Midterm_Skin Integrity and Wound Care Flashcards
Any disruption in the integrity of the body tissue
WOUND
Result of TRAUMA or SURGERY.
Impaired skin integrity, such as wounds
refers to the presence of normal skin and skin layers uninterrupted by wounds.
INTACT SKIN
largest ORGAN and is the primary defense against infection.
Skin
Factors that affect skin integrity
- Genetics and heredity
- Age
- Chronic illnesses and - their treatments
- Medications (rashes)
- Poor nutrition
Types of Wounds
Described according to:
- How they are acquired
- Likelihood and degree of contamination
Types of Wounds
- Likelihood and degree of contamination
- Clean
- Clean-contaminated
- Contaminated
- Dirty, infected
Types of Wounds
- Incision
- Contusion
- Abrasion
- Puncture
- Laceration
- Penetrating wound
Identify the Types of Wounds being described
- caused by Sharp instrument
- Open wound
- deep or shallow
- once the edges have been sealed together as a part of treatment or healing, it becomes a closed wound
Incision
Identify the Types of Wounds being described
- caused by Blow from a blunt instrument
- Closed wound, skin appears ecchymotic
(bruised) because of damaged blood vessels.
Contusion
Identify the Types of Wounds being described
- caused by Surface scrape, either unintentional or intentional
- Open wound involving the skin
Abrasion
Identify the Types of Wounds being described
- caused by Penetration of the skin and often the underlying tissues by a sharp instrument, either intentional or unintentional
- Open wound
Puncture
Identify the Types of Wounds being described
- caused by Tissues torn apart, often from accidents
- Open wound
- edges are often jagged
Laceration
Identify the Types of Wounds being described
- caused by Penetration of the skin and the underlying tissues and enters a tissue or a cavity
- Open wound
Penetrating
wound
- Injury to skin and/or underlying tissue usually over a bony prominence
- Preventable
Pressure Ulcers
Risk Factors of Pressure Ulcers
- Friction and shearing
- Immobility
- Inadequate nutrition
- Fecal and urinary incontinence
- Maceration- Tissue softened by prolonged wetting
- Excoriation (denuding)
- Area of loss of superficial layers of skin
- Decreased mental status
- Diminished sensation
- Excessive body heat
- Advanced age
- Chronic medical conditions
- Poor lifting and transferring techniques
- Incorrect positioning
- Hard support surfaces
- Incorrect application of pressure-relieving devices
Risk Assessment Tools
- Braden Scale for Predicting Pressure Sore Risk
- Norton’s Pressure Area Risk Assessment Form Scale
Stages of Pressure Ulcers
- nonblanchable erythema signaling potential ulceration.
Stage Ⅰ
Stages of Pressure Ulcers
- partial-thickness skin loss (abrasion, blister, or shallow crater) involving the epidermis and possibly the dermis.
Stage Ⅱ
Stages of Pressure Ulcers
- full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue.
Stage Ⅲ
Stages of Pressure Ulcers
- full-thickness skin loss with tissue necrosis or damage to muscle, bone, or supporting structures, such as a tendon or joint capsule. Undermining and sinus tracts may also be present
Stage Ⅳ
Stages of Pressure Ulcers
- full-thickness skin or tissue loss-depth unknown: Actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed.
Unstageable/unclassified
Stages of Pressure Ulcers
- purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar.
Suspected deep tissue injury-depth unknown
Phases of Wound Healing
- Inflammatory phase
- Proliferative phase
- Maturation phase
