Skin Integrity Flashcards
wound
break or disruption in normal skin and tissue integrity
wound types
closed/open
clean/dirty
closed
deep but skin is closed on top
incision
clean cut
sterile
edges well approximated
clean wound example
surgical
dirty wound example
PI
contusion
bruise
abrasion
like rug burn
scrape atop skin
puncture
anything going into skin
*bullet, IV
laceration
cut not clean
jagged
traumatic
partial thickness
epidermis
dermis
full thickness
down to SUBQ and muscle
acute wound
wound that heals in normal expected time
chronic wound
wound that takes extended time to heal
intentional wound
surgery
unintentional wound
trauma/accidents
what is the first line of defense
INTACT skin
what does normal healing require
circulation
clean environment
nutrition/hydration
primary healing
wound edges well approximated and closed
secondary healing
edges not approximated
extensive tissue loss
repair time longer
scarring greater
susceptibility to infection increased
*takes a long time bc cell regeneration
tertiary healing
wounds left open for 3-5 days then closed with sutures
hemostasis
clotting
*happens right away
inflammatory phase
white cells (macrophages) come in to clean wound, presents with redness and swelling
proliferation stage
cells are growing and renewing
epithelial cells and new tissue
maturation stage
wound stabilized
scar tissue
structure
is secondary intention for clean or dirty wounds
dirty
scar tissue is never as strong as
original intact skin
serous
plasma
clear/transparent
yellow tinge
sanguineous
blood
serosanguineous
clear with blood
pinkish tinge
purulent
pus
green/yellow/brown
infection and pathogens
biofilms
bacteria that grows in clumps of proteins and sugars that cover wound bed
*inhibits healing
hemorrhage
wound bleeds
dehiscence
usually for abdominal wounds
two edges have come apart
*post abdominal surgery, coughing/vomiting puts pressure on suture line and it busts
evisceration
busts through muscles and skin down to organs
teaching to prevent dehiscence and evisceration
splinting
hold pillow over stitches then cough
fistula
two things that should not be connected but are
actions for evisceration
cover with saline soaked sterile gauze and call physician
vitamins needed for wound healing
vitamin a
vitamin c
iron
zinc
copper
desication
dry skin
maceration
skin pruning
why do steroids affect wound healing
decrease immune response
why does aspirin affect wound healing
blood thinner
affects hemostasis
why do antineoplastic (chemo) meds affect wound healing
kills all cells
RYB
red - protect
yellow - clean
black - debride
albumin measures
protein from 6 weeks prior
prealbumin measures
protein NOW
purpose of wound culture
identify organisms on surface
*use Z method
*clean first
healing wound bed
pink granulation tissue
penrose drain
empties into dressing
*passive drain
*not sutured
retention sutures are used for
large areas
Jackson Pratt (JP) drain
bulb like drains adjacent to surgical area
*during inflammatory phase fluid is not drained, could cause abscess
*drains fluids or exudates
*we measure how much and what its draining
*take out if nothing after 8is hours
*active drain
*sutured in
hemovac
active
sutured
used for bigger volumes
when to use heat therapy
few days after injury
when to use cold therapy
initially
what does heat therapy increase
blood flow (healing)
O2 and nutrients
leukocytes to area
smooth muscle relaxation
cellular metabolism
what does heat therapy decrease
pain
what does cold therapy decrease
edema and inflammation
bleeding
muscle spasms
cellular metabolism (slows bacterial growth)
cold therapy causes ______ and ______
vasoconstriction (stops bleeding)
local anesthetic effect
why use cold therapy initially
causes vasoconstriction = decreased blood flow = hemostasis
decreases cellular metabolism = decreased pathogen amount
why use heat therapy after a couple days
increased blood flow = supplies O2, nutrients, and leukocytes to area = promotes inflammation and proliferation stage
normal saline
0.9 NS
surgical debridement
cut out in OR
chemical debridement
dakins bleach solution dressing
mechanical debridement
4x4 wet to dry and rip out tissue
maintain a moist wound environment
wet to moist dressing
if there is a wet to moist dressing and the dressing dries out, what do we do
rewet the dressing before removal
braden score less than ____ gets mepilex on the sacrum
18
tegaderm dressing
non-absorbent
protective
*clear sticker
for IV sites and redness
mepilex uses
prevents pressure wounds
waterproof
worn up to 7 days
absorbs drainage
never used for infected
protects wounds and surrounding skin
why don’t you use mepilex for infected wounds
it seals in the infection and makes it worse
mepilex can prevent _____ and _____
friction and shear
negative pressure wound therapy
creates vacuum over the wound surface
what does NPWT do
draws out fluids
decreases bacterial growth
increases blood flow
brings together wound edges
NPWT stimulates
epithelial growth tissue
silvadine cream for
burns
*silver in silvadine is antibacterial properties
what is hydrogel
water goop
*keeps moisture in
*put on pink granulated tissue
