Skin Integrity Flashcards
Moisture cools body and remove bacteria
Secretion and excretion
Underlying structures from physical and chemical injury holds in the body fluids and contains melanin to protect from ultraviolet rays
Protection
By dilation and constriction of blood vessels
Temperature regulation
Touch pain hot cold and pressure integration of this data from the environment is important in maintaining homeostasis
Sensation
Pinching and releasing the skin
Turgor
Clean, well approximated edges sutured closed
Primary
Tissue missing and must heal from inside out
Secondary
Delayed wound closure when infection anti payed lose suture may be used
Tertiary
Stressors that increase trial for skin break down
Life style and habit Immobilization Reduced sensation Poor nutrition Poor hydration Inadequate circulation External device Prolonged moisture Decreased mental status Excessive body heat Age/development change in the skin
Is the force acting parallel to the skin surface
Friction
One of the most common complication of prolonged immobility
Pressure ulcers
Non blanch able erythema usually reversible if pressure is relieved
Stage 1
Shallow crater skin blister take weeks to heal
Stage 2
Requires months to heal not painful foul smelling goes through subcutaneous tissue and capillary beds
Stage 3
All layers plus extends to the bone sore may appear small but deep tunnels necrotic edges may be black and takes months to years to heal
Stages 4
