Skin Integrity and Wound Care Flashcards
Skin is the largest:
organ
Skin is involved in thermoregulation through its ability to:
dilate and constrict blood vessels
The skin has a major tole in sensation by:
giving tactile feedback from the surrounding environment
The skins normally acidic pH provides:
a protective mechanism against pathogens
Epidermis
outermost layer of the skin, and the thinnest; regenerates ever 4-6 weeks
Subdivisons of the epidermis:
stratum corneum stratum lucidum stratum granulosum stratum spinosum stratum germinativum (basal layer)
Stratum Corneum:
made up of flattened dead cells
The middle 3 layers provide a transition from:
stratum corneum to stratum germinativum (which also help in reduction of friciton and shear)
Stratum Germinativum:
constantly produces new cells that are pushed up (protein keratin is synthesized here)
Keratin:
gives the skin strength and flexibility and allows the skin to repair itself
Melanin:
gives the skin its color and protects from UV light and Langerhans cells
Langerhans cells:
involved in digestion of bacteria and the immune system’s response to foreign materials
Dermis:
lying between the epidermis and the deeper subcutaneous layer
The epidermal and dermal layers are joined together by the:
basal membrane
Rete Ridges/Papillary Dermis:
provides the stick that anchors these layers of the skin together, preventing them from sliding back and forth
Embedded in the dermis:
sebaceous glands sweat glands hair/nail follicles nerves lymphatics
Subcutaneous layer:
layer of adipose tissue; in addition to attaching the dermis to the underlying muscles and bones delivers the blood supply to the dermis, provides insulation
Open wound:
actual break in the skin’s surface
example: abrasion,. puncture/surgical wound
Closed wound:
seen with bruising, and the skin is still intact
Superficial wound:
involves only the epidermis
Partial thickness wound:
involves the epidermis and the dermis but does not extend to the subcutaneous layer
What do partial thinkness and superficial wounds have in common?
these wounds heal quickly and leave no scaring
Full thickness wound:
extends through the dermis to the subcutaneous layer and may extend farther to the muscle, bone, or other underlying structures.
How do full thickness wounds heal:
heal slowly and leave scarring; more likely to become chronic
Burns:
tissue injuries caused by heat, electricity, chemical radiation, extreme cold, or friction
Clean wound:
no infection and risk for developing infection is low
Clean contaminated wound:
similar to a clean wound, but because the surgery involves organ systems that are likely bacteria, the risk for infection is greater
Contaminated wounds:
result from a break in sterile technique during surgery; have a higher risk of infection
Infected wounds:
shows clinical signs of infection including redness, warmth, and increased drainage
Colonized wounds:
1 or more organisms are present on the surface of the wound; when a swab culture is obtained but there is not overt sign of infection in the tissue below the surface
Acute wound:
wound that progresses through the phases of wound healing in a rapid, uncomplicated manner
Approximated:
the edges of a wound can be brought together
Primary Intention:
heal quickly and result in minimal scar formation
Chronic wound:
fails to progress to healing in a timely manner
Secondary Intention:
new tissue must fill in from the bottom and the sides of the wound until the wound bed is filled with new tissues
Tertiary Intention:
a delay occurs between injury and closure
Phases of wound healing:
inflammation
proliferative
maturation
Inflammatory Phase:
beings with the body’s initial response to wounding of the skin and last about 3 days (a the end of this phase, the wound bed is clean and ready to being the actual repair process)
Proliferative Phase:
healing/repair of the defect, filling in the wound bed with granulation tissue, and resurfacing the wound with skin.
Granulation tissue:
new tissues created to fill the wound
Angiogenesis:
development of new blood vessels that are needed to support the new tissue, collagen synthesis, wound contraction, and epithelialization
Fistula:
abnormal connections between two internal organs or between an internal organ through the skin, outside of the body q
Pressure Injury:
localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure, or pressure in combo with shear
Capillary closing pressure/critical closing pressure:
minimum pressure required to collapse a capillary
Low levels of pressure over long periods of time can be:
as damaging to the skin and underlying tissue as high levels of pressure over a short period of time
Maceration:
excessive moisture causes softening of the skin
Stage I pressure ulcer:
intact, nonblistered skin with nonblanchable erythema or persistent redness, in the ares that has been exposed to pressure.
Stage II pressure ulcer:
partial thickness would that involves the epidermis and/or dermis but does not extend below the level of the dermis
Maturation Phase:
(remodeling phase) can last up to a year; collagen continues to be deposited and remodeled and scar tissue is formed and strengthens
Scar Tissue:
a vascular mass of collagen that give strength to the repaired wound
(strength of the scar is never equal to that of unwounded tissues; it only reached about 80% of its previous tensile strength)
Factors affecting wound healing:
oxygenation and tissue perfusion diabetes nutrition age infection
Dehiscence:
partial or complete separation of the tissue layers during the healing process
Evisceration:
total separation of the tissue layers allowing the protrusion of visceral organs through the insision
Teach patient to splint the incision with a pillow or blanket or to use an abdominal binder while:
coughing, deep breathing, and movement
Serous drainage:
clear, watery fluid
Serosanguineous drainage:
pink to pale red and contains a mix of serous fluid, and red bloody fluid
Sanguineous fluid:
indicated bleeding and is bright red
Change a patient’s position at least:
every 2 hours
Debridement:
removal of necrotic tissue
Hospital acquired pressure ulcers are:
NOT reimbursed
Abnormal reactive hyperemia:
the redness in Stage I and is due to excessive vasodilation caused by pressure
Purulent drianage:
thick and indicates infection; can be yellowish, greenish, or beige
Hydrocolloids:
adhesive dressings that provide a moist wound environment and their absorbent capabilities prevent the wound bed and surround tissue from becoming to wet.
(not recommended for wounds suspected of being infected)
Stage III Pressure Ulcer:
full thickness wounds that extend into the subcutaneous tissue but do not extend through the fascia to muscle, bone, or connective tissue
Undermining:
area of tissue loss present under intact skin usually along the edges of the wound, forming a “lip” around the wound
Tunnel or sinus tract:
narrower passage way extending outward from the edge of the wound
Stage IV pressure ulcer:
deeper than stage III and involves exposure of muscle, bone, or connective tissue
Osteomyelitis:
infection of the bone
Unstageable pressure ulcer:
full thickness wound in which the amount of necrotic tissue in the wound bed makes it impossible to assess the depth of the wound or the involvement of underlying structures
Suspected deep tissue injury:
area of intact skin that is purple or a blood filled blister
Gels:
add moisture to a wound thus creating a most environment and allowing autolytic debridement and wound healing to occur. (don’t absorb little wound drainage and thus are inappropriate for a highly exudative wound
Foams:
pull fluid away from the wound bed yet maintain a most wound environment, used for wounds producing moderate to heavy amounts of exudate and should not be used for wounds with only a small amount of drainage (do not relieve pressure)`
Transparent films:
stick to the periwound skin but not to the actual wound bed- not appropriate for wounds with more than a minimal amount of drainage. the films prevent bacteria and fluids from enter the wound but allow oxygen and water vapor to move through the dressing. they imitate that action of a blister by keeping the body’s own wound fluid next to the wound bed, maintaining a moist environment
Gauze:
isn’t effective as a barrier against infection removal often results in pain and damage to the wound bed, fibers can be left, also has an inability to maintain a most wound environment required for healing for healing, gauze is preferable for allowing the wound to become dry useful in cover dressings, and for absorbing exudate from a healing draining wound
Alignates:
useful in highly exudative wounds should be avoided in dry wounds, have the ability to stop bleeding
