SKIN and WOUNDS Flashcards
how does circulation affect the integumentary function
Maintain cell life. Lead to abnormal color, texture, thickness or moisture of skin
how does nutrition affect the integumentary function
well-nourished skin cells are less likely to get injured or diseases
condition of epidermis
Outer wrapping
Epidermis avascular, no blood vessels, relies on underlying dermis for nutrition
The epidermis replace itself every 15-48 days
how does allergy affect the integumentary function
Rash, hives, and swellings stimulated by histamine release
how does infection affect the integumentary function
too many natural flora and portal of entry is opened can cause an infection
Ex. antibiotics gets rid of good and bad bacteria
how does abnormal growth rate affect the integumentary function
Psoriasis (infected on elbows, knees, scalpe, and soles of feet. Red raised patches with white scales due to systemic inflammation.
systemic diseases
Peripheral vascular disease / diabetes (slower healing)
renal failure/ hepatic failure. (itchy, hepatic is jaundice
intentional
break in skin integrity for a therapeutic purpose.
Surgery
unintentional
not done on purpose more prone to infection; therefore, a longer healing time.
Abrasions: hard surface
Lacerations: tearing up skin and tissue with a blunt or irregular instrument
Puncture wound: penetrates the skin
open or closed
Closed: soft tissue damaged but skin is still intact
Open: skin is broken
acute or chronic
Acute: heals in days to week. Normal healing process
Chronic: do not progress through the normal healing process and remina in the inflammatory stage of wound healing. More susceptible to infection.
healing process of children younger than 2 years old
Skin is thinner and weaker
An infant’s skin and mucous membranes are easily injured and subject to infection
Becomes increasingly resistant to injury and infection
healing process of elderly
Maturation of epidermal cells is prolonged, leading to thin, easily damaged skin
Circulation and collagen formation are impaired, leading to decreased elasticity and increased risk for tissue damage from pressure.
- Pressure injuries/ Bedsore
- Decubitus ulcers
- Bedsores
pressure intensity
restriction of blood flow leading to low supply of O2 and nutrients leading to ischemia
risks of pressure injuries
Impaired tissue tolerance
nutrition
not enough vitamin c leading to poor circulation
moisture
more moisture, more chance of pressure injury.
Incontinence
age
older skin
friction
two surfaces rubbing together cause skin break down
shear
one layer of skin is sliding over another layer causing damage to the skin
- boosting in bed. sliding instead of lifting
comorbid conditions
Altered level of consciousness
Sensory impairment
Impaired mobility
common sites for pressure injury
scapula
sacrum
coccyx
patella
sole, heel, calcaneus
stage 1 Pressure injury
non- blanchable erythema of intact skin
Clear area, barrier cream or foam dressing to prevent from getting worse
stage 2 pressure injury
partial-thickness skin loss. Presents as an abrasion or blister
Similar interventions to stage I. Relieve pressure, barrier cream, foam dressing
stage 3 pressure injury
full-thickness skin loss with damage or necrosis of SQ tissue. Presents as a deep craters
Undermining (sterile Qtip in shelf or lip of wound) and tunneling (hole in wound, stick sterile Qtip through)
Slough can be present but does not obscure the depth of woundChange dressings twice a day, waffle mattress, nutrition consult
stage 4 pressure injury
full-thickness skin loss with extensive destruction, necrosis, or damage to muscle, bone, or tendons
Osteomyelitis (infection of bone)
Takes months to years to heal. Same interventions of stage III
slough
Yellow, tan, gray, brown,
Non-viable tissue
eschar
Dark brown or black
crust-like , non viable tissue
unstageable
Full thickness tissue damage
Base of the wound is covered by slough or eschar
susceptible deep tissue injury (SDTI)
Purple or maroon localized area of intact skin
autolytic debridement
Use of hydrocolloid or foam dressings
Bodys own enzymes and defensive mechanisms to loosen and liquefy necrotic tissue
bio-surgical debridement
Use of surgical grade/ sterile fly larvae
Larvae secrete enzyme that liquifies necrotic tissue, then larvae consumes liquid and infections material in the wound
enzymatic debridment
Application of commercially prepared enzymes
Enzymes are prescribed treatments by a provider
mechanical debridement
Use of an external physical force (irrigating a wound)
Painful method of debridement
sharp/ surgical debridement
Use of scalpel
Performed by physicians and advanced practice nurses
wound healing: hemostasis
Vasoconstriction: shut down to slow bleeding
Exudate production
Clot formation –> 48 hours of bleeding
wound healing: inflammatory
Vasodilation: after platelets are there to allow more fluid to get to wound
Phagocytosis: ingestion of bacteria
Localized inflammatory response: looks like an infection
- Lasts 4-6 days.
- Wbc surround the tissue and take care of any debri
- Redness, warmth, swelling, tenderness
proliferative
Lasts 3-24 days
Fibroblasts and Growth Factor create collagen and blood vessels
Granulation tissue formation
- Very vascular. Gentle and support to prevent from causing harm
new tissue built to fill the wound space, primarily through the action of fibroblasts.
maturation
Can take up to 2 years
Collagen matures
Scar tissue is created by collagen as it cures.
- Never regains full strength after healed. About 70-80% of previous strength
primary wound healing
Sacring is minimal
Risk of infection is less
Skin is still intact
secondary wound healing
Pressure injuries or deep
Edges of skin are not next to each other.
Heal from bottom up
Scaring is more obvious and infections are more common
tertiary wound healing
Delayed closer
Wound is intentionally left opened for a certain time to view bleeding or cant close site
how does age effect wound healing
Older: diminished circulation → prolonged healing
Young: poor adherence of dermis and epidermis → more trauma from smaller action but heal quicker
how does nutrition affect wound healing
Protein,
Vitamins A & C,
Zinc
how does health status affect wound healing
Diabetes
Shock
Immunosuppression
Obesity
how does moisture affect wound healing
Desiccation: dry and crusty
Maceration: excessive moisture or prolonged exposure to moisture
caused by overhydration related to urinary and fecal incontinence?
necrosis
healing with not occur if there is dead tissue
biofilm
thick sticky collection of bacteria and their habit.
Protect from antibiotics, wound care, tubes, plaque on teeth
Can make a wound more difficult to threat
attachment of biofilm
bacteria fasten onto a variety of surfaces using specialized tall-like structures. this can occur in pipes and water fibers, in the human intestine, and on implants such as heart valves
expansion of biofilm
the cells grow and divide forming dense matmary layers thick. the bacteria communicate with each other using specific signals. at this stage, the biofilm is still too thin to be seen.
maturation of biofilm
when there are enough bacteria in the developing biofilm the microbes secrete a surgery glue and form mushroom-shaped structures that look like futuristic cities
resistance biofilm
the glue protects the bacteria in the biofilm from the harsh environment outside, shielding them from antibiotics, toxic chemicals, and the body’s immune system.
hemorrhage: hematoma
collection of blood under intact skin. Usually looks like a bruise, warm to the touch
- Ice packs can help
- HBG/HCT: will be low
dehiscence
wound edges separated because of infection
evisceration
organs push through incision
infection
7 days after the wound occurs because of the inflammation stage.
HAI → osteomyelitis, sepsis,
fistula
abnormal passageway or connection of two adjacent organs/ vessels that do not normally connect.
r/t: cancer, treatments of cancer, infection
5 signs of localized infection
Redness
Heat
Edema —> Purulent : white puss, stinky
Pain
Altered Function
implementation: health promotion
Being aware medications can cause sensitivity to skin
Wear sunscreen, looking for moles, wear glasses so they don’t fall
implementation: prevent pressure injuries
Positioning & skin care
Pressure reducing surfaces
implementation: patient teaching
Hygiene and Handwashing
Pressure injury prevention
Symptoms of infection
implementation: prevent and manage wounds
Remove nonviable tissue
Manage wound exudate
evaluate and revise interventions
New interventions include: apply skin barrier to bilateral heels BID; utilize boot to suspend both heels off the bed surface at all times
ways of thinking: remember
recall facts and basic concepts
ex. The use of sharp tools to remove devitalized tissue is called Surgical debridemen
ways of thinking: understand
explain ideas or concepts
ex.Assessing a wound on a foot, the nurse finds tissue destruction down to the bone. The nurse would correctly classify this wound as which of the following? Stage 4 Pressure Injury
ways of thinking: apply
use information in new situations
ex.Which statement best describes the healing process for a surgical wound that was closed with sutures? The edges of the wound are approximated
ways of thinking: analyze
draw connections among ideas
ex.Which patient is at highest risk for impaired wound healing?
72 year old with diabetes and cardiovascular disease who had surgical repair of a broken hip
ways of thinking: evaluate
justify a stand or decision
ways of thinking: create
produce new or original work
why is a protein needed for our skin?
Protein needed for regeneration and healing of wounds
characteristics of the dermis
Provides support and nutrition to epidermis, nerve ending, blood vessels, lymphatic vessel
Dermis for nutrition and shred and regrow every 27-45 days.
Dermis is the thickest of skin composed of connective tissue
characteristics of the subcutaneous tissue
Underlies skin contains fat and connective tissue to support and cushion the skin (different than adipose tissue)
