Skin and wound Flashcards
Skin is the bodies ___ organ
Largest
What are the functions of skin
Protective barrier against disease-causing organisms
Sensory organ for pain, temp, and touch
Can synthesize vitamin D
Contributes to self-esteem
Can absorb medications
Loss of water, electrolytes, & nitrogenous wastes in sweat
Epidermis-
Dermis-
Subcutaneous tissue-
Epidermis- top layer
Dermis- inner layer; contains collagen, __blood and lymph___ vessels, & nerves
Subcutaneous tissue- contains _____ & lymph vessels, nerves, & fat cells
Collagen- tough, fibrous protein
Collagen-
Collagen- tough, fibrous protein
types of wounds
Incision-
Incision- cutting sharp instrument wound
types of wounds
Contusion-
Contusion- blunt wound skin intact
types of wounds
Abrasion-
Abrasion- friction rubbing or scraping
types of wounds
Laceration-
Laceration- tearing of the skin not aligned cut
types of wounds
Puncture-
Puncture- enters the skin
types of wounds
Penetrating-
Penetrating- puncturing and loging in tissue possible scattering inside skin
types of wounds
Avulsion-
Avulsion- tearing from natural anatomical position damage to blood nerves and other structures
types of wounds
Irradiation-
Irradiation-ultraviolet or radiation exposure
types of wounds
Pressure ulcers-
Pressure ulcers- compromised circulation caseing preasure
types of wounds
Venous ulcers-
Venous ulcers- injury related to poor venus return due to underlying obstruction
types of wounds
Arterial ulcers-
Arterial ulcers- underlying ischemia from thrombosis
types of wounds
Diabetic ulcers-
Diabetic ulcers- caused by diebetic condition or
Wound Classification
Intentional & unintentional
Intentional-(planned therapy or treatment)
& unintentional-(unexpected trauma)
Wound Classification
Open & closed
Open-(skin surface is broken)
& closed(internal injury like hemmorigeing)
Wound Classification
Acute & chronic
Acute(low risk of infection healing proccess is normal)
& chronic(infection risk is high wound does not heal normally)
4 stages of wound healing?
Hemostats
Inflammation
proliferation
maturation
Hemostasis
blood vessels constrict clotting begins Exudate is released causing swelling and pain
Inflammation
Inflammatory phase- follows hemostasis & lasts 4-6 days. WBC mainly luekocytes move to the wound. Macrophages arrive about 24 hours after injury to ingest debris & release growth factors. The patient will have pain, heat, redness & swelling at the site. A mildly elevated temp,
proliferation
Proliferation phase- lasts for several days; filling of the wound with granulation tissue primarily thru the action of fibroblasts. Highly vascular, red, & bleeds easily. If healing by primary intention, epidermal cells seal the wound within 24-48 hours. Collagen synthesis and accumulation continue. Depending on the size of the wound can take several weeks to years. By the end of the second week the majority of WBC have left the wound area & the wound is lighter in color.
maturation
Maturation phase- Begins about 3 weeks after the injury. A scar forms- an avascular tissue that does not sweat, grow hair, or tan in sunlight. It is less elastic than uninjured tissue. Wounds that heal by secondary intention take longer to remodel.
Primary intention-
Primary intention- healing occurs by epithelialization; heals _Quickly(skin is connected still) with minimal scar formation
Secondary intention(open wound)-
Secondary intention(open wound)- wound heals by granulation tissue formation, wound contraction, and epithelialization
Tertiary or delayed primary-
Tertiary or delayed primary- closure of wound is delayed until risk of infection is resolved(we open the wound to try to get dangerous infection out)
Exudate
The accumulation of exudate causes swelling and pain.
What local factors effect healing?
LOCAL FACTORS: Pressure(longer to heal) Desiccation( extreme dryness) Maceration Trauma Edema Infection Excessive _Bleeding_ Necrosis(dead tissue in the way) Biofilm
What systemic factors effect healing?
SYSTEMIC FACTORS: _Age_ Circulation to & oxygenation of tissues Nutritional status(don’t eat protein slower heal) Wound etiology(what caused wound?) Health status(diabetic) Immunosuppression Medications Adherence to treatment plan
desiccation
the process of drying up delays healing wound should be kept moist(not wet)
maceration
over-hydration breakdown of skin to over hydration likely from incontinence
necrosis
death of tissue appearance of eschar dry black dead tissue wound will not heal with dead tissue present
biofilm
result of wound bacteria growing in clumps and weaking resistances
Dehiscence
Dehiscence(wound opened back up)
Evisceration
Evisceration(organs intestines comeing out of the wound)
Fistulas
an abnormal passage from an internal organ to the outside of the body
CLASSIFICATION OF PRESSURE ULCERS
STAGE I
Intact
Change in skin turgor, tissue consistency, and/or sensation
Defined area of persistent redness- light pigment
Persistent red, blue, or purple hues- darker skin tones
CLASSIFICATION OF PRESSURE ULCERS
STAGE II
Partial thickness skin loss involving epidermis and/ or dermis
Superficial
Abrasion, blister, or shallow crater
CLASSIFICATION OF PRESSURE ULCERS
STAGE III
Full-thickness __skin__ loss involving damage or necrosis of subcutaneous tissue
Does not extend thru underlying fascia
Deep crater w/ or w/o undermining of adjacent tissue
CLASSIFICATION OF PRESSURE ULCERS
UNSTAGEABLE PRESSURE INJURY
Full-thickness skin and tissue loss in which the extent of the tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a stage 3 or 4 pressure ulcer will be revealed. Stable eschar on the heel or ischemic limb should not be softened or removed.
CLASSIFICATION OF PRESSURE ULCERS
STAGE IV
STAGE IV
Full- thickness __skin__ loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures
May have undermining & sinus tracks
abcess
infected fluid that has not drained
“Pressure Ulcers increase hospital costs significantly. In the US, pressure ulcer care is estimated to approach $__ (USD) annually, with a cost of between $___ (USD) and $__ (USD) per individual pressure ulcer
“Pressure Ulcers increase hospital costs significantly. In the US, pressure ulcer care is estimated to approach $11 billion (USD) annually, with a cost of between $500 (USD) and $70,000 (USD) per individual pressure
FACTORS WHICH INFLUENCE PRESSSURE ULCER FORMATION
Nutrition Tissue perfusion Infection Age Psychosocial impact
Discuss nursing assessment of skin integrity and wound healing.
Identify the client’s __risk__ for developing impaired skin integrity
Identify signs and symptoms associated with impaired skin integrity or __poor__ wound healing
Examine client’s skin for actual impairment in skin integrity
Skin
Pressure ulcers- predicted measures measures; mobility, nutritional status, body fluids, & pain.
Wounds- emergency setting(control bleeding) vs. stable setting(prevent infection)
others Wound appearance Character of wound drainage Drains Wound closures Palpation of wound Wound cultures Client expectations
What are some wound related nurseing diagnosis?
Risk for infection
Acute or chronic pain
Impaired skin integrity
Risk for impaired skin integrity
Imbalanced nutrition- less than body requirements
Impaired physical mobility
Ineffective tissue perfusion
debidement
(removal) devitalized tissue removal
Necessary to rid the ulcer of a source of infection
Enable visualization of the wound bed
Provide a clean base necessary for healing
“heel ulcers w/ dry eschar need not be debrided if they do not have edema, erythema, fluctuance, or drainage.”
May observe an increase in wound exudate, odor, and ____
Manage pain
