Skin Integrity Flashcards
Skin
Synthesizes vitamin D, it’s a protective organ, barrier
Epidermis
Top layer of skin
Dermis
Inner layer of skin
Pressure ulcers
Have many names. It is the injury to skin and possibly underlining of the skin, usually over a bony prominence
Causes of pressure ulcers
Shearing, friction, pressure, pressure intensity, pressure duration and how much the tissue can handle
Impaired sensory perception
Patients can’t feel, usually diabetic, stroke or paralyzed victims
Shear
Skin and tissue moves while the muscle and bone stay stationary
Moisture
Reduces skin resistant and barriers. (Sweat, urine etc)
Friction
Sliding or dragging skin across another area
Classification of ulcers
Stage 1 (I) Stage 2 (II) Stage 3 (III) Stage 4 (IV)
Stage 1 (I) pressure ulcer
Intact skin with nonblanchable and redness
Stage 2 (II)
Partial thickness skin loss involving epidermis, dermis or both. Redness looks like its on fire
Stage 3 (III)
Full thickness tissue loss with visible fat exposed
Stage 4 (IV)
Full thickness tissue loss with exposed bone, muscle, or tendon. By this point the skin feels like a wet juicy sponge. This is where the tissues and cells are drying or have died
Norton scale Braden scale
Scales used to determine the stages of ulcers
Factors influencing pressure ulcer formation
Nutrition, tissue perfusion, infection, age, and psychosocial impact of wounds
Assessment of pressure ulcers
Look at all of the skin, presence of ulcers and if they are red or blanchable, if there were or are existing wounds
Treatment of ulcers
Topical skin care, skin barriers, positioning (turn every 2 hours), support surfaces (use pillows, pressure reducing mattresses that decrease the amount of pressure exerted on a bony prominence)
