Skin Flashcards
What are the structures of the skin
skin
hair
nails
scalp
Skin makes up ___% of total body weight
15
Melanin
gives color to skin
Epidermis
pH4.5-5.5
slightly acidic to protect from bacteria and fungus
Dermis
secondary layer of skin
made up of collagen (tensile strength) and elastin (recoil)
What is a pressure ulcer
an area of local tissue damage usual developing where soft tissue is compressed between a bony prominence and any external surface for prolonged time periods. It is a sign of local tissue necrosis and death
What are some risk factors for pressure ulcers
excessive exposure and moisture from bodily secretions impaired metal status impaired nutritional status immobility mechanical forces shearing and friction
What is the difference between shearing and friction
Friction causes removal of the stratum corneum and damage to underlying layers of the skin
Shearing occurs when friction hold the skin in place but gravity pulls the axial skeleton down which results in the pulling of the dermal layers of the skin
Hyperemia
occurs when pressure is applied for <30 minutes and resolves in 1 hour
Ischemia
Condition in which there is insufficient blood flow to the part of the body
Necrosis
death of body tissue. not enough blood going to tissies
Ulceration
breakdown of the skin
What are the 4 things you should think about with regard to ulcerations
Surface selection
Keep turning
Incontinence management
Nutrition
What is the first indication that a pressure ulcer may be developing
blanching of the skin (becoming pale and white)
Braden Scale
Scores sensory, perception, moisture nutrition, friction and shear, activity, and mobility.
Lower the score, the higher the risk for a pressure ulcer (score of <18)
Needs to be done consistently and updated frequently
What are facts that affect pressure ulcer development
Wrinkled sheets Pull of pt over linen surfaces Immobility Malnutrution and dehydration moisture on skin mental status and sense of recovery Age Heep HOB at 30 degrees or less to reduce pressure/fricton or shearing
Stage I pressure ulcer
non blanchable erythema
may contain changes in skin temp tissue consistency (firm or boggy feeling), itching (sensation)
may be red, blue, or even purple hues
*It is reversible if pressure is relieived
What re pressure ulcer relieving mechanisms
frequent turning
pressure-relieving devices
positioning
Stage II pressure ulcer
partial thickness and skin loss
looks like an abrasion, blister or shallow crater
Maintenance of moist healing environment with saline and occlusive dressing (promotes natural healing but prevents the formation of scar)
Stage III pressure ulcer
full thickness/loss of skin
damage/necrosis of subcutaneous tissue that can extend as far down as the fascia
may have fowl smelling drainage if it is infected and usually takes months to heal after the pressure is relieved
Stage IV pressure ulcer
full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone or supporting structures. Wound may appear small on surface but can have extensive tunneling
What are often associated with Stage IV pressure ulcers
Sinus tracts
Eschar
thick leathery scab or dry crust that is necrotic and must be removed from a pressure ulcer in order to determine what stage the ulcer is in
Unstageable pressure ulcers
full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, grey) and or/eschar in the wound bed
**True depth and stage cannot be determined until eschar is removed
What are things to assess/document when measuring pressure ulcers
location
stage
drainage
types of tissue present
Document: size of wound, side - side, top to bottom and depth
Determine presence of undermining, tunneling or sinus tracts
How do you clean a pressure ulcer
use a dressing change (careful and gentle motion)
avoid harmful cleaners
use 0.9% NaCl solution to irrigate/clean area
use a catheter tip syringe and 35ml/20ml/water pic at lowest setting
When dressing an ulcer what do you want to make sure to use
Use dressing that keep the wound moist
Wet to Dry dressing are for debridement ONLY
make sure dressing absorbs exudate
pack the wound cavities loosely - overpacking could increase wound pressure
What are some ways to debride a wound
surgically - use scalpel to cut the necrotic skin or eschar from the wound
mechanically - wet to dry dressing
enzymatically - using a chemical agent that degrades eschar
autolytically - covering the pressure ulcer with a gel or hydro colloid allowing the bodes moisture and enzymes to soft the eschar
debridement
removal of the devitalized tissue and foreign material so the wound can heal
What are the different types of drainage
serous
sanguineous
serosanguineous
purulent
Serous drainage
clear and watery
Sanguineous drainage
large numbers of RBCs and looks like blood
Indicative of fresh bleeding
Serosanguineous drainage
mixture of serum and RBCs (light pink)
Purulent
WBCs, liquefied dead tissue debris, dead and live bacteria
thick, musty/foul odor and can be yelled or green
What are the 4 things to assess for with a wound
COCA
Color Odor Amount Consistency
Intentional wound
result of planned invasive therapy or tx
Ex. IV, surgery wound etc.
Usually done under sterile conditions so risk for infection is decreased
Unintentional wound
accidental and usually caused by trauma, forcible injury (stabbing, gunshot etc.), or burns.
Contamination is likely since it occurred in a unsterile environment
Bleeding often uncontrolled and would edges are jagged
Acute wounds
usually heal within days to weeks and wound edges are well approximated: edges meet closely
Risk for infection is lessened
Chronic wounds
healing is impeded; wound edges are not well approximated, and increased risk of infection.
They remain in the inflammatory stage of wound healing
Ex. venous/arterial wounds and pressure ulcers
Before treating a wound what is it important to know
the etiology : venous, arterial, surgical, or trauma
Abrasions
superficial injury caused by rubbing or scraping of skiing against another surface
Laceration
open would with jagged edges
Contusions
closed wound; swollen, discolored and painful
What are the phases of wound healing?
Hemostasis
Inflammatory Stage
Proliferative Stage
Remodeling
Hemostasis phase
tissue injury initiates clotting process which leads to platelet aggregation. This leads to fibrin clot formation which prevents excessive blood loss and body fluids
Inflammatory phase
phagocytois occurs; increase of WBC to the area of wound; erythma, edema warmth, increase in temp, general malaise (approx 4-6 days after onset)
Proliferative phase
new tissue is built to fill the wound space days after the injury. Granulation tissue (new tissue) forms
Starts after 5-7 days
Remodeling (maturation) phase
starts about 3 weeks after injury and can continue for months to years. new collagen continues to be formed - leads to scar
What are common sites for the development of pressure ulcers
occipital bone scapula vertebra sacrum coccyx calcaneus ribs (side lying) iliac crest (side lying) greater trocanter (side lyings) lateral knee, malleolus and medial malleolus (side lying
Primary intention wound healing
would with little tissue loss, edges approximated. heals rapidly with minimal scarring, low risk of infections
healing occurs by direct union of granulating surfaces
Secondary intention wound healing
wounds involving loss of tissue, wound edges widely separated, healing occurs by granulation, large scar increases likelihood of infection, longer healing time
EX burns, pressure ulcers
Tertiary intention would healing
deep wound and is likely to contain extensive drainage and tissue debris. High risk of infection
wound dehiscence
surgical wound that tears open along the closure of the wound
When changing a dressing for a draining wound
promote comfort
maintain skin integrity
prevent infection
promote healing
NPWT - vacuum assisted closure therapy
used for recalcitrant wounds, acute and chronic wounds, pressure ulcers, surgical wounds, skin graft etc.
The negative pressure on the wound bed results in mechanical tension on the wound tissues, stimulating cell proliferation, blood flow to the wounds and the growth of new blood vessels
Growth factors
applied to the wound bed to bind to cells to promote granulation, cell proliferation and cell migration.
Used during the proliferative phase of wound healing in pts with chronic non-healing wounds
HBOT (hyperbaric oxygen tx)
placing patients in a pressurized chamber, where they breathe 100% to. Promotes cell proliferation, increased blood flow to wounds and promotes angiogenesis (growth of new blood cells)
When is VAC contraindicated
necrosis, malignancy, fistula, or if arteries or veins are exposed in the wound
Heat and Cold Therapy
heat accelerates the inflammatory response to promote healing
cold constricts blood vessels, reduces muscle spasms, and promotes comfort
