chapter 32 Flashcards
factors that effect skin integrity
age
the amount of underlying tissue
illness conditions
what is a wound
a break or disruption in the normal integrity of the skin and tissues
how does wound repair occur
primary intention
secondary intention
tertiary intention
what is a primary intention
minimal tissue loss
what is a secondary intention
the wound has edges that are not well approximated
require more tissue replacement
take longer to heal
the tertiary intention
delayed primary closure
left open for several days to allow edema or infection resolve for fluid to drain and then are closed
what are the phases of wound healing
phase one: hemostasis
phase two: inflammatory response
phase three: proliferation phase
phase four: maturation phase
what is a scar
an avascular collagen tissue that does not sweat, grow hair, or tan in sunlight
what is phase one: hemostasis
occurs immediately after the initial injury
blood vessels involved constrict to allow blood clotting to be through the platelet activation and clustering
what is phase two inflammatory response
follows hemostasis and lasts about 2 to 3 days
WBC move to the wound
leukocytes arrive first to ingest bacteria
then macrophages 24 hours after
what is what three proliferation phase
lasts for several weeks
new tissue is built to kill wound space, through the action of fibroblasts
what is the phase for maturation phase
the final stage of healing
begins about 3 weeks after the injury - continues for months or years
collagen deposited
new collagen is still deposited and compressing blood vessels and forming a scar
infection
patients immune systems fail to control the growth of microorganisms
hemorrhage
slipped suture, a dislodged clot at a wounds site, infection or erosion of a blood vessel by a foreign body
dehiscence
partial or total separation of wound layers as a result of excessive stress on wounds that are not healed
evisceration
a complication of dehiscence. occurs in the abdominal it completely separates, with protrusion of viscera through the incisonal area
fistula
the abnormal passage from an internal organ or vessel to the outside of the body
what is a pressure ulcer (pressure injury)
localized damage to the skin and underlying tissue that usually occurs over a bony prominence
what are factors in pressue injury development
external pressure
friction and shear
what are common supine position bony prominences
occipital bone scapula vertebrae sacrum coccyx calcaneus
what are common prone position bony prominences
frontal bone mandible humerus sternum tuberosity of pelvis patella tibia
what are common sims positions bony prominences
scapula ribs iliac crest greater trochanter of femur lateral knee lateral malleolus medial malleolus
what are the risks for pressure injuries
Aging skin Vascular disorders Obesity Immobility and incontinence Diabetes Skin friction Poor nutrition Reduced RBC's (anemia) Edema Sensory deficits Sedation
what are the warning signs of a pressure ulcer
blanching of skin
skin can feel warm
what is the Braden scale
assess patients for pressure ulcers
low risk: 22-23
less risk: 19-21
high risk: < 18
what is a type one pressure ulcer
skin is intact
nonblanchable redness
swollen tissue
darker skin - may appear blue/purple
what is a type two pressure ulcer
partial-thickness epidermis and the dermis superficial ulcer abrasion or ulcer - no fatty tissue is visible
what is a type three pressure ulcer
full-thickness SKIN loss damage to necrosis or subcut tissue no exposed muscle or bone ulcer extended down to the underlying fascia but not through it deep crater without tunneling
what is a type four pressure ulcer
full-thickness TISSUE loss
destruction of tissue
damage to muscle and bone
deep pockets of infection and tunneling
what is an unstageable pressure ulcer
when the stage cannot be determined due to eschar or slough covering the visibility of the wound making the depth unknown.
prevention of pressure ulcers
relive pressure
proper nutrition
skin hygiene
repositioning
what is a skin assessment
inspection and palpation used to assess the integumentary system
