chap 32 Flashcards
epidermis
outermost portion of skin
function of epidermis
protective layer
dermis
second layer of skin
what does the dermis contain?
- connective tissue
- collagen
- nerves
- hair follicles
- immune cells
- blood vessels
subcutaneous tissue
anchors skin layers to underlying tissues
what does the subcutaneous tissue contain?
- adipose tissue
- connective tissues
function of subcutaneous tissue
stores fat, heat insulator, cushion
functions of skin
- protection
- temp regulation
- person identity
- sensation
- vitamin D production
- immunologic
- absorption
- elimination
four stages of wound healing
- hemostasis
- inflammatory phase
- proliferation phase
- maturation phase
hemostasis
- immediate
- blood clotting
inflammatory phase
- 2-3 days
- WBC enters
- macrophages release growth factors
proliferation phase
- several weeks
- fibroplastic connective tissue
- beefy red
- bleed easy
- granulated tissue
maturation phase
- 3 weeks after-years
- collagen
- scar forms
factors affecting wound healing
- pressure
- desiccation
- maceration
- trauma
- edema
- infection
- excessive bleeding
- necrosis
- biofilm
pressure
persisten pressure disrupts blood flow
desiccation
when skin is dry, causes crust to form and delays healing
maceration
- soft due to prolonged exposure to moisture
- “prune”
- risk for skin tears
- delays healing
partial thickness loss
part of dermis is severed
full thickness loss
entire dermis is severed
wound complications
- infection
- hemorrhage
- dehiscence
- evisceration
dehiscence
partial or total separation of wound layers
-has been stapled or sutured
evisceration
wound completely separates w/ protrusion of organ through incision
pressure injuries caused by
- pressure
- friction or sheer
risks for pressure injuries
- nutrition and hydration
- mental status
- immobility
- moisture
- age
protein
collagen forming and wound remodeling
calores
fuel for cell energy
vitamin C
- collagen synthesis
- capillary wall integrity
- immunological function
- antioxidant
- fibroblast function
vitamin A
- wound closure
- inflammatory response
- collagen formation
zinc
- collagen formation
- protein synthesis
- cell membrane and host defense
fluid
essential fluid environment for all cell function
vital nutrients for wound healing
- protein
- calories
- vitamin C
- vitamin A
- zinc
- fluid
stage 1 pressure injury
- intact skin
- non-blanchable
- painful
- firm or soft
- warmer or cooler compared to adjacent tissue
stage 2 pressure injury
- partial thickness loss
- shallow, open ulcer
- red, pink wound bed
- “blister-like”
- no slough
- shiny or dry shallow ulcer
stage 3 pressure injury
- full thickness tissue loss
- subcutaneous fat may be visible
- slough may be present
- no bone or muscle visible
stage 4 pressure injury
- full thickness tissue loss
- bone/muscle/tissue visible
- slough or eschar may be present
- tunneling
suspected deep tissue injury
- purple or maroon
- blood-filled blister
- mushy/boggy
- warmer or cooler compared to adjacent tissue
unstageable pressure injury
- full thickness loss
- ulcer covered by slough or eschar
- slough must be removed to promote healing
wound assessment
- location of wound
- note size of wound
- approximated?
- drainage
primary intention
- surgical incisions
- well approximated and risk of infection is low
- minimal scar
secondary intention
- not well approximated
- large open wound
- filled by scar tissue
- longer to heal
- loss of tissue function is often permanent
tertiary intention
- delayed primary closure
- wounds open for several days
transparent films
- stage 1, partial thickness
- minimal drainage
- allows visualization of wound
- maintain moist wound environment
- allow exchange of oxygen
hydrocolloid
- partial & full thickness wounds
- stage 2 and 3 pressure injuries
- reduces friction
- 3-7 days
hydrogel
- partial & full thickness wounds
- stage 2-4 pressure injuries
- necrotic wounds
- minimal exudate
- on infected wounds
alginates
- absorbs exudate
- partial and full thickness wounds
- stage 3 & 4 pressure injuries
- infected & non-infected wounds
- moderate to heavy exudate
foams
- partial & full thickness wounds
- stages 2-4 pressure injuries
- surgical wounds
- absorbs light to heavy amounts of drainage
antimicrobials
- partial & full thickness wounds
- stage 2-4 pressure injuries
- burns
- draining non-healing wounds
- reduce/prevent infection
collagen
- partial or full thickness wounds
- stage 3 pressure injury
- infected/noninfected wounds
- primary dressing over grafts & donor sites
- tunneling wounds
contact layers
- partial and full thickness wounds
- shallow dehydrated wounds
composites
- partial & full thickness wounds
- stages 1-4 pressure injuries
negative pressure wound therapy
- stage 3-4 pressure injuries
- draining and non-healing wounds
- stimulates increased blood supply and granulation
hemovac drain
- circular device is squeezed flat
- device expands as it fills with fluids
jackson-pratt drain
- closed-suction drain
- grenade-shaped bulb
heat therapy
- dilates blood vessels
- increases tissue metabolism
- reduces muscle tension
- relieves pain
cold therapy
- constricts peripheral blood vessels
- reduces muscle spasms
- promotes comfort
- controls bleeding
- decreases swelling
