Skin Integrity Flashcards
What are the layers of the skin?
Epidermis, Dermis, Subcutaneous Tissue
What are the functions of the integumentary?
Protection, metabolism, thermoregulation, elimination, sensation, psychosocial, absorption
How does the integumentary protect?
-from physical and chemical injury
USING sebum and normal flora
How does the integumentary metabolize
Vitamin D
How does integumentary thermoregulate
The dilation and constriction of blood vessels
How does the integumentary eliminate?
Water, electrolytes, and wastes
How does the integumentary control sensation?
Nerve endings
How does the integumentary relate to psychosocial
Facial expressions and hair distribution
How does the integumentary control absorption
Substances can be absorbed from vascularity
What factors affect the integumentary
Circulation, nutrition, skin condition (wet dry), allergy, infection, abnormal growth rate, systemic diseases
Signs of altered integumentary function
Pain, pruritus, rash, lesions
What is pruritus
Itching
List alterations to the integumentary
Intentional/unintentional
Open/closed
Acute/chronic
Integumentary concerns with children under 2
-skin is thinner and weaker
-does not have good adhesion between skin layers
-skin/mucous membranes are easily injured and subject to infection
-will become increasingly resistant
Integumentary concerns of elderly
-maturation of epidermal cells is prolonged, causing thin and easily damaged skin
-circulation and collagen formation are impaired, causing decreased elasticity and increased risk for pressure injury
What is the largest organ that provides sensory and a regulatory process
Skin/integumentary
Key points of the epidermis
-replaced monthly
-outer skin layer
-no blood vessels
Facts about the dermis
-cares for the epidermis
-has blood vessels, nerves, lymph and connective tissues
How does circulation effect the skin
The skin needs oxygen, waste removal and nutrition. If the body has impaired circulation resources will be given elsewhere
What nutrients affects the skin
Vitamin C, protein, carbs
Key point about skin and allergies
Skin will be the first response to allergy
Most common infections to the skin, and what do viruses and fungi cause?
Strep and Staph
-Virus=Warts
-Fungus=Yeast
Systemic diseases that affect the skin
PVD, HF, kidney failure (toxins), liver failure, peripheral neuropathy, diabetes
Symptoms of psoriasis and aggregators
-skin will regenerate every 3-4 days
-chronic condition
-red scaly plaques (scalp, elbows, knees, feet)
Effected by stress and environment
Concern with unintentional wound
More prone to infection, with longer healing time
What makes something an intentional wound
Created under ideal conditions for therapeutic conditions
What makes a wound open/closed
Open=skin is broken
Closed=trauma is under the surface
Difference between acute/chronic wounds
Acute=predictable pattern
Chronic=inflamed, stuck in the inflammatory stage and will heal slowly
Define Laceration, puncture, abrasion, and exposure wound
L=tearing of skin, normally loose skin
P= increased infection risk, contaminated object enters skin
A= rubbing/scraping
E= temperature, pH, chemicals, electricity (causing skin cell death)
What is the primary intervention for pressure injuries
Prevention
What is the difference between pressure injuries, decubitus ulcers and bed sores
Nothing, they are all the same
What is a pressure injury
Death of tissue, caused by external pressure over a bone
Common causes and risk factors to pressure injuries
C= pressure intensity and duration
R= impaired tissue tolerance, nutrition, moisture, age, friction, shear, Braden score less than 18
comorbid conditions: quadriplegic, unaware, dementia, ICU pts. Stroke, anything effecting consciousness, sensory, mobility
What is shear
Epidermal and dermal layer moving in opposite direction
What is a stage 1 pressure injury
Non blanchable erythema of intact skin
What is a stage 1 pressure injury
Non blanchable erythema of intact skin
What is a stage 2 pressure injury
Partial thickness skin loss
Looks like abrasion or blister
What is a stage 3 pressure injury
Full thickness skin loss with damage or necrosis of SQ tissue
Presents as a deep crater
What is a stage 4 pressure injury
Full thickness skin loss with extensive destruction, necrosis, damage to muscle, bone or tendons
What is slough
Non viable tissue
-yellow, tan, gray, green, brown
WOUND WILL NOT HEAL WITH IT
What is Escher
Dark brown or black
-crust like, non viable tissue
WOUND WILL NOT HEAL WITH IT
What is an unstageable pressure injury
Full thickness tissue damage, base of the wound is covered with slough or Escher
-will be a 3-4 once dead tissue is removed and depth can be determined
What is a suspected deep tissue injury SDTI
Purple or maroon localized area of intact skin
-can be confused to be stage one, but is 3-4
What is autolytic debridement
Used of hydrocolloid or foam dressings
Body’s enzymes and defense mechanisms will remove necrotic tissue
-dressings stay on for 3-7 days
What is enzymatic debridement
Application of prepared enzymes
-most common treatment
What is sharp/surgical debridement
Use of a scalpel, done by physicians or advance practice can be done bedside or OR
What is mechanical debridement
Use of physical force, painful and old fashioned style
-pressure wash, wet/dry dressing
Can have pain meds or surgery to perform
-ex. hydrogen peroxide
What is bio-surgical debridement
Use of surgical grade larvae, secretes enzyme that eats necrotic tissue
-can be last option before amputation
-can also be non therapeutic
List types of debridement in order of least to most severe
Autolytic, enzymatic, sharp, mechanical, bio-surgical
Define hemostasis healing
Controls bleeding and lasts 48 hours
-vasoconstriction
-exudate production
-clot formation
Define hemostasis healing
Controls bleeding and lasts 48 hours
-vasoconstriction
-exudate production
-clot formation
What is exudate
Plasma/clear fluid
What is exudate
Plasma/clear fluid
What is inflammatory response in terms of wound healing
WBC are working (with temporary increase) lasting 4-6 days
-vasodilation
-phagocytosis (digestion of foreign substances)
-localized response — redness/heat
What is proliferative in terms of wound healing
New tissue is being formed, lasts 3-24 days
-fibroblasts and growth factor create collagen and blood vessels
-granulation formation —small/fragile skin cells
What is maturation in terms of wound healing
Can take 2 years
-collagen matures and scar tissue is created
-A vascular and less elastic
-10-12 weeks to reach 70-80% strength
Describe primary intention wound healing
Most common process and the goal
-think surgical wound
Describe secondary intention wound healing
What pressure injury would be
Describe tertiary intention wound healing
Delayed closure intentionally
Least common healing process
Systemic factors effecting wound healing
Age,
nutrition (protein/albumin, vitamin A/C, zinc)
Circulation/oxygenation
Health status- diabetes, shock, obesity, suppressed immune system (neutropenic)
What are some local factors effecting wound healing
Moisture
-desiccation—DRY
-maceration —MOIST
Trauma (injury that got injured)
Edema (impaired blood flow)
Infection (competition)
Bleeding
Necrosis
Biofilm (thick, slimy, sugar proteins of bacteria, resistant and tricky to manage)
Common complications of wound healing
Hemorrhage -bleeding in or out
-hematoma (inside, collecting blood, watch for pressing on nerve or vessel)
Dehiscence (caused by infection, bleeding, strength)
Evisceration
Infection
Fistula - passage between surfaces dont connect
(Wound healing, trauma, cancer)
Signs of localized infection
Redness — cant happen in late healing
Heat
Edema
Pain
Altered function
Drainage and dehiscence
