Skin Integrity and Wound Care Flashcards
Exam 3
What are the three main structures of the skin?
- Epidermis
- Dermis
- Subcutaneous
Epidermis
Protective waterproof layer of keratin
How are the cells of the Epidermis?
Cells have no blood vessels of their own
Regenerates easily and quickly
Dermis
Elastic tissue made primarily of collagen
What is the Dermis made up of?
Nerves, hair follicles, glands, immune cells, and blood vessels
Subcutaneous
Anchors the skin layers to underlying tissues
Functions of the Skin:
- Protection
- Body temp regulation
- Psychosocial
- Sensation
- Vitamin D production
- Immunologic
- Absorption
- Elimination
Cross section of Normal Skin
Slide 4
What are factors affecting the skin
- Unbroken and healthy skin and mucous membranes
- Resistance to injury is affected by age
- Adequately nourished and hydrated body cells
- Adequate circulation
What does unbroken and health skin and mucous membranes do?
Unbroken and healthy skin and mucous membranes defend against harmful agents
Resistance to injury of skin is affected by?
Resistance to injury is affected by age, amount of underlying tissues, and illness
What does adequately nourished and hydrated body cells do?
Adequately nourished and hydrated body cells are resistant to injury
What is adequate circulation of skin necessary for?
Adequate circulation is necessary to maintain cell life
In children 2 years and younger, how does the skin compare to adults?
In children younger than 2 years, the skin is thinner and weaker than it is in adults
How is an infant’s skin? How is a child’s skin?
An infant’s skin and mucous membranes are easily injured and subject to infection;
a child’s skin becomes increasingly resistant to injury and infection
When does the structure of skin change?
The structure of the skin changes as a person ages; the maturation of epidermal cells is prolonged, leading to thin, easily damaged skin
How is the skin of older adults?
Older adults: circulation and collagen formation are impaired, leading to decreased elasticity and increased risk for tissue damage from pressure
Causes of skin alterations
- Very thin and very obese people are more susceptible to skin injury
- Fluid loss during illness causes dehydration and predisposes skin to breakdown
- Jaundice
- Diseases of the skin, such as eczema and psoriasis, may cause lesions that require special care
What does Jaundice do to the skin?
Jaundice causes yellowish, itchy skin
Types of wounds?
- Intentional (surgical) or unintentional (traumatic)
- Neuropathic or vascular
- Pressure related
- Open or closed
- Acute or chronic
- Partial thickness, full thickness, complex
Wound terminology
Incision
Contusion
Abrasion
Laceration
Puncture
Penetrating
Avulsion
Chemical
Thermal
Irradiation
Pressure ulcers
Venous ulcers
Arterial ulcers
Diabetic ulcers
What is the first line of defense against microorganisms?
Intact skin is the first line of defense against microorganisms
What is used in caring for a wound?
Careful hand hygiene is used in caring for a wound
How does the body respond to trauma?
The body responds systematically to trauma of any of its parts
What is essential for normal body response to injury?
An adequate blood supply is essential for normal body response to injury
How is normal healing promoted?
Normal healing is promoted when the wound is free of foreign material
What affects wound healing?
The extent of damage and the person’s state of health affect wound healing
How can response to wound be more effective?
Response to wound is more effective if proper nutrition is maintained
What are the phases of wound healing?
- Hemostasis
- Inflammatory
- Proliferation
- Maturation
Hemostasis- when does it occur?
Occurs immediately after initial injury
What occurs during hemostasis?
Involved blood vessels constrict and blood clotting begins
Exudate is formed, causing swelling and pain
Increased perfusion results in heat and redness
Platelets stimulate other cells to migrate to the
injury to participate in other phases of healing
Inflammatory Phase- when does it occur?
Follows hemostasis and lasts about 2 to 3 days
Inflammatory Phase- what occurs?
White blood cells, predominantly leukocytes and macrophages, move to the wound
Macrophages enter the wound area and remain for an extended period. They ingest debris and release growth factors that attract fibroblasts to fill in the wound
Exudate is formed and accumulates, causing pain, redness, and swelling at the site of injury
The patient has a generalized body response
Proliferation Phase- how long does it occur?
Lasts for several weeks
Proliferation Phase- what occurs?
New tissue is built to fill the wound space through the action of fibroblasts
Capillaries grow across the wound
A thin layer of epithelial cells forms across the wound
Granulation tissue forms a foundation for scar tissue development
Maturation Phase- when does it occur?
begins about 3 weeks after the injury, possibly continuing for months or years
Maturation Phase- what occurs?
Collagen is remodeled
New collagen tissue is deposited, which compresses the blood vessels in the wound, causing a scar
Scar
Scar: flat, thin, white line; avascular collagen tissue that does not sweat, grow hair, or tan in sunlight
Local Factors Affecting Wound Healing
Pressure
Desiccation (dehydration)
Maceration (overhydration)
Trauma
Edema
Infection
Excessive bleeding
Necrosis (death of tissue)
Presence of biofilm (thick grouping of microorganisms)
Biofilm
(thick grouping of microorganisms)
Necrosis
Death of tissue
Maceration
overhydration
Desiccation
dehydration
Systemic Factors Affecting Wound Healing
- Age
- Circulation and oxygenation
- Nutritional status
- Wound etiology
- Health status
- Immunosuppression
- Medication use
- Adherence to treatment plan
Systemic Factors Affecting Wound Healing: Age
children and healthy adults heal more rapidly
Systemic Factors Affecting Wound Healing: Circulation and oxygenation:
adequate blood flow is essential
Systemic Factors Affecting Wound Healing: Nutritional status
healing requires adequate nutrition
Systemic Factors Affecting Wound Healing: Wound etiology
specific condition of the wound affects healing
Systemic Factors Affecting Wound Healing: Health status
corticosteroid drugs and postoperative radiation therapy delay healing
Wound complications
- Infection
- Hemorrhage
- Dehiscence and evisceration
- Fistula formation
- Dehiscence and evisceration
Slide 20?
Factors Affecting Pressure Injury Development
Aging skin
Chronic illnesses
Immobility
Malnutrition
Fecal and urinary incontinence
Altered level of consciousness
Spinal cord and brain injuries
Neuromuscular disorders
Microclimate
temperature and moisture of the skin
Mechanisms in Pressure Injury Development
External pressure compressing blood vessels
Friction or shearing forces tearing or injuring blood vessels
Microclimate
Risks for Pressure Injury Development
Nutrition and hydration
Immobility
Mental status
Age
Stages of Pressure injuries: How many actual stages are there?
4
(not including unstageable and deep tissue pressure injury)
Stages of Pressure injuries: Stage 1
Stage 1: nonblanchable erythema of intact skin
Stages of Pressure injuries: Stage 2
Stage 2: partial-thickness skin loss with exposed dermis
Stages of Pressure injuries: Stage 3
Stage 3: full-thickness skin loss; not involving underlying fascia
Stages of Pressure injuries: Stage 4
Stage 4: full-thickness skin and tissue loss
Stages of Pressure injuries: Unstageable
Unstageable: obscured full-thickness skin and tissue loss
Stages of Pressure injuries: Deep tissue pressure injury
Deep tissue pressure injury: persistent nonblanchable deep red, maroon, or purple discoloration
Psychological Effects of Wounds
- Pain
- Anxiety
- Fear
- Impact on activities of daily living
- Change in body image
Health History
Recent changes in skin
Activity and mobility
Nutrition
Pain
elimination
Skin Assessment- What is included
Inspection and palpation
Systematically—head to toe
Include bony prominences
When is skin assessments done?
On admission and at regular intervals:
On admission and at regular intervals: what intervals
Acute care
Long-term settings
Home health care
For acute care, when are skin assessments done?
Acute care—every shift
For long term settings, when are skin assessments done?
Long-term settings—weekly for 4 weeks then quarterly
For home health care, when are skin assessments done?
Home health care—each visit
When assessing a wound, what are you looking for in general?
- Appearance
- Drainage
What are you assessing for in appearance of wound?
Size of wound
Depth of wound
Presence of undermining, tunneling, or sinus tract
What are you assessing for in drainage of wound?
Serous
Sanguineous
Serosanguineous
purulent
Preventing Pressure Injuries
Assess at risk patients daily
Cleanse the skin routinely
Maintain higher humidity; use moisturizers
Protect skin from moisture
Minimize skin injury from friction or shearing
Proper positioning, turning, transferring
Appropriate support surfaces
Nutritional supplements
Improve mobility and activity
What are the purposes of wound dressings?
Provide physical, psychological, and aesthetic comfort
Prevent, eliminate, or control infection
Absorb drainage
Maintain moisture balance of the wound
Protect the wound from further injury
Protect the skin surrounding the wound
Debride (remove damaged/necrotic tissue), if appropriate
Stimulate and/or optimize the healing response
Consider ease of use and cost-effectiveness
Types of Wound dressings?
Those that maintain moisture
Those that absorb moisture
Those that add moisture
What are the steps for changing the dressing?
Prepare the patient
Use appropriate aseptic techniques
Hand hygiene before and after
Adhere to standard and transmission-based precautions
Remove the old dressing
Cleanse the wound
Apply a new dressing
Secure the dressing
Cleaning a Pressure Injury/Wound steps
Clean with each dressing change
Use new gauze for each wipe and clean from top to bottom and/or from the center to the outside
Use 0.9% normal saline solution to irrigate and clean the injury
Once the wound is cleaned,
dry the area using a gauze sponge in the same manner
Report any drainage or necrotic tissue
What kind of saline solution should you use when cleaning a pressure injury/wound
Use 0.9% normal saline solution to irrigate and clean the injury
Types of bandages- NOT GOING TO BE ASKED ON TEST JUST STUDY IF YOU HAVE TIME
Roller bandages
Circular turn
Spiral turn
Figure-of-eight turn
Types of Binders
Slings
Abdominal binders
Chest binders
T-binders
Types of Drainage Systems
- Open systems
- Closed systems
Types of Drainage Systems: Open systems
Penrose drain
Types of Drainage Systems: Closed systems
Jackson-Pratt drain
Hemovac drain
Color Classification of Open Wounds
R= red
Y= yellow
B= Black
Mixed wound- contain components of RY &B wounds
Color Classification of Open Wounds: R
R= red- protect
Color Classification of Open Wounds: Y
Y= yellow- cleanse
Color Classification of Open Wounds: B
B= black- debride
Color Classification of Open Wounds: Mixed wound
Mixed wound- contains components of RY&B wounds
Topics for home health care teaching
Supplies
Infection prevention
Wound healing
Appearance of the skin/recent changes
Activity/mobility
Nutrition
Pain
Elimination
Factors Affecting the Response to Hot and Cold Treatments
Method and duration of application
Degree of heat and cold applied
Patient’s age and physical condition
Amount of body surface covered by the application
How long should you leave a heating pad on?
Heating pad no more than 20 minutes.
Effects of Applying Heat
Dilates peripheral blood vessels
Increases tissue metabolism
Reduces blood viscosity and increases capillary permeability
Reduces muscle tension
Helps relieve pain
Effects of Applying Cold
Constructs peripheral blood vessels
Reduces muscle spasms
Promotes comfort
