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
Phases of Wound Healing
- Immediately after injury
- Lasts 3 to 6 days
- Hemostasis (process to prevent and stop bleeding)
- Phagocytosis (process by which a cell uses its plasma membrane to engulf a large particle, giving rise to an internal compartment called the phagosome)
Inflammatory phase
its a process to prevent and stop bleeding
Hemostasis
its process by which a cell uses its plasma membrane to engulf a large particle, giving rise to an internal compartment called the phagosome
Phagocytosis
Phases of Wound Healing
- From post-injury day 3/4 until day 21
- Collagen synthesis
- Granulation tissue formation
Proliferative phase
Phases of Wound Healing
- From day 21 until 1 or 2-years post injury
- Collagen organization
- Remodeling or contraction
- Scar stronger
- Keloid
- Hypertrophic scar with abnormal amount of collagen
Maturation phase
Types of Wound Healing
- Primary intention healing
- Secondary intention healing
- Tertiary intention healing
Types of Wound Healing
- Tissue surfaces approximated (closed)
- Minimal or no tissue loss
(e.g., clean surgical incision)
- Formulation of minimal granulation tissue & scarring
- Proliferative phase
Primary intention healing
Types of Wound Healing
- Extensive tissue loss
- Edges cannot be approximated.
- Repair time is longer.
- Scarring is greater.
- Susceptibility to infection is greater
Secondary intention healing
Types of Wound Healing
- Also known as delayed primary intention
- Initially left open 3-5 days
- Edema, infection to resolve, or exudate to drain
- Closed with sutures, staples, or adhesive skin closures
Tertiary intention healing
- Material (fluid, cells) escaped from blood vessels during inflammatory process
- Deposited in tissue or on tissue surface
Exudate
3 major Types of Wound Exudate
- Serous
- Purulent
- Sanguineous
Types of Wound Exudate
- Mostly serum
- Derived from blood and serous membranes of the body
- Looks watery, few cells
- E . g., fluid in blister from a burn
Serous exudate
Types of Wound Exudate
- Thicker
- Presence of pus
- Consists of leukocytes, liquefied dead tissue debris, dead and living bacteria
- Color varies with causative organism
Purulent exudate
Types of Wound Exudate
- Large number of R B Cs
- Indicates severe damage to capillaries
- Frequently seen in open wounds
Sanguineous exudate
Types of Wound Exudate
- Serosanguineous
- Purosanguineous
Mixed exudate
Clear and blood-tinged drainage
Serosanguineous
Pus and blood
Purosanguineous
Complications of Wound Healing
- Massive bleeding
- Hematoma
Hemorrhage
Localized collection of blood under skin
May appear as reddish blue bruise
Hematoma
Complications of Wound Healing
- Contamination of a wound surface with microorganisms
Infection
Complications of Wound Healing
- Partial or total rupturing of a sutured wound
- Protrusion of the internal viscera through an incision
- Sudden straining may precede dehiscence
Dehiscence with possible evisceration
Separation or splitting open of layers of a surgical wound
Dehiscence
Extrusion of viscera or intestine through a surgical wound
Evisceration
Factors Affecting Wound Healing
- Developmental considerations
- Nutrition
- Lifestyle
- Medications
How medications affect wound healing
impair wound healing and damage skin integrity include antibiotics, anticonvulsants, angiogenesis inhibitors, steroids, and nonsteroidal anti-inflammatory drugs. Conversely, drugs such as ferrous sulfate, insulin, thyroid hormones, and vitamins may facilitate wound healing.
