Integumentary Flashcards
Two layers
epidermis and dermis
Epidermis
exposed to the outside, basal layer is constantly regrowing and pushing to surface
Dermis
inner layer
strength + support + protection
capillaries, hair follicles, sweat glands
Skin purposes
protection + sensory perception
Edema vs. pitting edema
pitting edema = from excess fluid built up in body
edema = injury
two different causes of swelling
0-4+
Erythema
- redness, difficult to see in darker skin tones, palpate skin as well to look for warmth and texture changes
- Face, skin, pressure prone areas
- Indication: inflammation, vasodilation, sun exposure, elevated body temp
Shear
Sliding movement of skin and subcutaneous tissue when muscle and bone are not moving
- skin is not moving
Friction
Two surfaces moving across one another
Pallor
look particularly in the mucous membranes
- loss of color, grey in black skin tones
- anemia, shock, lack of blood flow
Cyanosis
bluish discoloration
- black skin tones = yellow-brown or grey
- nail beds, lips, mucosa
- hypoxia, impaired venous return
Pts at risk of impaired skin integrity
- older adults who have experienced a trauma
- spinal-cord injuries
- nutritional deficits
- long-term care facilities
- acutely ill or in hospice
- pts with DM
- incontinence
- pts in ICU
Pressure injury
pressure ulcer, decubitus ulcer, bedsore
Tissue ischemia
Pressure applied OVER a capillary (in the skin) exceeds normal capillary pressure
Necrosis
necrosis is the death of cells and tissues, often as a result of ischemia
Ischemia
loss of blood flow to tissues
Three major factors involved in pressure injury development
Pressure intensity
Pressure duration
Tissue tolerance = Low blood pressure, poor nutrition, aging, hydration status all affect tolerance
Blanchable
turns lighter when pressed and then erythema returns
Pressure injury classification
Stage 1- Stage 4
Depends on skin/tissue layer involvement
Deep tissue injury
persistent non-blanchable deep red, maroon, or purple discoloration
- Cannot tell what layers are involved
Unstageable
obscured by infection or dying skin (slough/eschar), cannot determine involvement
MASD
Moisture Associated Skin Damage
- Incontinence related (prolonged exposure to urine or stool)
- Intertriginous
- Periwound/Peristomal
Intertriginous
inflammatory dermatitis r/t moist skin on rubbing against each other
- under the breasts, under the pannus
- skin can crack, develop yeast
Periwound/Peristomal
associated with wound or stomas and enzyme breakdown associated with the exudate
Acute wound
- proceeds through normal/timely repair process
- results in return to normal/sustained function and anatomical integrity
- trauma, surgical incision
Chronic wound
- wound that fails to proceed through normal healing process
- does not return to normal function/anatomical integrity
- Example: pressure ulcer, vascular insufficiency wound, diabetic ulcers
Nutrition for wounds
Deficiencies result in delayed healing
Protein, vitamins A,C, zinc, Copper are critical for wound healing
Adequate caloric intake necessary
Labs associated: serum albumin & prealbumin
Vitamin A, C, zinc, copper
a = liver, sweet potatoes, carrots, spinach, eggs, dairy
c = citrus, broccoli, kiwi
zinc = oysters, beef, chicken, seafood, nuts, seeds, legumes
copper = organ meat, seafood, nuts, seeds
Important for wound healing
tissue perfusion
Infection + wounds
- Infection prolongs the inflammation and delays healing
- Indications that a wound is infected: purulent drainage, changes in color/volume/redness around the tissue, fever, or pain
- Low WBC also can delay healing because inability to fight
Wounds + age
- Aging affects all aspects of wound healing
- Delayed inflammatory responses, delayed collagen synthesis, and slower epithelization
Braden score
higher is good
- sensory/mental
- moisture
- activity
- mobility
- nutrition
- friction/shear
Turn every
2 HOURS
at least every hour while pt is in chair
Lift assistive devices
better than causing shear or friction
Factors affecting wound healing
- Age
- Loss of skin turgor
- Impaired immune function
- Dehydration
- Decreased WBC (leukocyte) count
- Infection
- Medications (chemo/anti-inflammatory/steroids!)
- Low hemoglobin levels
Wound management
Assessment
Cleansing
Protection
Wound assessment
- Appearance
- Length, width, depth
- Closed wounds: skin edges should be ‘well approximated’
- Staples, sutures, tissue adhesives
- Note drains/tubes present
- Pain around the incision
- Odor?
First measurement in cm
head to toe
Second measurement in cm
side to side
Third measurement in cm
depth
Tunneling
when cotton-tipped applicator is placed in wound, there is movement
Undermining
when cotton-tipped applicator is placed in wound, there is a “lip” around the wound
Charting wounds
in respect to a clock
- with 12 o’clock being toward the patient’s head
Wound drainage
Accumulates during the inflammatory and proliferative phases of healing
- scant, moderate, large, copious
1 gram
1 ml of drainage
Serous
portion of blood (serum) that is watery and clear or slightly yellow in appearance (think what is in blisters)
Eschar is…
not going to regenerate
Sanguineous
serum and red blood cells, thick/appears reddish
Brighter indicates active bleeding
Darker indicates older bleeding
Serosaingenous
contains serum and blood, watery, looks pale/pink
Well approximated
fits back together well
Purulent
result of INFECTION; thick, contains WBCs, tissue debris, and bacteria
Yellow, tan, green, brown (Depends on organism present)
Good fluid intake and nutrition
High protein, carbohydrates & vitamins w/ moderate fat intake
Monitor albumin & pre-albumin levels
Remove sutures and staples
as ordered by HCP
Woven gauze
help to absorb exudate
Non-adherent materials
changing dressing frequently, we can pull off healthy tissues
Wet to dry
used to mechanically debride a wound until granulation tissues starts to form
- moist wound bed helps to facilitate closure
Tegaderm
be leary of these, can cause more damage than good
Hydrocolloid
occlusive dressing that swells in presence of exudate, duoderm
3 days
can be changed more, need to be changed once full
Hydrogel
mostly water, gels after contact with exudate, promotes autolytic debridement, rehydrates and fills dead space
- May need a secondary occlusive dressing
- For infected, deep wounds or necrotic tissue
- Not for wounds that are draining a lot
- Provides moist wound bed & can reduce pain
- Prevents skin breakdown in high-pressure area
Alginates
non-adherent dressing that conform to wounds shape and absorb exudate
Collagen
powders, pastes, granules, gels
- stop bleeding and promote healing
Vacuum-Assisted Closure System
wound vac
- Use of foam strips into the wound bed with occlusive dressing– creates negative pressure to occur once the tubing is connected
- Helps with tissue generation, decrease swelling, and enhance healing in moist, protective environment
Complications of wound healing
Adhesions
Contractions
Hemorrhage *
Dehiscence *
Evisceration *
Fistula formation
Infection*
Excessive granulation tissue
Keloid formation
Contractions
Surgical wound contraction is a natural part of the healing process where the edges of a wound pull inward, decreasing the wound’s size
Adhesions
Adhesions are bands of scar tissue that can form after surgery, often in the abdomen, causing organs and tissues to stick together. While many adhesions are harmless, they can lead to pain, bowel obstruction, or other complications, especially after abdominal surgery
Hemorrhage
- Greatest risk 24-48 hours after injury/surgery
- Can be caused by clot dislodgement, slipped suture, or blood vessel damage
- Internal bleeding may present with swelling, distention in area and may cause sanguineous drainage (& initially, subtle change in V.S.)
- Wound hemorrhage can be an emergency - apply pressure dressing, notify provider, and monitor vital signs
Hematoma
a local area of blood collection that appears as red or blue bruise
Dehiscence
Partial or total rupture (separation) of a sutured wound, usually with a separation of underlying skin layers
3-11 days after surgery
- small wet-dry dressing
Evisceration
A dehiscence that involves the protrusion of visceral organs through wound opening
Evisceration manifestations
- Significant increase in flow of serosanguinous fluid on the wound dressing
- Immediate history of sudden straining
- Patient reports of a sudden change or ‘popping’ or ‘giving way’ in wound area
- Visualization of the viscera
Risk factors for dehiscence or evisceration
Chronic disease
Advanced age
Obesity
Invasive abdominal cancer
Vomiting
Excessive straining, coughing, sneezing
Dehydration, malnutrition
Ineffective suturing
Abdominal surgery
Infection
Nursing management of evisceration/dehiscence
- If evisceration or severe dehiscence: notify provider immediately due to need for surgical intervention
- Stay with the patient
- Cover wound and any protruding organs with sterile towels or sterile dressings (gauze) soaked with sterile normal saline
- Do not attempt to reinsert organs
- Position patient supine with hips and knees bent (decrease abd tension)
- Maintain calm environment
- Keep patient NPO in prep for returning to surgery
STERILE
Infection and surgical wounds
Big risk, always monitoring
Risk factors: age extremes, immune suppression, impaired circulation/oxygenation, wound condition & nature, malnutrition, chronic disease, poor wound care
Manifestations of infection in surgical wounds
2-11 days after injury or surgery
Pain
Redness, edema & purulent drainage (around wound)
Fever & chills
Odor
Increased pulse and respiratory rate
Increased WBC
