Skin integrity and wound healing Flashcards
The three layers of skin
Epidermis
Dermis
Subcutaneous fat
Skin protects against ….
pathogens
Dermis is relied on for
nutrition
Wound type:
epidermis and partial loss of dermis
partial thickness wound
Wound type:
All through dermis up to subcutaneous fat and possibly muscle and bone
Full thickness wound
another name for flesh eating disease
necrotizing fasciitis
Wound that heals in 6 months or less
acute
Wound that takes more than 6 months to heal
Chronic
Any break in skin is
an open wound
Open traumatic wound like a compound fracture is
Contaminated wound
wound caused by friction
abrasion
wound caused by penetrating trauma
Puncture
Deep, jagged cut in skin
laceration
laceration may be kept open for __ days to make sure no infection occurs
3 days
Another name for pressure ulcer
Decubitus
wound caused by skin trapped between a boney prominence and a hard surface
Pressure ulcer
Blood vessel collapse=
no blood flow
No blood flow =
necrosis
MDRPI
Medical device related pressure injury
Pressure ulcers are
not billable because they are preventable
Pressure Ulcer stage:
Blanchable, Redness fades in 1-2 hours
At risk
Pressure ulcer stage:
Non blanchable, stays red over compressed area, Skin intact
Stage 1
Pressure ulcer stage:
Skin break, superficial, like an abrasion, blister
Stage 2
treatment for stage 1 pressure ulcer
Relieve pressure, reposition, report
Treatment for stage 2 pressure ulcer
Saline dressing, moist environment
Esbar
Black slough dead tissue rubbed off
Pressure ulcer stage:
Full thickness with damage or loss of subcutaneous tissue
Stage 3
Treatment for stage 3 ulcer
Usually requires debridement, wet to dry dressings, surgical intervention
Debriding agent- chemical
santyl and collagenase combined with saline to activate
If an ulcer is completely yellow, it is considered
unstageable
An unstageable ulcer needs _____ to determine stage
debriding
Pressure Ulcer stage:
Full thickness loss with destruction of muscle, bone or supporting structures (tendons, joint capsule)
Stage 4
Treatment for Stage 4 Ulcer
Non adherent dressing. May need skin grafts, flaps
Purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure &/or shear.
Deep tissue injury
Deep tissue injury on an arm is considered
a bruise
Base of wound builds from inside out, taking up to a year to heal
Epithelization
A process by which fibrous tissue rich with blood capillaries replaces blood clots formed at the site of a healing wound.
Tissue granulation
Stable eschar on heels should
not be removed
Scale used to determine risk for ulcer
Braden scale
Sometimes stage 3 and 4 are less ____ than stage 1 and 2
less painful
Rash level with the skin surface
Macular rash
rash involving elevated, raised area
papular rash
rash covering most of body
generalized rash
Itching and redness
pruritus
increased pressure with one anatomical compartment characterized by pain, numbness, decreased mobility that is caused by edema
Compartment syndrome
Bring back to normal
hemostasis
Last 3 days with vasodilation, red, pain, warm swelling
inflammation
hemostasis
Inflammation
Proliferation
maturation
partial thickness wound healing or full thickness healing
Wounds with minimal tissue loss ex. clean surgical wounds
Edges of the primary wound can be approximated by sutures, staples, or tape
Healing by collagen synthesis occurs
Granulation tissue is not visible
Primary intention
Tissue loss, edges that do not easily approximate ex. burns, pressure ulcers, deep lacerations
Healing involves inflammation, filling by granulation tissue & then epithelial cells
Scar is usually large & definite
Secondary Intention
Occurs when there is a delay between injury and wound closure.
Usually due to wait for underlying infection or edema to resolve.
Some granulation tissue forms.
Tertiary intention
An abnormal tube- like passageway that forms between two organs or from one organ to the outside of the body
Fistula
A total or partial disruption of wound edged. The patient feels a “giving away” sensation
Dehiscence
Is the protrusion of viscera through the abdominal opening
Evisceration
Wound terms:
Watery, clear, light yellow
Serous
Wound term:
Bloody
Sanguineous
Wound term:
Pink, yellow drainage
Serosanguinous
Wound term:
Yellow, green, tan and foul smelling (infection)
Purulent
DSD
Dry sterile dressing
Dressing types needed are determined by
Doc order
MARSI
Medical adhesive related skin injury
Using negative pressure to speed tissue healing
Vacuum assisted closure
Vacuum uses continuous pressure at
125
High Air Loss-air blows through “sand like” silicon beads making the surface less than capillary pressure in the skin.
Feels like a water bed when on & becomes a firm hard surface when off is capable of holding a patient in position
Causes a high fluid loss from the patient
Alternating Air-Pressure Mattress
Heating unit consistent of waterproof pad thru which water circulates-for inflammation muscle spasms etc.
Aquathermia Pads
