Fund 50 - week 7 - integumentary Flashcards
Skin is largest
organ in body: Covers the entire body and continuous with mucous membrane
skin outer to inner
epidermis, dermis, subq.
Epidermis
Thin, barrier layer
Made of by epithelial cells
Keratinocytes provide strength and elasticity
Melanocytes gives skin pigment
Langerhan cells phagocytize foreign material and trigger immune response
Dermis (dermis has everything and sailing into the sun)
Contains collagen: elastic connective tissue to provide structural integrity
Blood vessels
Sweat and oil glands, hair follicle, sensory receptor
function of skin (skin IS TEPAD)
protection, thermoregulation, elimination, storage Vitamin D
Absorption
Sensation
Body image
Protection (the skin keeps what low for protection)
Physical barrier from infection
Low pH (4-6.8), inhibit microbes
Sebum on skin contains antimicrobials
Provides immunity
Epidermis: Langerhan cells
Dermis: macrophages and mast cell
Prevents excess fluid loss
Thermoregulation through (think sweating VV)
vasoconstriction
vasodilatation
perspiration
Elimination through (just think sweat)
sweat: it’s certain byproducts
electrolytes
water
Storage (skin is all blood and water)
stores 15% body’s water
stores 1/3 of the body’s blood supply
Synthesis of Vitamin D
when exposed to UV sunlight
Sensation and absorption
pain, pressure, temperature
absorb certain drugs
Definition of wound:
any break in the normal integrity of the skin and tissues
Classifications of wounds (was that wound intentional?)
Intentional vs Unintentional
Closed vs Open
Acute vs Chronic
Pressure injury stages
Intentional wounds:
Planned procedures
Surgeries, interventional radiology therapies, paracentesis, etc.
Done under sterile field
Wound edges clean and bleeding usually under control
Infection minimal and healing facilitated
Unintentional wounds
Accidental
Unexpected trauma (accidental cuts, stabbing, gunshot, burns)
Contamination of wound likely d/t unsterile environment
Bleeding may be uncontrolled
High risk of infection and longer healing time
Open wound through intentional or unintentional
means
Risk of infection dependent on intention (if intentional, its surgery so it’s sterile)
Closed wound
skin remains intact
Blunt force trauma: Falls, internal injury from a car accident, assault
Contusion, hematomas, ecchymosis
Acute wounds - how long to heal? (and ex. - the surgery was a cute one)
Heal within days to week
Progresses through the normal healing process Ex: surgical incision
Risk of infection < chronic
Chronic wounds - how long is healing? (and ex. of chronic wounds)
Healing is delayed >30 days
Healing stalled d/t infection, ischemia, continued pressure, or edema
Ex: diabetes ulcers, PVD, PI
Wound healing is a
process of tissue repair by physiological mechanisms that regenerate functioning cells and replace connective tissue with scar tissue.
phases of wound healing (it’s a BIPR remodel)
bleeding, inflammatory, proliferative, remodeling
phases of wound healing - hemostasis (hemo = blood)
Occurs immediately after tissue injury
Vasoconstriction and blood clotting via platelet and fibrin aggregation
Inflammation (followed by what?) The flame became white and macros attracted the growth
(main point - redness, heat, pain)
Followed by vasodilation (heat and redness) → ↑capillary permeability leaking of plasma→ exudate→ swelling→ loss of function
Chemicals on tissues attract WBCs
WBC and macrophages migrate to injured site
Macrophages also attract growth factors for regeneration of epithelial cells and fibroblasts to fill in wound
Inflammation is a NON-SPECIFIC
reaction
Not the same as infection; although infections may trigger inflammation
Intended to neutralize, control or eliminate offending agent
Chemical Response during inflammation (Local symptoms) which one causes the inflammation? (and also PKH)
the cytokines are what cause inflammation. Chemicals mediators such as histamine, kinins, prostaglandins released at site of injury also responsible for early stage vasodilation
Kinins attract neutrophils to area
Systemic Response during inflammation - and who is responsible for unleashing?
Fever*** caused by endogenous pyrogens released by neutrophils and macrophages
Chills occur in fevers d/t resetting of hypothalamic thermostat control
5 cardinal signs of inflammation***(flaming cardinals swap roles - SWP RL)
Redness, warmth, swelling, pain, loss of function
Proliferation - how long does it last? (it’s been a proliferative several weeks since granny is connecting with the blast)
(Granulation, fibroblastic, connective tissue)
Lasts several weeks
Maturation (Remodeling) when does it start? (the remodel will take about 3 weeks after we breakdown the collagen)
Begins 3 weeks after injury
Initial collagen broken down and remodeled into scar tissue to add strength to wound
Scar tissue is avascular, no sweat gland follicles or tan in sunlight
Contraction of wound
Level of contamination*** (clean to contaminated)
(contamination does not equal infection)***
Clean
Clean-contaminated
Contaminated
Infected wounds
>100,000 organisms per gram of tissue
Organisms present BEFORE procedure
signs of infection - when do they start? (infection 28 days later)
Usually occurs 2-7 days after injury or surgery
Contaminated wounds more likely to get infected
signs and symptoms of infection - think of abcesses (and don’t forget color)
Erythema, warmth and edema around the wound
Foul odor
Fever, malaise, ↑ WBC
Increased pain, delayed wound healing
Increased drainage esp purulent (yellow pus)
Changes in wound color (slough, eschar)
pressure injury
“A PRESSURE INJURY is a localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device”
The injury can present as intact skin or an open ulcer.
pressure injuries are a huge….(and how much pressure to cause one?
and growing problem in health care expenditures
Increases morbidity & mortality
Capillary pressure over bony prominences is only ~20 mm Hg-very low pressure
Excess pressure disrupts blood flow and causes ischemia
2 hours is max tissue can tolerate ischemia before tissue begins to die
stages of a pressure injury
STAGE 1
STAGE 2
STAGE 3
STAGE 4
SUSPECTED DEEP TISSUE INJURY
UNSTAGEABLE PRESSURE INJURY
Devices Related PI That Can Be Staged (my ears, nose and throat on stage)
Behind ears from nasal cannula
Nasogastric tubes
Endotracheal tubes
devices related to PI - Mucosal Membrane Pressure Injury - can or cannot be staged?
Found on mucous membranes with a history of medical device at location of injury
Due to the anatomy of the tissue these injuries cannot be stage
pressure injury stage I (and what about the temp?)
skin is intact
Non-blanchable erythema
Not maroon or purple (Deep tissue injury)
Skin intact
Over bony prominence or device related
Area may be painful
Warmth or firmness compared to adjacent area
Difficult or assess in patients with dark skin tone or areas of hyperpigmentation
PI stage 2 (color and what level of skin is exposed?)
Partial thickness skin loss with exposed dermis
Wound bed viable, shallow, pink or red and moist
Intact serum filled or ruptured blister
No adipose tissue, granulation tissue, slough or eschar
May be mistakenly used to describe skin tears, burns, maceration, excoriation, incontinence associated dermatitis or, abrasions
PI stage 3 (there are 3 stages for a fat granny, but fascists, muscle, and bone tend to be elsewhere)
Full thickness skin loss
Adipose and granulation tissue visible in the ulcer
Fascia, muscle, tendon, bone not visible
PI stage 4 (everyone is on stage at 4, even ebola - BUT one isn’t completely covering)
Full thickness tissue loss
Exposed bone, tendon, muscle, tendons, ligaments
Epibole (rolled around edges) undermining and/or tunneling common
Slough or eschar may be present but does not completely obscure wound bed
May cause osteomyelitis if bone exposed
pressure injury healing stage 4 (4 stages of my scar)
Healing Stage 4 filled with Scar Tissue – made of protein/collagen tightly woven together
DIFFERENT from original tissue– will always be a Stage 4
(Chart as a Healing Stage 4 – Not a Stage 2 !!! No reverse staging)
pressure injury - Stage 4 PI reopened
though shallow, it is not called stage 2 (no dermis, fat or muscle inside) chart it as “reopened Stage 4”
PI unstageable**
UNSTAGEABLE PRESSURE INJURY
Obscured full-thickness tissue loss
Extent of tissue damage cannot be terminated d/t obscurity from slough or eschar
If slough or eschar removed (black stuff) from unstageable, it always reveals stage 3 or 4 PI
pressure injury - deep tissue***(deep tissue deep purple)
Persistent nonblanchable deep red, maroon, or purple discoloration
Result of intense, prolonged pressure and shearing at bony prominence
May rapidly reveal the actual extent of tissue injury or resolve without tissue loss
Difficult to detect in dark skin tones (compared to adjacent tissue, may be painful and firm)
at risk PI (slakin and fresh)
Friction:
May be caused by wrinkled sheets, when patients drag their elbows, heels when repositioning themselves
Shear:
When one layer of tissue slides over another layer of tissue
Causes the skin to separate from its underlying layers
Blood vessels and capillaries damaged → impaired circulation
When patient partially sitting up in bed and person sliding down toward foot of bed; skin sticks to sheet
at risk PI immobility
Generalize weakness, chronic illness
Paralysis, neurological disorders, cognitive dysfunction
Bed or chair bound from spinal cord injuries
Pain
Sedated and comatose patient
Age related factors- Skin regenerates slowly, vulnerable to damage, cognitive impairment, nutrition, etc.
Hypoperfusion - impaired circulation
Extreme low weight – Less cushioning
Poor nutrition and hydration
factors that affect wound healing PI -local factors
Pressure and edema? (too swollen for blood flow)
interferes blood flow
biofilm and wound healing
Biofilm may contain multiple species of bacteria that shield against the immune system and antimicrobial agents
A reservoir for infection
factors that affect wound healing - nutrition - vitamins
Nutrition - wound healing requires adequate protein, carbohydrates, fats, vitamins and minerals, fluid intake
Fat (20-30% of intake): provides energy, protein sparing, vit A absorption
Adequate circulation - to carry oxygen and nutrients to wound
Fever affects wound healing how? (think sweating and bmr)
Wounds heal slower BECAUSE Increases BMR → increased O2/nutrient requirements
Diaphoresis on skin → maceration
factors that affect wound healing - Medication and Overall health (steroids and overweight)
Overly thin and obese people more susceptible to skin irritation and injury
Corticosteroids decrease the inflammatory process
Anemia - Add iron supplements
Smoking - provide smoking cessation program
Hypothermia - causes vasoconstriction
Impaired immune function and chronic illness: chemo agents, DM, prolonged abx, immunocompromised
obesity and wound healing (hiss at obese ppl)
Higher risk for dehiscence (when wounds opens up) d/t increased tension on skin
More vulnerable to pressure ulcers
Many obese people are actually malnourished despite their weight
diabetes and wound healing - how does hyperglycemia affect wound healing?
Hyperglycemia impairs wound healing and leads to higher risk of infection
Stress of wound increases blood sugar level
Peripheral arterial disease (perry art is thin and dead)
Limits activity d/t pain and leads to muscle atrophy
Thin tissue that is prone to ischemia and necrosis
Need to restore arterial blood perfusion for wound healing
Chronic venous disease (veins get edema)
Results in engorged tissue with high levels of waste products resulting in edema, ulceration, and breakdown
Contamination - it can spread from surrounding skin, that’s it
Wounds may get colonized from surrounding skin and local skin organisms
Internal sources like mucous membranes of GI tract and chronic wounds also colonized with bacteria
Subtle signs of contamination (bacteria has not invaded tissue)
Infection
Bacteria invades tissue → systemic response
Contamination - signs (this contamination is causing odor in the tunnel, and granny isn’t here.
When is it critically colonized?
include:
new foul odor, ↑drainage, new tunneling of wound, absent or friable granulation tissue, change in color of wound bed
No active infection until critically colonized (>100K per gram of tissue)
age related skin changes - what about sweat and why do they get cold?
Diminished activity of sebaceous and sweat glands→xerosis (itchy, red, dry, cracked, or fissured skin)
Epidermis and dermis thins and atrophies
Less effective thermoregulation d/t loss of lean body mass and subcutaneous tissue
age related skin changes - collagen
Changes in collagen/elastin fibers decreases elasticity and integrity → prone to tearing
Regeneration of healthy skin takes twice as long in an 80 year old vs 30 year old
Impaired tactile sensitivity
Blood vessels thinner and more fragile-bruise easily
nursing care plan - just look, that’s it
Skin Integrity – each time you change pt’s position, look for redness, swelling, heat, and break in the skin, especially over bony prominences.
nursing care plan interview (think paraplegic)
Inquire about skin/existing skin condition, mobility, nutrition, pain, elimination continence
nursing care plan - inspect where? ***and what is most important thing patient should do?
Under medical devices: oxygen delivery devices, catheters, orthopedic braces, casts, airway or ventilator tubing/tape, NG tube, cervical collars, chest tubes, bony prominence
If wound present: appearance, drainage, size, closed or open, odor
unhealthy), biofilm
Educate patient to report any changes or new onset of pain
wound assessment - what to measure and the q-tip
Measure dimensions
L X W X D
Assess for presence of tunneling/undermining using moistened Q-tip
Length-greatest length in cm (measure from head to toes)
Width-greatest width side to side
Depth-mark with Q-tip at deepest point and hold to ruler
wound assessment undermining (it’s literally just a mine)
Erosion under the wound edges, resulting in a large wound with a small opening
May have multiple directions
wound assessment - tunneling (the tunnels destroy fascists w/ abscesses)
Destruction of the fascial planes which results in a narrow passageway
Potential for abscess formation
Usually one direction
wound assessment - approximated (approximately together)
edges come together.
can be rolled or calloused
wound assessment - location
Describe location using anatomical terms
Non-healing wounds on feet usually d/t diabetes or PVD (peripheral vascular disease)
wound assessment odor
Odor - Foul smelling wounds indicate infection
wound characteristics and amount - drainage (SSSPP) seriously sang w/ blood, serosang, pur, and pursang.
Presence of biofilm
Exudate/drainage:
Serous
Sanguineous-bloody
Serosanguineous
Purulence
Purosanguineous-thick
wound assessment - palpate
Pain, discomfort over bony prominences/pressure points (sacrum, ischium, trochanters, heels, elbows, and the back of the head. Don’t forget to look between the toes)
Changes in temperature
Texture of skin
