Skin Flashcards
5 functions of skin
- protection
- thermoregulation
- sensation
- metabolism
- Communication
2 parts of skin that help with protection
melanin and sebum
How does skin help with metabolism?
synthesis of vitamin D
What is the most prevalent skin related issue in healthcare
pressure ulcer
Newborn and infant skin changes
- reduced ability to thermoregulate
- more susceptible to rashes, blistering, chafing
Toddlers and preschooler skin changes
- sunscreen
- playing causes injuries
School age and adolescent skin changes
- lice/scabies/impetigo
- acne
- sunscreen
Adult and older adult skin changes
- dry skin more common
- wrinkling and poor skin turgor
- slower healing
3 Mechanical forces that damage skin?
-pressure, friction, sheering
Wound type- injury such as knife, gunshot, burn, or surgical incision, heals within 6 months
acute
wound that persists beyond usual 6 month healing time or recurs with new injury to area
chronic
open wound
break present in the skin; tissue damage present
closed wound
no break seen in the skin, but soft tissue damage evident
clean surgical wound
closed surgical wound that did not enter GI/Resp/Genituourinary system
-low infection risk
clean/contaminated wound
wound entering GI/Resp/Genituourinary system
-infection risk
contaminated surgical wound
open, traumatic wound; surgical wound with break in asepsis
-high infection risk
infected surgical wound
wound site with pathogens present
-signs of infection
What is pressure?
localized damage to skin or underlying tissue over bony prominence as a result of pressure or pressure in combination with shear
Stage I Pressure Ulcer
- skin intact
- nonblanchable redness (stays red when you press it)
- painful or different feel to rest of skin
- will feel cool in temperature
Stage II pressure ulcer
- shallow OPEN ulcer with PINK wound bed
- no sloughing/no eschar
- PARTIAL thickness loss of dermis
- skin shear, tape burn, maceration, excoriation
- will feel warm
Stage III pressure ulcer
- FULL thickness tissue loss
- may have slough or eschar
- NO bone tendon muscle exposure
- UNDERMINING or TUNNELING possible
Stage IV pressure ulcer
- EXPOSED bone tendon muscle
- may have slough or eschar
- tunneling or undermining
tunneling
-narrow passageway in soft tissue of open wound going down
undermining
area of tissue deconstruction under the edge of wound opening
eschar
dea tissue, bacterial debris, dark in color
What is an unstageable pressure ulcer?
- wound cannot be visualized
- base is covered in slough or eschar
Tool for pressure ulcer screening
Braden Scale
What is in protective creams to help healing and prevention?
-zinc, vitamin A,D,E
____ rather than ____ when repositioning patient in bed
lift, pull
small spot like freckle or petechia
-circumscribed, flat, non palpable changes in skin color
macule, primary lesion
larger than macule like vitiligo,flat, non palpable changes in skin color
patch, primary lesion
up to 0.5 cm like elevated nevus, palpable elevated solid mass
papule, primary
flat elevated surface larger then 0.5 cm, often formed by coalescence of papules
plaque, primary
larger than 0.5 cm, deeper and firmer than a paule, palpable elevated solid mass
nodule, primary
large nodule, palpable elevated solid mass
tumor, primary
somewhat irregular, relatively transient superficial area of localized skin edema like mosquito bite or hive
wheal, primary
up to 0.5 cm, filled with serous fluid, circumscribed superficial elevation of the skin formed by free fluid in cavity within skin layers
vesicle, primary
> 0.5 cm , filled with serous fluid, like 2nd degree burn
bulla, primary
filled with pus like acne or impetigo
pustule, primary
loss of the superficial epidermis, surface moist but does not bleed ex:moist area after rupture of vesicle from chicken pox
loss of skin surface,secondary
dried residue of serum, pus, blood
crust, secondary
deeper loss of skin surface, may bleed and scar like from venous stasis or syphlitic chancre
ulcer, secondary
think flake of exfoliated epidermis like dandruff, dry skin, psoriasis
scale, secondary
linear crack in the skin like from athletes foot
fissure, secondary
primary vs secondary skin lesion
primary-arise from normal skin
seconary-result from changes in primary lesion
4 phases of wound healing in order
- hemostasis
- inflammatory
- proliferative
- maturation
what happens in heomstasis part of wound healing?
- vasoconstriction
- platelet aggregation
- clot formation
timeline for phases of wound healing for full thickness wound
- hemostasis- immediate
- inflammatory- up to day 3
- proliferative-4-21 days
- maturation- 21 days to 2 years
what happens in inflammatory phase
- vasodilation
- phagocytosis
when does shear occur?
skin stays in place but subq tissue beneath shifts
- might not be visible break in skin
- can result in breakage/stretching of blood vessels–> soft tissue ischemia
the presence of _____ causes skin to be ______ resistant to damage from friction and shear
moisture, less
granulation tissue, what phase of wound healing
bright red tissue that is a manifestation fo wound healing but is also prone to trauma
- see in proliferative phase of wound healing
- full thickness wound
epithelialization tissue, what phase of wound healing
pink in color, temporary protection, begins at wounds edges and moves inwards
- action promoted by moist environment
- partial thickness wound
what happens in the proliferative phase
partial thickness wound: epithelialization
full thickness wound: granulation tissue, contracture
When does maturation phase of wound healing occur? what kind of wounds?
21 days to 2 years
-only happens with full thickness wounds
timeline for phases of partial thickness wounds
- hemostasis- immediate
- inflammatory- up to day 3
- proliferative-4-21 days
Primary Intention wound
- clean incision
- early suture
- hairline scar
- decreased infection and scarring
Secondary Intention wound
- gaping irregular wound
- granulation
- epithelium grow over scar
- increase scarring and infection
Tertiary Intention
- wound
- granulation
- closure with wide scar
- delayed closure
- increase scarring, may already have an infection that has to be cleared in order to heal
Adhesive strips that hold edges of wound together
steri-strip
Thread or metal that holds edges of wound together
suture, staple, clips
Used to close wound on parts of the body that do not experience tension or stretching
cyanoacrylte glue
Protocol for elastic wraps/bandages/stretch netting
- apply distal to proximal
- ensure it is not too tight
- check distal circulation
Complications from wounds
- hemorrhage or hematoma
- infection
- dehiscence
- evisceration
- fistula
what is dehiscence?
partial or total reopening of a wounds edges
what is evisceration?
protrusion of viscera thru wound opening
-insides go outside
what is a fistula? how is it named?
passage b/w 2 body parts/areas that don’t normally connect
-named for location ex: entercutaneous- goes intestine to epidermis
What do you assess on a wound?
type, location, size, classification, base
- drainage
- undermining or tunneling
- infection or pain
- check fxality of drainage system
Bloody drainage =
sanginous
pale yellow pink drainage =
serosangiunous
pale yellow watery fluid drainage
serous
Penrose drain
- tube placed in wound
- no suction
Hemovac
- bloody cavity
- suction
Jackson Pratt drain
-gently suction when bulb compressed
2 types of drains with suction
hemovac and JP
A wound is present, who should assess it first?
Wound, Ostomy, Continence Nurse
Who assesses surgical wounds?
- only surgeon removes the dressing
- surgeon will write orders on how to do the dressing change
Alginate
Used for absorption for draining wounds
Collagens used for what kind of wound?
partial and full thickness
Composites
use multiple products
Foams
hydrophilic polyurethane
-partial and full thickness with small to moderate drainage
Hydrocolloids
water resistant gel like wafer dressing
hydrofiber
- sodium carboxymethylcellulose
- very absorptive
Hydrogels
-assist in autolytic debridement of necrotic tissue in full thickness wounds
Nonadherent dressing function
minimize disruption of new cells
silver dressing
- antimicrobial for infected wound
- need wound care of physician order
Transparent film fx
cover the wound but be able to see it
What is negative pressure wound therapy?
hydrophobic sponge fills a wound cavity
- cover with transparent dressing
- connect to machine providing negative pressure = no pressure on wound, not even gravity
Surgical Debridement
- not done by nurses
- use of sharp tools to remove debris
Enzymatic debridement
-place chemical products on wound to break down debris
Autolytic debridement
- occlusive or hydrogel to soften eschar
- debris gets eroded then irrigated with saline
wet to dry dressing is what kind of debridement
mechanical use:
-pulsating lavage
4 types of debridement
- surgical
- enzymatic
- autolytic
- mechanical
3 benefits of using heat therapy
- promote healing and suppuration
- decrease inflammation by accelerating inflam. response
- decrease musculoskeletal discomfort
When to use heat therapy
- surgical/infected wounds, hemorrhoids, episiotomies
- phlebitis and IV infiltration
- low back pain, menstrual cramps, contractures, arthritis, muscle spasms
3 benefits of cold therapy
- controls bleeding
- decrease edema
- relieves pain
When to use cold therapy
- fractures, trauma, superficial lacerations, puncture wounds
- sprains, muscle strains, sports injuries
- arthritis, trauma, musculoskeletal injuries
When not to use hot or cold therapy
- acute appendicitis/abscess tooth
- broken skin/deep wound
- circulatory impairment
- sensory deficit
- mental status impairment
- age extremes
- metallic implants
Diet for wound healing
high protein, vitamin A/C/E, zinc, water, arginine, carbohydrates, fats
What are 2 medicationd that can impair wound healing
- anticoag
- corticosteroids (decrease ability to fight off infection)
