Skin Integrity Flashcards
refers to the presence of normal skin and skin layers uninterrupted by wounds.
intact skin
Factors affecting skin integrity
genetics
age
illnesses
medications
nutrition
Types of wounds
cut
stab
stab and cut
torn
bitten
chopped
crush
hurt
firearms
scalped
surgery
poisoned
are uninfected wounds in which there is minimal inflammation and the respiratory, gastrointestinal, genital, and urinary tracts are not entered
clean wounds
are surgical wounds in which the respiratory, gastrointestinal, genital, or urinary tract has been entered.
clean contaminated wounds
include open, fresh, accidental wounds and surgical wounds involving a major break in sterile technique or a large amount of spillage from the gastrointestinal tract.
contaminated wounds
include wounds containing dead tissue and wounds with evidence of a clinical infection, such as purulent drainage.
dirty or infected wounds
Types of Wounds
incision
contusion
abrasion
puncture
laceration
penetrating wound
Sharp instrument (e.g., knife or scalpel)
Open wound; deep or shallow; once the edges have been sealed together as a part of treatment or healing, the incision becomes a closed wound
incision wound
Blow from a blunt instrument
Closed wound, skin appears ecchymotic (bruised) because of damaged blood vessels.
contusion
Surface scrape, either unintentional (e.g., scraped knee from a fall) or intentional (e.g., dermal abrasion to remove pockmarks)
Open wound involving the skin
abrasion
Penetration of the skin and often the underlying tissues by a sharp instrument, either intentional or unintentional
puncture
Tissues torn apart, often from accidents
lacerations
Penetration of the skin and the underlying tissues, usually unintentional (e.g., from a bullet or metal fragments)
penetrating wound
are one of the many signs of nursing home abuse, nursing home neglect, or medical malpractice in a hospital.
bedsores
consist of injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of force alone or in combination with movement.
pressure ulcers
What are the risk factors of pressure ulcers?
friction and shearing
immobility
inadequate nutrition
fecal and urinary incontinence
decreased mental status
diminished sensation
excessive body heat
advance age
presence of certain chronic condition
is a force acting parallel to the skin surface.
friction
is a combination of friction and pressure. It occurs commonly when a client assumes a sitting position in bed.
shearing force
refers to a reduction in the amount and control of movement a person has.
immobility
causes weight loss, muscle atrophy, and the loss of subcutaneous tissue.
inadequate nutrition
More specifically, inadequate intake of
1.
2.
3.
4.
5.
contributes to pressure ulcer formation
protein
carbohydrates
fluids
zinc
vitamin c
Moisture from incontinence promotes skin maceration (tissue softened by prolonged wetting or soaking) and makes the epidermis more easily eroded and susceptible to injury.
fecal and urinary incontinence
tissue softened by prolonged wetting or soaking
maceration
area of loss of the superficial layers of the skin; also known as denuded area
excoriation
Individuals with a reduced level of awareness, for example, those who are unconscious, heavily sedated, or have dementia, are at risk for pressure ulcers because they are less able to recognize and respond to pain associated with prolonged pressure
decreased mental status
Paralysis, stroke, or other neurologic disease may cause loss of sensation in a body area.
diminished sensation
is another factor in the development of pressure ulcers. An elevated body temperature increases the metabolic rate, thus increasing the cells’ need for oxygen
excessive body heat
The aging process brings about several changes in the skin and its supporting structures, making the older person more prone to impaired skin integrity. These changes include the following:
loss of lean body mass
Generalized thinning of the epidermis
• Decreased strength and elasticity of the skin due to changes in the collagen fibers of the dermis
• Increased dryness due to a decrease in the amount of oil produced by the sebaceous glands
• Diminished pain perception due to a reduction in the number of cutaneous end organs responsible for the sensation of pressure and light touch
• Diminished venous and arterial flow due to aging vascular walls.
These conditions compromise oxygen delivery to tissues by poor perfusion and thus cause poor and delayed healing and increase risk of pressure sores.
chronic medical conditions
Other factors contributing to the formation of pressure ulcers are
1.
2.
3.
4.
poor lifting and transferring technique
incorrect positioning
hard support surfaces
incorrect application of pressure-relieving devices
nonblanchable erythema signaling potential ulceration
what stage
stage 1
partial-thickness skin loss (abrasion, blister, or shallow crater) involving the epidermis and possibly the dermis
what stage
stage 2
full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia
stage 3
full-thickness skin loss with tissue necrosis or damage to muscle, bone, or supporting structures
what stage
stage 4
is material, such as fluid and cells, that has escaped from blood vessels during the inflammatory process and is deposited in tissue or on tissue surfaces.
exudate
consists chiefly of serum (the clear portion of the blood) derived from blood and the serous membranes of the body, such as the peritoneum.
serous exudate
is thicker than serous exudate because of the presence of pus, which consists of leukocytes, liquefied dead tissue debris, and dead and living bacteria.
purulent exudate
The process of pus formation is referred to as
suppuration
consists of large amounts of red blood cells, indicating damage to capillaries that is severe enough to allow the escape of red blood cells from plasma.
sanguineous exudate
consisting of both clear and blood-tinged drainage, is commonly seen in surgical incisions.
serosangioneous exudate
discharge, consisting of pus and blood, is often seen in a new wound that is infected.
purosanguineous
complications of wound healing
hemorrhage
infection
dehiscence with possible evisceration
is the partial or total rupturing of a sutured wound
dehiscence
usually involves an abdominal wound in which the layers below the skin also separate
dehiscence
is the protrusion of the internal viscera through an incision.
evisceration
a scalpel or scissors is u s e d to separate and remove dead tissue.
sharp debridement
removal of the necrotic material
debridement
is accomplished through scrubbing force or damp-todamp dressings.
mechanical debridement
is more selective than sharp or mechanical techniques. Collagenase enzyme agents such as papainurea are currently most recommended for this use.
chemical debridement
dressings such as hydrocolloid and clear absorbent acrylic dressings trap the wound drainage against the eschar
autolytic debridement
