Skin Integrity Flashcards
layers of the skin
epidermis, dermis, subcutaneous tissue,
What layer of epidermis is the first line of defense?
Stratum corneum
what layer of the epidermis produces new cells
stratum germinativum
What layer houses sweat glands and hair follicles?
dermis
as we age what skin layer gets thinner and thinner?
subcutaneous
how do we classify wounds?
what layers it has entered
what factors affect skin integrity
surgery, injury, psoriasis, atopic dermatitis, meds, impaired circulation, slow healing
Of the following factors, which would put a client at greatest risk for impaired skin integrity:
Medication, digoxin
Moisture
Decreased sensation
Dehydration
decreased sensation
what is maceration
breakdown of skin from being wet
what are the stages of skin healing?
cleansing & granulation, epithelialization
how long does it take to form granulation tissue?
5-21 days
how long does it take to form scar tissue?
3-6 months
What is serous exudate?
clear, watery
what is sanguoneous drainage?
blood
what is serosanguinous drainage?
combination of blood and serous
what is purulent exudate
pus- thick, white/yellow
what is purosanguineous exudate?
red-tinged pus/purulent
what position do you place PT in for wound assessment?
neutral
what are some types of wounds
abrasions, abscess, contusion, crushing, excoriation (scratching), incision, laceration, penetrating wound, puncture wounds (mechanism goes in & out), tunnel wound
symptoms of internal hemorrhage
diaphoretic, anemic, tired
what is a dehiscence
separation of edges of a wound
EX; (sutures releasing and wound opening)
what are the signs to look for infection
Soft red hens produce furry fluffy chicks
swelling, redness, heat, pain, fever, foul smell, color change
What is an evisceration?
wound opens with internal tissue outside of the body
what is a fistula?
unnatural opening between two body cavities
what wounds would you culture?
any wound with a sign of infection or delayed healing of 2 weeks or <
what is the biggest thing to remember about drains?
to document excrement’s
what is a debridement?
cleaning out dead tissue/slough
how do you take care of wounds at home?
Wet – dry it
Open – cover it
Unclean – clean it
Necrotic – Don’t scrub it
Dry – Moisten it
what are pressure ulcers
Injury to the skin and underlying tissue over a bone
How are ulcers staged?
by type of tissue involved
can stages go back? can you go from a stage 4-stage 2?
No, they can only heal
how can you prevent ulcers?
repositioning at least every 2 hours
inspect skin daily
assess the injury-Braden scale
manage moisture
what is the Braden scale?
a scale used for predicting pressure ulcer risk
what is a stage 1 pressure injury?
localized
non-blanchable redness
under a bony prominence
only epidermis is affected
what is a stage 2 pressure injury?
partial thickness lost of dermis
open but shallow
red wound bed
can be blister or ulcer
no bruising/sloughing
what is a stage 3 pressure injury?
crater with full thickness sin loss
damage or necrosis of SQ tissue
viable adipose tissue
no bone visible
may be very deep
what is a stage 4 pressure injury?
full thickness skin loss
tissue necrosis
damage to muscle/bone
exposed bone/tendon/cartilage
slough or eschar may be present
minimum a year to heal
what is a deep tissue injury?
skin is intact but discolored
purplish
boggy
blister
what is an unstageable pressure injury?
full thickness skin loss
base of wound is not visible
collagen
tough fibrous protein
blanching
normal red tones of light skin are absent
pressure factors that contribute to pressure ulcer development
pressure intensity
pressure duration
tissue tolerance
risk factors that predispose a patient to pressure ulcer formation
impaired sensory perception
-impaired mobility
-alteration in LOC
-shear
-friction
-moisture
granulation tissue
red, moist tissue composed of new blood vessels, which indicate wound healing
slough
stringy substance attached to wound bed that is soft, yellow or white tissue
eschar
black or brown necrotic tissue
hemostasis
injured blood vessels constrict, and platelets gather to stop bleeding; clots form a fibrin matrix for cellular repair
potential or actual nursing diagnoses related to impaired skin integrity
risk for infection
-imbalanced nutrition: less than body requirements
-acute or chronic pain
-impaired skin integrity
-impaired physical mobility
-risk for impaired skin integrity
-ineffective tissue perfusion
-impaired tissue integrity
advantages of a transparent film dressing
-adheres to undamaged skin
-serves as barrier to external fluids and bacteria but allows wound surface to breathe
-promotes moist environment
-permits viewing
-does not require secondary dressing
functions of hydrocolloid dressing
absorbs drainage through the use of exudate aborbers
-maintains wound moisture
-slowly liquefies necrotic debris
-impermeable to bacteria
-self-adhesive and molds well
-acts as a perventative dressing for high-risk friction areas
-may be left in place for 3-5 days, minimizing skin trauma and disruption of healing
advantages of hydrogel dressing
soothing and reduces pain
-provides a moist environment
-debrides the wound
-does not adhere to the wound base and is easy to remove
warm, moist compresses
improve circulation, relieve edema, and promote consolidation of pus and drainage
warm, moist compresses
improve circulation, relieve edema, and promote consolidation of pus and drainage
What can the nurse do for clients with a Braden score of no risk?
educate, evaluate on change of condition
What can the nurse do for clients with a Braden score of mild/moderate risk?
reposition
promote activity
manage individual risk factors
educate
evaluate change of condition
What can the nurse do for clients with a Braden score of high/severe risk?
supplement with small positional shifts
seating/posture assessment
nutrition assessment
educate
evaluate change of condition
Fstage
