NUR 118 - Lecture 2 - Wounds/Skin Integrity Flashcards
What are the 12 factors that affect skin integrity?
Age
Impaired Mobility
Nutrition
Hydration (Over/Under)
Impaired Circulation
Medications
Moisture
Infection
Fever
Lifestyle
Diminished Sensation
Diminished Condition
Explain the following factors affect on skin integrity: Age, impaired mobility, nutrition,
Age: Decreased Sebaceous, sweat glands = dry skin; Subcutaneous layer thins; epidermis-dermis bond weakens = tears
Impaired mobility: Weight of body leads to pressure = breakdown
Nutrition: Protein required to keep IntraVASCULAR volume (albumin); Ascorbic acid, zinc copper = wound healing
Explain the following factors affect on skin integrity: Hydration, diminished sensation, diminished cognition
Hydration (over/under): Edema vs dehydrated, edema = build up of serous fluid in tissue (skin too tight); dry, dehydrated skin
Diminished Sensation: May not be able to feel heat/cold/pain
Diminished Cognition: Unaware of reposition, can feel pain but may not realize need to fix it
Explain how these factors affect skin integrity: Impaired circulation, medications, moisture
Impaired circulation:
- Arterial: impairs oxygen and nutrient flow to wound
- Venous - Impairs venous return = edema, stasis, blood clots
Medications: Steroids = infection, anticoagulants = bleeding
Moisture: Maceration (softening of skin), Incontinence = when someone can’t hold urine/feces
Explain how these factors affect skin integrity: Fever, infection, lifestyle
Fever: Sweating = maceration (fingers pruning), increase metabolic rate
Infection: Increase metabolic demand, skin vulnerable to breakdown, impedes healing
Lifestyle: tanning, diet, bathing (too much or too little), smoking
Classification of wounds: Skin integrity
Open - break in skin or mucus membrane
Closed - no break in skin (bruise, edema, hematoma)
Classification of wounds: length of time for healing
Acute - Short, no complications; 3 phases = inflammation, proliferation, maturation
NOT NECESSARILY DEPENDENT ON TIME (i.e. over/under 6 months)
Chronic - Longer to heal d/t (due to) interrupted healing (ex: infection, trauma, edema)
Classification of wounds: level of contamination
Clean: No infection, limited inflammation = low infection risk
ex: hand surgery
Clean contaminated: Surgical incisions within GI, GU or Respiratory system = increased infection risk
Contaminated: Open wounds, pressure ulcers; surgeries with break in asepsis
Infected: Bacteria >100k per gram of tissue, signs and symptoms of infection
Classification of wounds: Depth of wound
Superficial: 1 layer = AT epidermis; friction, sheer, burn
Partial thickness: 2 layers = through epidermis, NOT DERMIS
Full thickness: 3+ layers = epidermis to dermis to sub q to bone
Penetrating - FULL THICKNESS TO INTERNAL ORGANS
List and describe types of wound drainage
Serous: WATERY - SERUM - CLEAR TO STRAW COLORED = CLEAN WOUNDS
Sanguineous: BLOOD - BRIGHT RED TO DARK RED/BROWN = FRESH BLEEDING
- Initial bleeding
Serosanguineous : COMBO OF BLOOD & SEROUS = NEW WOUNDS
This is following the initial blood gushing
Purulent : THICK - ODOROUS - WHITE - YELLOW - GREY = INFECTION
Purosanguinous: RED TINGED PUS & BLOOD = INFECTION / NEW WOUND
List and describe TYPES (not phases) of wound healing
Regeneration/epithelial - epidermis & dermis regeneration
Primary intention: clean, approximated = SURGICAL wound
Secondary intention: not approximated, heals inside out by filling with granulation tissue = PRESSURE ULCER
Tertiary intention: Delayed closure to allow edema/infection to diminish, then sutured afterwards
List and describe the 3 PHASES (not types) of wound healing
1) Inflammatory - Cleansing
- 1-5 days
- Hemostasis - Vessels constrict, platelets aggregate to slow bleeding
Inflammation - erythema, WBCs mobilize, scab formation
2) Proliferative/Granulation/Healing
- 5 to 21 days, higher risk of infection here
- Cells grow to fill in from base of wound (from inside out)
3) Maturation/Epithelialization/Remodeling
- 12 to 21 days & up to 3-6 months
- Collagen fibers broken down, reorganized into organized structure = increased strength of wound
Complications of wound healing
Hemorrhage - Blood loss
Infection
Dehiscence - Sutures came undone
- Raise head of bed 20 degrees, pull in knees, place binder
Evisceration - Organ came out
- Raise head of bed 20 degrees, pull in knees & prepare pt for surgery, cover with sterile drape + sterile saline
Fistula formation - Creation of abnormal passageway in GI/GU tracts
Define pressure injury
“Localized injury to the skin & underlying tissue, usually over a bony prominence”
Intrinsic factors in the development of pressure injuries (internal, patient health status)
Age - Thinner subq, epidermis-dermis bond weakens
Poor nutrition - Low protein = weakened intravascular
Immobility - Weight of patient = breakdown
Edema
Impaired sensation - Patient can’t feel breakdown or pain/heat/cold
Impaired cognition - May feel pain, but won’t realize attention is needed
Fever