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
Healing process in which new tissue of wound must fill in from the bottom and sides of the wound until the wound bed is filled with new tissue, often involves diabetes or vascular disease.
Secondary intention
Healing process in which delay occurs between injury and closure.
Tertiary process
What are the three phases of wound healing? IPM
Inflammatory
Proliferative
Maturation
This phase is the initial response to wounding of the skin, lasts 3 days, and the coagulation cascade occurs and the formation of a clot occurs as well. Pain, redness, warmth, and swelling occur.
Inflammatory phase
This phase in wounding involves the filling in the wound bed with new tissue called granulation tissue. Lasts several weeks.
Proliferative phase
This phase is the last phase of wound healing and is known as the remodeling phase. It can last up to a year. Collagen continues to be deposited and remodeled, and scar tissue is formed and strengthens.
Maturation phase
What are the five factors that affect wound healing?
Oxygenation
Tissue perfusion
Diabetes
Nutrition
Age
A patient with _________ the presence of a wound is accompanied by a reduction in collagen synthesis, a decrease in the strength of that collagen, impaired functioning of leukocytes, and a reduction in the number and action of macrophages.
Diabetes
This factor affects wound healing: the action of the macrophages and fibroblasts is reduced, inflammatory response is decreased, decrease in collagen, and slowing of epithelialization.
Age
Usually occurs in connection with surgical incisions, the partial or complete separation of the tissue layers during the healing process.
Dehiscence
This is the total separation of the tissue layers, allowing the protrusion of visceral organs through the incision. People at risk for this are people with delayed wound healing.
Evisceration
If dehiscence or evisceration occurs, what should you do?
Cover the wound with gauze moistened with a sterile normal saline and notify physician immediately.
An abnormal connection between two internal organs between two internal organs or between an internal organ, and through the skin, the outside of the body. These predispose the affected person to fluid and electrolyte loss, nutritional deficits, and alterations in skin integrity.
Fishtula
This burn causes damage to only the epidermis with resulting pain and erythema.
Superficial burn
This burn causes blistering and pain and destroys the epidermis and and part or all of the dermis.
Partial-thickness burn
This burn destroys the epidermis, dermis, and part of the subcutaneous tissue. Cause area to be white, brown, charred, and without sensation.
Full thickness burn
What are the three evidence-based practice steps to prevent pressure injury?
- Determine pt risk level through assessment
- Reduce pressure on bony prominences
- Improve pressure Tolerance by making sure pt is well nourished, skin dry, intact, padded, and perfused.
Capillary closing pressure is _______ mm Hg. It is the minimum pressure required to collapse a capillary.
12-32
If possible, what should you place under a medical device that could cause a pressure injury?
prophylactic dressing.
Nurses follow protocol CARE which stands for what in regards to medical device related injuries
Choose a size-appropriate device
Assess the skin under the medical device
Reposition and Reapply the device using padding
Empowered to evaluate daily discontinuation
Which patients are at risk for pressure injuries due to sensory loss or immobility?
patients with neurologic conditions
Inflammation or skin erosion caused by prolonged exposure to moisture such as urine, stool, sweat, wound drainage, saliva, or mucus.
Moisture-associated skin damage (MASD)
A condition in which excessive moisture causes a softening of the skin.
Maceration
When it comes to nutrition, what 3 things could cause the inability of tissue to withstand friction and shear?
Low BMI
Deficient in vitamins A, C, E, copper, zinc
Protein-calorie malnutrition
Name pressure injury stage: intact non-blistered skin with nonblanchable erythema or persistent redness in the area that has been exposed to pressure.
Stage 1 pressure injury
Name pressure injury stage: A partial thickness wound that involves the epidermis and or dermis, shallow, superficial, with pink wound bed, ruptured blisters.
Stage 2 pressure injury
Name pressure injury stage: full thickness wounds that extend to the subcutaneous tissue but do not extend through the fascia to muscle or bone.
Stage 3 pressure injury
Name pressure injury stage: this wound is deeper and involves exposure of muscle, bone, or connective tissue such as tissue and cartilage. Makes osteomyelitis or an infection of the bone likely.
Stage 4 pressure injury
Name pressure injury stage: this is a full thickness wound in which the amount of necrotic tissue or eschar in wound bed makes it impossible to assess its depth or underlying structures.
Unstageable pressure injury
Name pressure injury stage: a wound that is seen as intact skin that is purple or maroon or a blood-filled blister. True depth of wound is not readily apparent on initial inspection.
Suspected deep-tissue pressure injury
Which 2 tools have been developed to assist in the identification of patients at risk for development of pressure injuries?
Braden scale
Norton scale
This scale ranks the patient on risk categories of sensory perception, moisture, activity, mobility, nutrition, and friction and shear. Score lower than 18 places pt at risk for pressure injury.
Braden scale
This scale ranks patients on risk categories of physical condition, mental state, activity, mobility, and continence.
Norton scale
