Skin Flashcards
Largest organ in body
Skin
Layers of skin
Dermis
Epidermis
What separates the two layers of skin
Dermal epidermal junction
Role of epidermis
Divides and proliferates, sloughs off dead cells
Role of dermis
Provides strength and support or upper layers, protects underlying layers (muscles, bones)
Primary purpose of skin
- protection
- sensory protection
Main assessments of skin
- color
- moisture
- temperature
- texture
- turgor
- vascularity
- edema
- lesions
- have you noticed any changes or issues?
Pitting edema
1+ 2 mm deep, barely detected
2+ few seconds to rebound
3+ 10 -12 secs to rebound
4+ more than 20 secs to rebound
Pallor
Loss of color, in black skin tones it can be gray
- mucous membranes
- indications: anemia, shock, lack of blood flow
Cyanosis
Bluish discoloration, brown/dark skin can turn yellow-brown, gray
- nail beds, lips, mucous membranes
- indications: hypoxia, impaired venous return
Jaundice
Yellow discoloration
- sclera, skin, mucous membranes, can do palms of hands
- indication: liver dysfunction (RBC break down causing yellow)
Risk factors for impaired skin integrity
- impaired senseroy perception
- impaired mobility
- altered LOC
Shear
Sliding movement of skin and subq tissue when muscle and bone are not moving
- more dermal layer
- affects capillary, stretch and damage, cause ischemia
friction
Two surfaces moving across one another
-most common, easy to identify
- occurs when pulling up pt in bed
- outer layer of skin
Moisture
Duration and amount of moisture determine risk, softens your skin making it susceptible to damage (incontinence, sweating, wound exudate)
who’s at risk for skin integrity
- older adults: trauma
- spinal cord injuries
- nutritional deficiencies
- long term homes
- acutely ill, hospice
- diabetes
- ICU, critical care
- incontinence
Pressure injuries
Impaired skin related to prolonged, unrelieved pressure
- localized
- can be caused by medical device
* pressure applied over a capillary (weak) exceeds normal capillary pressure then it can lead to ischemia *
Major factors of pi
Pressure intensity (can be affected by heavier wt)
Pressure duration
Tissue tolerance
Deep tissue injury
Persistent non-blanchable deep red, maroon, purple discoloration
- can’t tell what layers are involved
Unstageable
Obscured by infection or dying skin, cannot determine involvement
Blanchable
Skin turns red when pressure relieved
Non blanchable
Redness does not occur
MASD
Moisture associated skin damage
- incontinence related
- intertriginous: inflammatory dermatitis, moist skin or rubbing together
- periwound/peristoma: wounds or stoma related, enzyme in exudate associated w breakdown
Wound
Disruption of the integrity and function of the tissue
Acute wounds
- proceeds through normal and timely repair
- results in return to normal and sustained function and anatomical integrity
- ex: trauma/surgical incisions
Chronic wounds
- wound that fails to proceed through normal healing process
- does not return to normal function/anatomical integrity
- ex: pi, vascular insufficiency wound
Nutrition for wounds
- def result in delayed healing
- protein, vitamin a,c, since, copper
- adequate calories
- labs: serum albumin, pre albumin
Tissue perfusion
Ability to perfume tissues w oxygenated blood crucial to wound healing
- diabetes and peripheral vascular at risk
Infection and wounds
- prolongs inflammation and delays healing
- will have purulent drainage, changes in color, fever, pain
- low WBC can delay healing, dec ability to fight
Age and wounds
- affects healing
- delayed inflammatory responses
- delayed collagen synthesis,
- slower epitheliation
Braden Risk Assessment
table 48.3, 1244
- 6-23
- lower the score, the increased risk of impairment
- not great for ICU so use a diff one
Interventions to prevent impaired skin
- nutrition: extra supplements, protein, calories, nutrients
- incontinence/moisture management: moisture barrier, products that wick moisture away
- positioning: q2, move to chair, use assist device to prevent drag, specialized equipment
slide 78
Factors that affect wound healing
- age, loss of skin turgor, skin fragility, dec collagen
- dec circulation and oxygenation
- slower tissue regeneration
- dec absorption of nutrients
- impaired immune function
- dehydration
Factors affecting wound healing pt 2
- overall wellness
- dec WBC
- infection
- medications
- low HgB levels
- obesity, smoking, chronic disease
- malnutrition
Inflammation
Localized protective response to injury to destruction of tissue
3 components of management
- assessment —> thorough and document
- cleansing
- protection
Wound assessment
- Appearance: red, yellow, black
- length, depth, width
- closed: well approximated?
- drains, tubes?
- pain
Wound assessment: appearance
- red: signs of inflammation, good thing is localized
- yellow: likely indication of infection
- black: eschar that requires surgical debridement
Wound assessment: length, width, depth
Sinus tracks, tunnels, redness/swelling
- common in the vaginal, sacral, anal areas
- mark and measure areas around too that are not normal
Wound assessment: closed wound
Edges are well approximated (clean and closed)
- staples, sutures, tissue adhesive
- can break open bc too much movement, swelling, etc
- always consider how long the staples should be there
Wound assessment: drains/tubes
- where are the drains located
- what is the color of drainage
- how much drainage is present
- making sure the drains are not clogged
Wound assessment: pain
- pain is typically good bc its a indicator that something is wrong and we can solve that problem
- control it w meds
- understand if the pain is appropriate for the wound
Wound drainage
- can be normal/abnormal
- doc amount, odor, consistency, color
- note integrity of skin surrounding
- can weigh dressing for amount of drainage (1g=1ml) but most ppl just say scant moderate large copious)
Types of exudate
- serous
- serosanguinous
- sangiuneous
- purulent
Serous exudate
Portion of blood (serum) that watery and clear or slightly yellow in appearance
- think blisters
Serosanguinous
Contains serum and blood, more watery
- looks pale pink
Sanguineous
Serum and red blood cells, thick and appears reddish
- brighter red is indicative of actual bleeding
- darker red is indicative of older bleeding
Purulent
Thick, contains WBC, tissue debris, and bacteria
- results of an infection
- yellow, tan, green, brown (any color not pink or red)
Nursing intervention for pt wounds
- adequate hydration and nutrition
- monitor albumin and prealbumin
- wound cleaning
- remove sutures
- admin analgesics
- admin antimicrobials and monitor effectiveness
- document
Wound dressing types
- woven gauze
- non adherent material
- wet to dry
- self adhesive, transparent
- hydrocolloid
Purpose of gauze sponges
Helps absorb exudate
Purpose of non adherent material
Don’t want dressing to stick to wound bed
Purpose of wet to dry
Used to mechanically debride a wound until granulation tissue starts to form
- mechanically: remove damage skin off wound
Self adherent, transparent purpose
Allow you to watch the wound w out having to
- typically superficial wounds
- not really good for fragile skin
Hydrocolloid
Occlusive dressing that swells in the presence of exudate
- forms seal abound wound surface preventing evaporation from the skin
- helps maintain granulating wound bed
some can last 3-5 days, but if the dressing is filled w exudate then change it
Hydrogels
Mostly water, gels after contact w exudate
- promoted autolytic debridement
- rehydrates and fills dead space
- used for infected deep wounds or necrotic tissue
- dont use if lots of drainage
- provides moist wound bed and reduce pain
- prevents skin breakdown in high pressure areas
Alginates
Non adherent dressing that conform to wounds shape and absorb exudate
- provides moist wound bed
- back wounds
- support debridement
Collagen
Powders, pastes, granules, gels
- helps stop bleeding, promotes wound healing
Vacuum assisted closure system
Use foam strips into wound bed with occlusive dressing, create negative pressure to occur once tubing is connected
- helps w tissue generation, dec swelling, and enhance healing in moist protective environment
- suctions wound close and brings blood supply towards wound
- some can infuse antibiotics
Complications wound healing
- adhesions
- contractions
- hemorrhage
- dehiscence
- evisceration
- fistula formation
- infection
- excessive granulation tissue
- keloid formation
Hemorrhage
Blood ruptures from vessel
- greatest risk first two days after surgery
- can be caused by clot dislodgment, slipped suture, blood vessel damage
- may be swelling, distinction, sanguineous drainage
- subtle change in vs
- can be emergency
Hematoma
Local are of blood collection that appears as red or blue bruise
Hemorrhage emergency actions
Apply pressure dressing, notify provider, monitor vs
Dehiscence
Partial or total rupture of a sutured wound, usually w a separation of underlying skin
- inc risk if obese, move too early
- will not be resutured, left to heal/close on own
Evisceration
A dehiscence that involved the protrusion of visceral organs through wound opening
- typically traumatic incidents or occurs around vaginal/anal canals
Eviscerations manifestations
Significant inc in flow of serosanguinous fluid on the wound dressing
- immediate history of sudden straining (coughing, vomiting, going to the bathroom)
- pt reports sudden change/popping/giving way
- visualize viscera
Risk factors for dehiscence and evisceration
- chronic disease
- advanced age
- obesity
- invasive abdominal cancer
- vomiting (other excessive strains like coughing, sneezing)
- dehydration
- malnutrition
- ineffective suturing
- abdominal surgery
- infection
Dehiscence and evisceration, nursing management
- notify provider
- stay w pt
- cover wound w gauze and any organs w sterile towel/sterile dressings soaked w sterile saline
- dont try to put organs back
- position pt supine with hips and knees bent
- calm environment
- NPO
Infection info
- big risk always being monitored for
- risk factors: age extremes, immune suppression, impaired circulation/oxygenation, wound condition, chronic disease, poor wound care
- 2-11 days after injury: pain, redness, swelling, edema, purulent drainage, fever, chills, odor, inc pulse/RR/WBC
Infection, nursing interventions
-prevent infection by using aseptic technique w dressing changes
- provide optimal nutrition
- provides adequate rest
- administer antibiotics therapy
