Skin Integrity and Wound Care Flashcards
Any disruption in the integrity of the body
tissue is called a
WOUND
Impaired skin integrity, such as wounds,
may occur as a result of
TRAUMA or
SURGERY
refers to the
presence of normal skin and
skin layers uninterrupted by
wounds
Intact Skin
Body’s largest ORGAN and is
the primary defense against
infection.
Skin
Skin Integrity
* Affected by:
- Genetics and heredity
- Age
- Chronic illnesses and their
treatments - Medications (rashes)
- Poor nutrition
Types of Wounds
- Clean
- Clean-contaminated
- Contaminated
- Dirty, infected
Types of Wounds (How they are acquired)
Incision
Contusion
Abrasion
Puncture
Laceration
Penetrating wound
- Sharp instrument (e.g., knife or
scalpel) - 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
Incision
- Blow from a blunt instrument
- Closed wound, skin appears ecchymotic
(bruised) because of damaged blood
vessels.
Contusion
- Surface scrape, either unintentional
(e.g., scraped knee from a fall) or
intentional (e.g., dermal abrasion to
remove pockmarks) - Open wound involving the skin
Abrasion
Penetration of the skin and
often the underlying tissues by
a sharp
instrument, either intentional or
unintentional
- Open Wound
Puncture
- Tissues torn apart, often from
accidents (e.g., with
machinery) - Open wound; edges are often jagged
Laceration
- Penetration of the skin and the
underlying tissues and enters a
tissue or a cavity (e.g., from a
bullet or metal fragments) - Open wound
Penetrating wound
- Injury to skin and/or
underlying tissue usually
over a bony prominence - Formerly decubitus ulcers,
pressure sores, bedsores - Preventable
Pressure Ulcers
Risk Factors of Pressure Ulcers
- Friction and shearing
- Force acting parallel to skin
- Combined friction and
pressure - Immobility
- Inadequate nutrition
- Fecal and urinary
incontinence
- Tissue softened
by prolonged wetting
Maceration-
Risk Assessment Tools
- Braden Scale for Predicting
Pressure Sore Risk - Norton’s Pressure Area Risk
Assessment Form Scale
nonblanchable erythema
signaling potential ulceration.
Stage Ⅰ
partial-thickness skin loss
(abrasion, blister, or shallow crater)
involving the epidermis and possibly the
dermis.
Stage Ⅱ
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
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
fullthickness 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
purple or maroon localized
area of discolored intact skin or bloodfilled blister due to damage of underlying
soft tissue from pressure and/or shear.
Deep tissue injury 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
thin eschar.
Suspected deep tissue injury-depth
unknown
Regeneration (renewal) of tissues
Wound Healing
Phases of Wound Healing
nflammatory, Proliferative, Maturation
Types of Wound Healing
Primary, Secondary, Tertiary
- Immediately after injury
- Lasts 3 to 6 days
- Hemostasis
- Phagocytosis
Inflammatory phase
process to prevent and stop bleeding
Hemostasis
process by which a cell uses its plasma membrane
to engulf a large particle, giving rise to an internal compartment
called the phagosome)
Phagocytosis
- From post-injury day 3/4 until day 21
- Collagen synthesis
- Granulation tissue formation
Proliferative phase
- From day 21 until 1 or 2-years
post injury - Collagen organization
- Remodeling or contraction
- Scar stronger
- Keloid
- Hypertrophic scar with abnormal
amount of collagen
Maturation phase
- Tissue surfaces
approximated (closed) - Minimal or no tissue loss
- (e.g., clean surgical incision)
- Formulation of minimal
granulation tissue & scarring - Proliferative phase
- Primary intention healing
- Extensive tissue loss
- Edges cannot be
approximated. - Repair time is longer.
- Scarring is greater.
- Susceptibility to infection is
greater
Secondary intention healing
- 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
Tertiary intention healing
Material (fluid, cells)
escaped from blood
vessels during
inflammatory process
Exudate
3 major types of Exudtae
- Serous
- Purulent
- Sanguineous
- Mostly serum
- Derived from blood and serous
membranes of the body - Looks watery, few cells
- E . g., fluid in blister from a burn
Serous exudate
- Thicker
- Presence of pus
- Consists of leukocytes, liquefied
dead tissue debris, dead and living
bacteria - Color varies with causative organism
Purulent exudate
- Large number of R B Cs
- Indicates severe damage to
capillaries - Frequently seen in open wounds
Sanguineous exudate
Mixed exudate
Serosanguineous
Purosanguineous
Clear and blood-tinged drainage
Serosanguineous
Pus and blood
Purosanguineous
Complications of Wound Healing
Hemorrhage
Hematoma
Infection
Dehiscence
Evisceration
Massive bleeding
Hemorrhage
- Localized collection of blood under
skin - May appear as reddish blue bruise
Hematoma
Contamination of a wound surface with
microorganisms
Infection
Partial or total rupturing of a sutured
wound
Dehiscence
Protrusion of the internal viscera through
an incision
Evisceration
