Exam 4 Tissue Integrity and Wound Care Flashcards
What does the concept of tissue integrity deal with?
damage done to the epidermal and dermal layers of epithelial tissue; impaired skin integrity will focus on the varying levels of damage to one or more of those groups of cells
What are the causes of skin alterations?
very thin and very obese people are more susceptible to skin injury- fluid loss during illness causes dehydration, skin appears loose and flabby; excessive perspiration during illness predisposes skin to breakdown; jaundice causes yellowish, itchy skin; diseases if the skin, such as eczema and psoriasis, may cause lesions that require special care
What are the types of wounds?
intentional or unintentional;
open or closed; acute or chronic; partial thickness, full thickness, complex
What are the principles of wound healing?
intact skin is first line of defense, CAREFUL HAND HYGIENE, adequate blood supply, normal healing promoted when the wound is free of foreign material, proper nutrition aids in wound healing
What are the phases of wound healing?
hemostasis, inflammatory, proliferation, maturation
What happens in hemostasis phase of wound healing?
occurs immediately after injury; involved blood vessels constrict and blood clotting begins; exudate is formed causing swelling and pain; increased perfusion results in heat and redness; platelets stimulate other cells to migrate to the injury to participate in other phases of healing
What happens in the inflammatory phase of wound healing?
follows hemostasis and lasts about 4 to 6 days; WBCs move to wound; macrophages enter wound area and remain for an extended period; they ingest debris and release growth factors that attract fibroblasts to fill in the wound; pt has generalized body response
What happens in the proliferation phase of wound healing?
begins within 2 to 3 days of injury and may last up to 2 to 3 weeks; new tissue is built to fill the wound space through the action of fibroblasts; capillaries grow across the wound; a thin layer of epithelial cells form across the wound; granulation tissue forms a foundation for scar tissue development
What happens in the maturation phase?
final stage of healing; begins about 3 weeks to 6 months after injury; collagen is remodeled; new collagen tissue is deposited; scar becomes flat, thin, white line
What are local factors that affect wound healing?
desiccation, maceration, trauma, edema, infection, excess bleeding, necrosis, presence of biofilm
What to do for dishiscence?
usually abdominal wound; wound separates (sometimes by coughing or when they get out of bed); presents as burning; put patient back to bed and have them hold onto their abdomen; pull back dressing to look; put dressing back and take vital signs; immediately call surgeon to inform them-
interventions- some need surgery to fix, others need wound packed in hopes it will close and heal; prevention is key;
muscle is still intact
What to do for evisceration?
wound separates and muscle also separates, with protruding bowel; need to not touch it and keep it moist with sterile saline or sterile water, keep pt in bed, call surgeon,
What are the stages of pressure ulcers?
Stage 1-Stage 4, and also unstageable
What is a stage 1 pressure ulcer?
nonblanchable erythema of intact skin
What is a stage 2 pressure ulcer?
partial-thickness skin loss
