Chapter 33 - Skin Integreity And Wound Care Flashcards
What’s the body’s largest organ and how much does it weigh?
The largest organ is skin and it weighs 15% of total body weight
What’s the physiology if the skin?
Functions of the skin: Protection, body temperature regulation, psychosocial, sensation, vitamin D production, immunologic, Absorption, Elimination
What’s the two layers of skin?
The epidermis and the dermis
How long does it take for the epidermis to regenerate?
4-6 weeks
What is contained in the dermis?
Blood supply, nerve endings, sebaceous glands, hair follicles, collagen fibers and elastin fibers
True or false, Skinny and very obese people are more susceptible to skin injuries?
True
What types of wounds are there
Intentional or unintentional
Open or closed
Acute or chronic
Partial thickness, full thickness , complex
What is hemostasis?
The process that prevents and stops bleeding. It involves series of steps including blood vessel constriction, platelet plug formation, and blood clotting, to seal a wound and prevent further blood loss.
What is inflammatory?
Vasodilation, WBC ( leukocytes and macrophages move to the wound )
What is proliferation?
The process where new skin cells grow, new blood vessels form, collagen is made, and a type of tissue called granulation tissue forms to help build scar tissue
What is maturation?
Collagen remodeling, scar tissue becomes a flat , thin, white line
What is primary intention in wound healing ?
Is when the edges of a wound are brought together ( like in a surgical incision ). The wound heals with minimal scarring and risk of infection is low
What is second intention in wound healing?
This is seen in wounds such as burns and severe cuts, these injuries does not have the edges brought together. The wound heals from the inside out, filling with scar tissue. This type of healing takes long and has a higher risk of infection and may lead to permanent loss of tissues functions.
What are the local factors affecting wound healing?
Pressure, desiccation ( dehydration ), maceration ( over-hydration , trauma, edema, infection, excessive bleeding, necrosis, death of tissue, presence of biofilm ( thick grouping of microorganisms )
How does age play a role in wound healing?
Children and healthy adults heal more rapidly
How does circulation and oxygenation play in affective wound healing?
Adequate blood flow is essential for promoting quality wound healing
What nutrition do you want to recommend for your patients to promote positive wound healing?
Patients needs 1500 kcal/day for skin and wound healing
Vitamin A,C, calories and protein to heal
Malnourished patients do not have good wound healing
Corticosteroid drugs and postoperative radiation therapy may do what to healing
Delaying healing for the patient
What are postop patients at greatest risk for after surgery
Assess post op patients after surgery’s due to being increase risk for Hemorrhaging internal or external risk 24-48 hours after surgery/injury
What are some signs of an infected wounds?
Erythema, increased amount of wound drainage, change in appearance of the wound drainage ( thick, color, odor ), peri wound warmth, pain, edema. Fever, tenderness, pain, elevated WBC, wound edges inflamed, drainage is present odor, purulent-yellow, green, brown color)
What is Dehiscence?
Partial or total separation of wound layers
What does Evisceration?
Protrusion of visceral organs through a sound opening
What is the two types of Fistula
Tunneling - channel that extends in any directions from the wound through subcutaneous tissue
Undermining - tissue destruction underlying intact skin along wound margins
What is the BRADEN scale used for and what is a good score for the Braden scale?
The Braden scale is a risk assessment for pressure injuries and the lower the score indicates higher risk for pressure ulcer development
