Skin Integrity Flashcards
list some functions of the skin
- Protects against disease causing organisms
- Sensory organ for temperature, pain, and touch
- Synthesizes Vitamin D
- Injury to skin poses a risk to safety and triggers a complex healing process
factors affecting skin
- Genetics and heredity
- Age
- Chronic illnesses and their treatments
- Medications
- Poor nutrition
outer and top layer of the skin that you can see and touch
epidermis
protein inside skin cell
keratin
inner layer of skin
dermis
what is the function of the epidermis
functions to resurface wounds & restore the barrier against bacteria
what is the function of the dermis
functions to restore structural integrity-collagen & physical properties of skin
list the types of wounds
open wounds
closed wounds
ulcers
list types of open wounds
abrasion
laceration
puncture
avulsion
This kind of wound is not deep, so there is little to no bleeding that occurs
abrasion
deep and jagged cut that results in skin tears and heavy bleeding
laceration
hole-shaped wounds caused by pointy objects such as needles and nails
puncture
severe wound that can result in the partial or complete tear of the skin and tissues
avulsion
list types of closed wounds
contusions
blisters
seroma
hematoma
crush injury
happens when small blood vessels get torn and leak blood under the skin
contusion
bubbles that pop up when fluid collects in pockets under the top laver of your skin
blisters
accumulation of clear fluid under the skin, typically near the site of a surgical incision
seroma
pool of mostly clotted blood that forms in an organ, tissue, or body space
hematoma
result of physical trauma from prolonged compression of the torso, limb(s), or other parts of the body
crush injury
list types of ulcers
pressure
venous
arterial
neuropathic
Injury to skin and/or underlying tissue usually over a bony prominence
pressure injuries
Deficiency in blood supply to tissue
ischemia
Bright red flush to skin when pressure is received
reactive hyperemia
Extra blood floods to compensate for preceding period of impeded blood flow
vasodilation
trauma caused by tissue lavers sliding across each other, results in disruption or angulation of blood vessels
shear
what are the common pressure sites within the supine position
heels
sacrum (tailbone)
scapulae (shoulder)
back of head
what are the common pressure sites of the lateral position
malleolus (ankle)
knee
ilium (hips)
shoulder
ear
side of head
what are the common pressure sites within the prone position
toas
knees
genitalia (men)
breasts (women)
shoulder (acromial process)
cheek and ear (zygomatic bone)
what are the common pressure sites within the fowlers position
heels (calcaneus)
buttocks
sacrum
ball of foot
pelvis
vertebrae
Intact skin with non-blanchable redness or erythema of a localized area usually over a bony prominence. Darkly pigmented skin may not have blanching: its color may differ from the surrounding area
What stage of pressure ulcer is this
stage 1
list stage 1 pressure ulcer treatment
- Off-load pressure
- Transparent film dressing
- Hydrocolloid dressing
- Moisture barrier
Partial thickness skin loss involving the epidermis and/or dermis. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow open ulcer. Presents as shiny or shallow ulcer red/ pink wound bed) without slough or bruising
what stage of pressure ulcer is this
stage 2
list stage 2 pressure ulcer treatments
hydrocolloid dressing
absorptive dressing
hydrogel
off-load pressure
Full thickness skin loss involving damage or necrosis to subcutaneous tissue that may extend down to, but not through underlying fascia. Ulcer presents as a deep crater with or without undermining or tunneling of adjacent tissue
what stage of pressure ulcer is this
stage 3
list stage 3 pressure ulcer treatments
- Requires physician order for Stage Ill or
- Draining vs. Non-draining
- Necrotic vs. Granulating
- Draining wounds.-Absorptive dressings
- Granulating wounds..*Hydrogel
- Necrotic wounds-Require debridement (Chemical. Mechanical, Autolytic, Sharp
Full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone, or supporting structures. Exposed bone or tendon is visible or directly palpable
what stage of pressure ulcer is this
stage 4
Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown, black) in the wound bed. The true depth of the wound cannot be determined until slough or eschar is removed
what is this referred as
unstageable wound
types of wound healing
primary intention
secondary intention
tertiary intention
- Tissue surfaces approximated (closed) with sutures
- Minimal or no tissue loss
- Formulation of minimal granulation tissue and scarring
healing by which intention
primary intention
- Extensive tissue loss
- Edges cannot be approximated.
- Repair time is longer.
- Scarring is greater.
- Susceptibility to infection is greater
healing by which intention
secondary intention
- Also known as delayed primary intention
- Initially left open 3-5 days
- Edema, infection to resolve, or exudate to drain
- Closed with sutures, staples, or adhesive skin closures
healing by which intnetion
tertiary intention
list phases of wound healing
inflammatory phase
proliferative phase
maturation phase
list complications of wound healing
hemorrhage
infection
dehiscence with possible evisceration
list factors affecting wound healing
- Developmental considerations
- Nutrition
- Lifestyle
- Medications
types of exudates
- Serous
- Purulent
- Sanguineous
- Mixed Exudates
- Mostly serum
- Derived from blood and serous membranes of the body
- Looks watery, few cells
Serous Exudates
- Thicker
- Presence of pus
- Consists of leukocytes, liquified dead tissue debris, dead and living bacteria
- Color varies with causative organism
Purulent exudate
- Large number of RBCs
- Indicates severe damage to capillaries
- Frequently seen in open wounds
Sanguineous exudate
mixed exudate is composed of what
Serosanguineous
Purosanguineous
Clear and blood-tinged drainage
Serosanguineous
Pus and blood
Purosanguineous
dry, leathery, black or brown
Eschar
stringy, cheesy, loose, yellow, tart
Slough
healthy, viable pink to beefy red
Granulation
occurs along wound edges or as islands inside wound bed, pale pink resurfacing of wound
Epithelialization
may mean infection
Erythema
Whitish, wrinkled appearance
Maceration
Macular or papular, may indicate fungal infection
Rash
