Chapter 32: Skin Integrity Flashcards
4 Processes involved in wound healing
- hemostasis
- inflammatory phase
- proliferation phase
- maturation phase
2 categories of factors that affect wound healing
- local
2. systemic
9 local factors that affect wound healing
- pressure
- desiccation
- maceration
- trauma
- edema
- infection
- excessive bleeding
- necrosis
- biofilm
6 systemic factors that affect wound healing
- age
- circulation and oxygenation
- nutritional status
- wound etiology
- medications and health status
- Immunosuppression
6 factors placing person at risk for skin alterations
- Age
- Lifestyle variables (homosexuality, IV drug use, multple sexual partners, occupation w/ prolonged sun exposure, body piercings)
- Changes in health state (dehydration, malnutrition, paralysis, local nerve damage, circulatory insufficiency)
- Illness (diabetes)
- Diagnostic measures (GI series -diarrhea)
- Therapeutic measures (bed rest, casts, aquathermia unit, meds, radiation therapy)
6 factors to assess in skin assessment
- Appearance of Skin
- Recent changes in skin
- Activity/mobility
- nutrition
- pain
- elimination
4 types of wound complications
- infection
- hemorrhage
- dehiscensce and evisceration
- fistula formation
2 factors in Pressure Injury development
- external pressure
2. friction and shear
5 factors placing person at risk for pressure injury development
- immobility
- nutrition and hydration
- moisture
- mental status
- age
3 pressure injury risk assessment scales
- Norton Scale
- Waterlow Scale
- Braden Scale
Hemostasis
Vasoconstriction, platelet aggregation, and clot formation are part of the first phase of wound healing
Inflammatory Stage
the inflammatory phase, is marked by vasodilation and phagocytosis as the body works to clean the wound
Proliferative phase
In partial-thickness wounds, in the third phase, the proliferative phase, epidermal cells reproduce and migrate across the surface of the wound in a process called epithelialization
Maturation
Maturation is the final stage of full-thickness wound healing, in which the number of fibroblasts decreases, collagen synthesis is stabilized, and collagen fibrils become increasingly organized.
Avulsion
tearing of structure from normal anatomic position
laceration
tearing of skin with blunt or irregular instrument, tissue not aligned, often with loose flaps of skin
possible systemic reactions to wound
increase in temp increase in HR increase in resp rate anorexia vomiting musculoskeletal tension hormonal changes
Nutrition and wound healing
Vitamin A - collagen synthesis and epithelializiation
Vitamin B - cofactor of important enzyme reacitons
Vitamin C - collagen synth, capillary formatin, resistance to infeciton
Vitamin K - prothrombin synth
Zinc, copper, iron - collagen synth
Manganese - enzyme activator
proliferation phase alternate names
fibroblastic phase
regenerative phase
connective tissue phase
connective tissue that synthesize and secrete collagen and produce specialized growth factors responsible for inducing blood vessel formation and increasing number and movement of epithelial cells
fibroblasts
epidermal stripping
unintentional removal of epidermis with tape
hematoma
localized mass of usually clotted blood
risk factors for wound complications
obese smoking excessive coughing, vomiting, straining malnourished anticoagulants infection
dehiscence and evisceration response
- low fowlers
- cover exposed abdominal contents with saline moist sterile towels
- contact provider immediately
- NPO
with 2 hour repositioning, how long before a reddened area due to reactive hyperemia fades
60-90 minutes
what stage would a large intact serum filled blister be
stage 2
Focused critical thinking guide
- identify goal of thinking
- asses adequacy of knowledge
- pertinent circumstances
- prerequisite knowledge
- room for error
- time constraints - Address potential problems
- consult helpful resources
- Critique judgement/decision
Focused skin assessment
- appearnce of skin
- recent changes in skin
- activity/mobility
- nutrition
- pain
- elimination
skin assessment based on setting
acute care: on admission, reassess every shift and with any change in condition
long-term care: on admission then reassess weekly for 4 weeks, then quarterly and whenever condition changes
Home health care: on admission, then reassess at every visit
T-tube
T-shaped tube placed in common bile duct,, collects bile after gallbladder surgery
Braden scale
- mental status
- continence
- mobility
- activity
- nutrition
autolytic debridement
uses occlusive dressings, such as hydrocolloids, or transparent films, uses body’s own enzymes
