green, or brown necrotic tissue in the wound bed
it is usually wet, but can be dry
Usually soft, stringy, and pale yellow or gray
Exudate
Drainage
Xerosis
Dry skin
Rough, dry skin with that may have scales or small cracks.
Ischemia
Lack of oxygen to area
Superficial wounds
Involve only the epidermal layer of the skin. The injury is usually the result of friction, shearing, or burning.
Partial thickness wounds
Extend through the epidermis but not through the dermis
Full thickness wound
Extend into the subcutaneous tissue and beyond, (potentially to the bone)
Phases of healing
*Inflammatory phase- cleansing
(two major processes: hemostasis and inflammation) 1-5 days
- proliferative phase - granulation
(fibroblasts migrate to the wound where they form collagen) 5-21 days - maturation phase - epithelialization
(Aka remodeling phase) scar tissue
3-6 months
Epithelialization
Phase of wound healing that describes collagen fibers breaking down and remodeling
Primary causes of maceration
- fever
- incontinence
What Types of scheduled hygiene are provided in healthcare facilities?
- hourly rounds
- early morning care
- morning care
- afternoon care
- hour of sleep care
PICOT
Pressure injury and the poorly nourished older adult
Excoriation
Superficial wound, usually self-inflicted due to excessive scratching or mechanical force
Contusion
A closed wound caused by blunt trauma, may be referred to as a bruise or ecchymotic area
Phases of healing
- Inflammatory phase - cleansing
- proliferative phase -granulation
- maturation phase - epithelialization
Types of healing
-regenerative/epithelial healing: occurs when a wound affects only the epidermis and dermis, no scar.
-primary intention healing:
Has edges that will approximate closed, no tissue loss
-secondary intention healing:
When there is tissue loss, and the wound edges are not able to close together.
-Tertiary intention healing: aka delayed primary closure, occurs when two surfaces of granulation tissue are brought together.
