Skin Integrity and Wound Care (chapter 29) Flashcards
What are the three main layers of the skin?
- Epidermis
- Dermis
- Subcutaneous layer
This is the outermost layer of the skin that contains 5 subdivisions, and has the ability to regenerate every 4-6 weeks.
Epidermis
The outermost of the epidermal layers that is made up of flattened dead cells and provides protection from outside danger, and regulates fluids and electrolytes.
stratum corneum
These 3 middle layers of the epidermis help in the reduction of friction and shear.
stratum lucidum
stratum granulosum
stratum spinosum
Innermost layer of epidermis that consists of a single layer that constantly produces new cells that are pushed upwards.
Stratum germinativum (basal layer)
This is synthesized in the stratum germinativum and gives the skin strength, flexibility, and allows it to repair itself.
Keratin
This layer is much thicker than the epidermis and embedded is the sebaceous glands, sweat glands, hair and nail follicles, nerves, and lymphatics.
Dermis
This layer of the skin is made up of adipose tissue that delivers blood supply to the dermis, provides insulation, and has a cushioning effect.
Subcutaneous layer
What are five factors that affect skin integrity? WVMDA
Wounds
Vascular disease
Malnutrition
Diabetes
Aging process
These occur when superficial layers of skin are removed by medical adhesive, in which erythema and or other manifestations of skin trauma occur longer than 30 minutes after removal of the adhesive.
Medical adhesive related skin injuries (MARSIs)
These wounds are characterized by an actual break in the skin’s surface. Some of these include abrasions, puncture wounds, and surgical incisions.
Open wounds
These wounds involve the skin still being intact and they are seen with bruising
Closed wounds
Wound depth that only involves the epidermis.
Superficial wound
Wound depth that involves the epidermis , dermis, and they heal quickly without leaving a scar.
Partial thickness wound
This wound extends through the dermis to the subcutaneous layer and can extend farther to the muscle, bone, and other underlying structures. They are slow to heal, leave scarring, and can be chronic.
Full thickness wound
A wound in which there is no infection and risk for development of infection is low. Example includes a closed surgical incision made in a sterile environment that does not involve bacteria.
Clean wound
A clean wound that involves organ systems that are likely to contain bacteria
Clean contaminated wound
Wounds that result from a break in sterile technique during surgery or from certain types of trauma or accidents.
Contaminated wounds
This wound shows signs of infection, redness, warmth, and drainage that may or may not be purulent. Also has bacterial count of at least 10^5 per gram of tissue sampled.
Infected wound
This wound has one or more organisms present on the surface of the wound when a swab culture is obtained but no overt sig of infection in tissue below it.
Colonized wound
A wound that progresses through the phases of wound healing in a rapid uncomplicated manner. Examples are surgical incisions or traumatic wounds in which edges of wound can be approximated.
Acute wound
Healing process in which wound heals quickly and results in minimal scar formation.
Primary intention