Skin Integrity and Wound Care Flashcards
It refers to the presence of normal skin and skin layers uninterrupted by wounds.
Intact skin
Factors Affecting Skin Integrity
Genetics
Age
Illnesses
Medications
Nutrition
The Types of Wounds
(12)
Cut
Stab
Stab and Cut
Torn
Bitten
Chopped
Crush
Hurt
Firearms
Scalped
Surgery
Poisoned
Wounds, excluding pressure ulcers and burns, are classified by _, that is, the tissue layers involved in the wound.
depth
_: confined to the skin, that is, the dermis and epidermis; heal by regeneration.
Partial thickness
_: involving the dermis, epidermis, subcutaneous tissue, and possibly muscle and bone; require connective repair.
Full thickness
Wounds can be described according to _ and _ of wound contamination.
likelihood and degree
Wounds can be described according to the likelihood and degree of wound contamination:
(4)
Clean wounds
Clean-contaminated wounds
Contaminated wounds
Dirty or infected wounds
_ are uninfected wounds in which there is minimal inflammation and the respiratory, gastrointestinal, genital, and urinary tracts are not entered. _ are primarily closed wounds.
Clean wounds
_ are surgical wounds in which the respiratory, gastrointestinal, genital, or urinary tract has been entered. Such wounds show no evidence of infection.
Clean-contaminated wounds
_ include open, fresh, accidental wounds and surgical wounds involving a major break in sterile technique or a large amount of spillage from the gastrointestinal tract. _ show evidence of inflammation.
Contaminated wounds
_ include wounds containing dead tissue and wounds with evidence of a clinical infection, such as purulent drainage.
Dirty or infected wounds
Classifying Wounds by Depth
Partial thickness
Full thickness
Types of Wounds
Wounds may be described according to how they are acquired: (6)
Incision
Contusion
Abrasion
Puncture
Laceration
Penetrating Wound
Type of Wound: ?
Cause: Sharp instrument (e.g., knife or scalpel)
Incision wound
Type of Wound: ?
Description and Characteristics:
• Open wound
• Deep or shallow
• Once the edges have been sealed together as a part of treatment or healing, the incision becomes a closed wound.
Type of Wound: ?
Cause: Blow from a blunt instrument
Contusion
Type of Wound: ?
Cause: Surface scrape, either unintentional (e.g., scraped knee from a fall) or intentional (e.g., dermal _ to remove pockmarks)
Abrasion
Type of Wound: ?
Cause: Penetration of the skin and often the underlying tissues by a sharp instrument, either intentional or unintentional
Puncture
Type of Wound: ?
Cause: Tissues torn apart, often from accidents (e.g., with machinery)
Laceration
Type of wound: ?
Cause: Penetration of the skin and the underlying tissues, usually unintentional (e.g., from a bullet or metal fragments)
Penetrating Wound
Type of wound: ?
Description and Characteristics:
Closed wound, skin appears ecchymotic (bruised) because of damaged blood vessels.
Contusion
Type of wound: ?
Description and Characteristics:
Open wound involving skin
Abrasion
Types of wound: ?
Description and Characteristics:
Open wound
Puncture
Penetrating wound
Type of wound: ?
Description and Characteristics:
Open wound; edges are often jagged
Laceration
BEDSORES
As many as _ in _ nursing homes residents currently suffer from bedsores.
1 in 10
Staging of pressure ulcers: (4)
Stage 1: Skin is unbroken but inflamed
Stage 2: Skin is broken to epidermis and dermis
Stage 3: Ulcer extends to subcutaneous fat layer
Stage 4: Ulcer extends to muscle or bone. Undermining is likely
_, also known as _, _, and _, are one of the many signs of nursing home abuse, nursing home neglect, or medical malpractice in a hospital.
Bedsores
pressure sores, decubitus ulcers and pressure ulcers
_ consist of injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of force alone or in combination with movement.
Pressure ulcers
Pressure Sore Areas: (7)
Back of head and ears
Shoulder
Elbow
Hip
Lower back and buttocks
Inner knees
Heel
Etiology of Pressure Ulcers
Pressure ulcers are due to localized _, a deficiency in the blood supply to the tissue.
ischemia
Etiology of Pressure Ulcers
- When pressure is relieved, the skin takes on a bright red flush, called _.
- The flush is due to _, a process in which extra blood floods to the area to compensate for the preceding period of impeded blood flow.
reactive hyperemia
vasodilation
Risk Factors
Several factors contribute to the formation of pressure ulcers: (9)
• friction and shearing
• immobility
• inadequate nutrition
• fecal and urinary incontinence
• decreased mental status
• diminished sensation
• excessive body heat
• advanced age,
• presence of certain chronic conditions.
Risk Factors
_ is a force acting parallel to the skin surface.
Friction
Risk Factors
- For example, sheets rubbing against skin create _.
- _ can abrade the skin, that is, remove the superficial layers, making it more prone to breakdown.
friction
Risk Factors
_ is a combination of friction and pressure.
Shearing force
Risk Factors
- It occurs commonly when a client assumes a sitting position in bed. In this position, the body tends to slide downward toward the foot of the bed.
Shearing force
Risk Factors
_ refers to a reduction in the amount and control of movement a person has.
Immobility
Risk Factors
- Normally people move when they experience discomfort due to pressure on an area of the body.
- Healthy people rarely exceed their tolerance to pressure.
Immobility
Risk Factors
Prolonged _ causes weight loss, muscle atrophy, and the loss of subcutaneous tissue.
inadequate nutrition
Risk Factors
Inadequate Nutrition
- These three conditions reduce the amount of padding between the skin and the bones, thus increasing the risk of pressure ulcer development.
weight loss
muscle atrophy
loss of subcutaneous tissue
Risk Factors
Inadequate Nutrition
More specifically, inadequate intake of _, _, _, _, and _ contributes to pressure ulcer formation.
protein, carbohydrates, fluids, zinc, and vitamin C
Risk Factors
Inadequate Nutrition
- _ (abnormally low protein content in the blood), due either to inadequate intake or abnormal loss, predisposes the client to dependent edema.
Hypoproteinemia
Risk Factors
Inadequate Nutrition
- _ (the presence of excess interstitial fluid) makes skin more prone to injury by decreasing its elasticity, resilience, and vitality
Edema
Risk Factors
Fecal and Urinary Incontinence
- Moisture from incontinence promotes _ (tissue softened by prolonged wetting or soaking) and makes the epidermis more easily eroded and susceptible to injury.
skin maceration
Risk Factors
Fecal and Urinary Incontinence
- Digestive enzymes in feces, urea in urine, and gastric tube drainage also contribute to _ (area of loss of the superficial layers of the skin; also known as denuded area).
skin excoriation
Risk Factors
Decreased Mental Status
- Individuals with a reduced level of awareness, for example, those who are unconscious, heavily sedated, or have dementia, are at risk for pressure ulcers because _.
they are less able to recognize and respond to pain associated with prolonged pressure
Risk Factors
Diminished Sensation
- _, _, or _ may cause loss of sensation in a body area.
Paralysis, stroke, or other neurologic disease
Risk Factors
Diminished Sensation
_ reduces a person’s ability to respond to trauma, to injurious heat and cold, and to the tingling (“pins and needles”) that signals loss of circulation.
Loss of sensation
Risk Factors
Diminished Sensation
- Sensory loss also _.
impairs the body’s ability to recognize and provide healing mechanisms for a wound
Risk Factors
- _ is another factor in the development of pressure ulcers.
Body heat
Risk Factors
Excessive Body Heat
- An elevated body temperature increases the _, thus increasing the cells’ need for oxygen.
- This increased need is particularly severe in the cells of an area under pressure, which are already _.
metabolic rate
oxygen deficient
Risk Factors
Advanced Age
These changes include the following: (6)
• Loss of lean body mass
• Generalized thinning of the epidermis
• Decreased strength and elasticity of the skin due to changes in the collagen fibers of the dermis
• Increased dryness due to a decrease in the amount of oil produced by the sebaceous glands
• Diminished pain perception due to a reduction in the number of cutaneous end organs responsible for the sensation of pressure and light touch • Diminished venous and arterial flow due to aging vascular walls.
Risk Factors
Chronic Medical Conditions
- Certain chronic conditions such as _ and _ are risk factors for skin breakdown and delayed healing.
diabetes and cardiovascular disease
Risk Factors
- These conditions compromise oxygen delivery to tissues by poor perfusion and thus cause poor and delayed healing and increase risk of pressure sores.
Chronic Medical Conditions
Risk Factors
Other Factors Conditions
- Other factors contributing to the formation of pressure ulcers are _, _, _, and _.
poor lifting and transferring techniques, incorrect positioning, hard support surfaces, and incorrect application of pressure-relieving devices.
Stages of Bedsores
Stage 1: Persistent Redness
Stage 2: Partial-Thickness Skin or Tissue Loss
Stage 3: Full-Thickness Skin Loss
Stage 4: Full-Thickness Tissue Loss
Stages of pressure ulcers:
_: nonblanchable erythema signaling potential ulceration.
Stage 1
Stages of pressure ulcers:
_ : partial-thickness skin loss (abrasion, blister, or shallow crater) involving the epidermis and possibly the dermis.
Stage II
Stages of pressure ulcers:
_ : full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue.
Stage III
Stages of pressure ulcers:
_ : full-thickness skin loss with tissue necrosis or damage to muscle, bone, or supporting structures, such as a tendon or joint capsule. Undermining and sinus tracts may also be present.
Stage IV
Stages of pressure ulcers:
_ : full-thickness skin or tissue loss—depth unknown: Actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed.
Unstageable/unclassified
Stages of pressure ulcers:
_ —depth unknown: purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear.
- _ may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by _.
Suspected deep tissue injury
Deep tissue injury
thin eschar
Pressure Ulcers Sites:
Supine: (6)
Heels
Sacrum
Spine
Elbow
Scapulae
Back of head
Pressure Ulcers Sites:
Side-lying: (8)
Toes
Malleolus
Medial and lateral condyles
Greater trochanter
Iliac crest
Ribs
Acromion process
Ear
Pressure Ulcers Sites:
Prone: (7)
Toes
Knees
Genitalia (Males)
Anterior superior spinous processes
Breasts (women)
Acromion process
Cheek and ear
Phases of wound healing:
Inflammatory Phase
Proliferative Phase
Maturation Phase
Phases of wound healing:
• Begins when the wound develops, lasts 4-6 days
• Marked by oedema, erythema, inflammation and pain
• Healing process triggered
• Immune system works to prevent microbial colonization
Inflammatory Phase
Phases of wound healing:
• Lasts another 4-24 days
• Granulation tissue fills in the wound
• Fibroblasts lay collagen in the wound bed, strengthening new granulation tissue.
• Wound edges begin to contract
• Epithelial cells migrate from the wound margins
Proliferative Phase
Phases of wound healing:
• Can lasts 21 days - 2 years
• Length of time depends on patient - and wound-related complicating factors (e.g. duration of wound, patient comorbidities, wound infection status)
• Filled-in wound is covered and strengthened.
• Scar tissue forms
Maturation Phase
_ is a quality of living tissue; it is also referred to as _ (renewal) of tissues.
Healing
regeneration
Types of Wound Healing
Primary intention healing
Secondary intention healing
Types of Wound Healing
_ occurs where the tissue surfaces have been approximated (closed) and there is minimal or no tissue loss; it is characterized by the formation of minimal granulation tissue and scarring.
Primary intention healing
Types of Wound Healing
Primary intention healing
- It is also called _ or _.
- An example of wound healing by primary intention is a _.
primary union or first intention healing.
closed surgical incision
Types of Wound Healing
A wound that is extensive and involves considerable tissue loss, and in which the edges cannot or should not be approximated, heals by _.
secondary intention healing
Types of Wound Healing
Secondary intention healing
- An example of wound healing by secondary intention is a _.
pressure ulcer
Types of Wound Healing
Secondary intention healing differs from primary intention healing in three ways:
(1) The repair time is longer
(2) the scarring is greater
(3) the susceptibility to infection is greater.
Types of Wound Healing
- Wounds that are left open for 3 to 5 days to allow edema or infection to resolve or exudate to drain and are then closed with sutures, staples, or adhesive skin closures heal by _.
- This is also called _.
tertiary intention
delayed primary intention
Phases of Wound Healing
- The _ begins immediately after injury and lasts 3 to 6 days.
- Two major processes occur during this phase: _ and _.
inflammatory phase
hemostasis and phagocytosis
Phases of Wound Healing
Inflammatory Phase
- _ (the cessation of bleeding) results from vasoconstriction of the larger blood vessels in the affected area, retraction (drawing back) of injured blood vessels, the deposition of fibrin (connective tissue), and the formation of blood clots in the area.
Hemostasis
Phases of Wound Healing
Inflammatory Phase
- During cell migration, leukocytes (specifically, neutrophils) move into the interstitial space. These are replaced about 24 hours after injury by macrophages. These macrophages engulf microorganisms and cellular debris by a process known as _.
phagocytosis
Phases of Wound Healing
Proliferative Phase
- _ is a whitish protein substance that adds tensile strength to the wound.
Collagen
Phases of Wound Healing
Proliferative Phase
- As the capillary network develops, the tissue becomes a translucent red color. This tissue, called _, is fragile and bleeds easily.
granulation tissue
Phases of Wound Healing
Proliferative Phase
- If the wound does not close by epithelialization, the area becomes covered with dried plasma proteins and dead cells. This is called _.
eschar
Phases of Wound Healing
Maturation Phase
- In some individuals, particularly dark-skinned individuals, an abnormal amount of collagen is laid down. This can result in a _, or _.
hypertrophic scar
keloid
_ is material, such as fluid and cells, that has escaped from blood vessels during the inflammatory process and is deposited in tissue or on tissue surfaces.
Exudate
Exudate
- The nature and amount of exudate vary according to the _, _ and _, and _.
tissue involved, the intensity and duration of the inflammation, and the presence of microorganisms
Types of Wound Exudate
Serous exudate
Purulent exudate
Sanguineous exudate
Types of Wound Exudate
A _ consists chiefly of serum (the clear portion of the blood) derived from blood and the serous membranes of the body, such as the peritoneum.
serous exudate
Types of Wound Exudate
A _ is thicker than serous exudate because of the presence of pus, which consists of leukocytes, liquefied dead tissue debris, and dead and living bacteria.
purulent exudate
Types of Wound Exudate
Purulent exudate
- The process of pus formation is referred to as _. Purulent exudates vary in color, some acquiring tinges of blue, green, or yellow. The color may depend on the causative organism.
suppuration
Types of Wound Exudate
A _ consists of large amounts of red blood cells, indicating damage to capillaries that is severe enough to allow the escape of red blood cells from plasma.
sanguineous exudate
Types of Wound Exudate
- This type of exudate is frequently seen in open wounds.
sanguineous exudate
Complications of Wound Healing
Hemorrhage
Infection
Dehiscence with possible evisceration
Complications of Wound Healing
- _ (massive bleeding), however, is abnormal. A dislodged clot, a slipped stitch, or erosion of a blood vessel may cause severe bleeding.
Hemorrhage
Complications of Wound Healing
- Some clients will have a _, a localized collection of blood underneath the skin that may appear as a reddish blue swelling (bruise).
hematoma
Complications of Wound Healing
_ is the partial or total rupturing of a sutured wound.
Dehiscence
Complications of Wound Healing
- _ usually involves an abdominal wound in which the layers below the skin also separate.
Dehiscence
Complications of Wound Healing
- _ is the protrusion of the internal viscera through an incision.
Evisceration
Factors Affecting Wound Healing
Characteristics of the individual such as _, _, _, and _ influence the speed of wound healing.
age, nutritional status, lifestyle, and medications
