LP4: Integumentary Disorders Flashcards
What is the classification of wounds?
-Intentional (surgical; time is taken to clean the area)
-Unintentional (open wounds)
What are the different types of wounds?
-Incision
-Contusion (bruises)
-Abrasion (scrape)
-Laceration
-Avulsion (skin is torn away)
-Puncture (Stepping on a nail)
-Penetrating wound (gun shot, stabbing)
What is Partial Thickness?
Affects the dermis and epidermis
What is a Full Thickness wound?
Affects the dermis, epidermis, SQ, muscle and bone.
What are pressure ulcers?
Any lesión caused by unrelieved pressure that results in damage to underlying tissue.
What is the Etiology of pressure ulcers?
Due to localized ischemia (no blood in tissues)
Tissues dies
After skin is compressed it appears pale; when pressure is relieved, a bright red flush appears (reactive hyperemia)
What are some Risk Factors for Pressure Ulcers?
-Friction and shearing (skin stays, tissue moves)
-Immobility
-Inadequate nutrition (reduces padding; decreased proteins, fluids, vitC, and Zinc)
What is Maceration?
When fecal or urinary incontinence causes tissue to soften
What is Excoriation?
When fecal and urinary incontinence cause loss of superficial layer of skin
What does Stage I of pressure ulcers consist of?
Red and unopened areas.
Tx:
-Barrier cream
-Cussions
-Reposition
-Protein/ fluids
What does Stage II of pressure ulcers consist of?
Open superficial layer of skin.
Tx:
Dressings on
What does Stage III of Pressure Ulcers consist?
SubQ layer (fatty) is visible.
What’s does stage IV of Pressure Ulcers consist of?
Gets to the muscle and bone
What is a Suspected Deep a Tissue Injury?
Purple or maroon localized area of discolored intact skim. May be mushy, boggy warmer/cooler than adjacent skin.
What is an Unstageable Pressure Ulcer?
Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow dead tissue) or eschar (black dead tissue).
What is the EXCEPTION of an Unstageable Ulcer?
When it’s located on the heal and it’s:
-Stable
-Dry
-Eschar is body’s natural cover
-Should not be removed
What is the Primary Intention of Wound Healing?
•Tissue surfaces approximated (closed)
•Minimal or no tissue loss
•Surgical incision
What is the Secondary Intention of Wound Healing?
•Edges not approximated
•Extensive tissue loss
•Pressure ulcer
What is the Tertiary Intention of Wound Healing?
Also know as Delayed Primary Intention
•Wounds are left open for 3-5 days to allow edema or infection to resolve, then are closed with sutures, staples or adhesive skin closure.
What is the Inflammatory Phase of the Process of Wound Healing?
Defensive phase (3-6 days)
Hemostasis and phagocytosis
What is the Proliferative Phase of the Process of Wound Healing?
Reconstructive phase (4-21 days).
Formation collagen, new blood vessels and tissues, wound closure.
What is the Maturation Phase of the Process of Wound Healing?
Scar tissue gains strength. Up to 2yrs.
What is PUSH Tool?
Pressure Ulcer Scale for Healing
Assigns scores to the ulcer length, width, amount of exudate (drainage), and tissue type.
What are the different kinds of Wound Drainage?
•Serous exudate (watery)
•Purulent exudate (blue, green, or yellow pus)
•Hemorrhagic exudate (blood)
•Serosanguineous exudate (pink color. Watery and bloody drainage)
What are some potential complications of wounds?
•Hemorrhage
•Infection
•Dehiscence (wounds opens up)
•Evisceration (wound opens up and organs come out)
WhT are some factors that affect wound healing?
•Developmental conditions
•Nutrition
•Lifestyle
•Meds
What is the assessment of untreated wounds?
•Assess size & severity
•Inspect for bleeding
•Inspect for foreign bodies
•Assess for other injuries
•Check for last tetanus
What are the cares for untreated wounds?
•Control severe bleeding
•Prevent infection
•Control swelling and pain
•Assess for shock
RYB Wound Classification System
Red, yellow, and black wounds
Red wounds consist of:
Color of normal granulation tissue
Tx:
-Gentle cleansing
-Avoid dry gauze
-Antimicrobial
-Apply transparent film
-Change infrequently
Yellow wounds consist of:
Fibrinous slough or purulent exudate.
Tx:
-Cleanse to remove nonviable tissue
-Antimicrobial
-Hydrocolloid dressing
Black wounds consist of:
Contain necrotic (black/eschar) tissue; may be black, gray, brown, or tan.
Tx:
-Debridement (remove necrotic (black) tissue)
What are the Effects of Heat?
-Vasodilation (opens blood vessels)
-Increases blood flow
-Promotes soft tissue healing
-Increase edema and bleeding (shouldn’t be used the first 24hrs after injury)
What are the effects of cold?
-Vasoconstriction (good for bruises)
-Limits post injury swelling and bleeding
-Reduces blood flow (should not be used on open wounds or impaired circulation)
