Skin Integrity and Wound Healing Flashcards
Wound Healing
process the body takes anything there is a break in skin integrity
Epidermis
Outermost layer of skin. It is avascular and made of stratified epithelial squamous cells. Relies on the dermis for nutrition
Dermis
Second layer of skin. Thick. Vascular. Made of tough skin tissue
Subcutaneous Layer
Fatty tissue that provides insulation.
Sweat
Water and salt. Keeps body cool and helps get rid of fluids
Sebaceous Glands
Secrete waxy substance that regulates pH of skin and keeps it lubricated
Functions of Integument
Protection, Absorption, Metabolism, Thermoregulation, Elimination, Sensation, Psychosocial
Insensible Water Loss
unmeasurable but occurs
Factors affecting Skin Function
Circulation, Nutrition, Allergies, Abnormal Growth Rate, Infection, Conditions of Epidermis
Neuropathy
Affects the skin’s ability to feel
Diabetes
Affects the skin’s healing process
Psoriasis
Increased skin production resulting in red skin. Chronic issue that is most present on the joints
Intentional Alteration to Skin Integrity
Surgury
Unintentional Alteration to Skin Integrity
Accidental and more prone to infection
Abrasions
Rubbing or scraping of epidermis
Lacerations
Tearing of skin and tissue with blunt or irregular objects. Tissue is not aligned
Puncture
pointed object penetrates the skin
Exposure Wound
Thermal wound leading to cellular death
Causes of Exposure wound
Radiation, electricity, caustic chemicals
Closed wound
Soft tissue damage under in-tact skin
Open wound
Break in the Skin
Chronic
Remains in inflammatory stage and remains susceptible to infection
Acute
heals quickly and easily
Primary Intervention for a Pressure Injury
Prevention
Pressure Injury
Pressure over a boney surface that reduces the oxygen/bloodflow/nutrients to skin and underlying tissue
At Risk Patients for Pressure Injury
excess moisture, age, low nutrition, more friction, comorbid condition
Shearing Forces
Any force that breaks the skin from the tissue underneath. For this reason, we do not raise HOB more than 40 degrees
Identification of Pressure injury
Name the pressure injury based on the boney location that it is from (Ex. Coccyx pressure injury 2)
Stage 1 Pressure Injury
Non-blanchable erythema. For this, reduce pressure
Stage 2 Pressure Injury
Partial thickness skin loss. Looks like an abrasion or blister. For these, we relieve pressure
Stage 3 Pressure Injury
Full-Thickness skin loss to subcutaneous tissue with damage or necrosis. presents as a deep crater. Frequent dressing changes
Stage 4 Pressure injury
Full thickness skin loss with extreme destruction, necrosis, or damage to the muscle, bone, or tendon. Months to Years to fully heal
Slough
Yellow, pale, green, tan, grey tissue within a wound bed. Non-Viable and must be removed
Eschar
Dark brown or black crust-like non-viable tissue that must be removed
Suspected Deep Tissue Injury
Skin is closed but there is something underneath
Debridement
Cleaning a wound
autolytic
allowing the body’s enzymes to clean its self by changing wound with special dressings. Good for small and shallow wounds. Takes 3-7 days
Enzymatic
Use of prescribed/commercially prepared enzymes in bandages by a physician.
Sharp/Surgical
Use of a scalpel to cut away dead tissue. Needs a physician or a trained nurse
Bio-Surgical:
Use of grade/science large from flies to eat the enzymes in the wound
Mechanical
Rare and painful. Use of wet-dry towel method, irrigation, or H2O2 for removal.
4 Phases of Wound Healing
- Hemostasis
- Inflammatory
- Proliferative
- Maturation
Homostasis
Vasoconstriction occurs to stop the bleeding and platelets begin clustering
Voasodhilation occurs to increase the volume of the wound and allows the plasma to seep into the wound
Exudate Production: Plasma seeps into the wound
Clot Forms
48 Hours
Inflammatory
White Blood Cells arrive to injury
Phagocytosis takes place
Localized inflammatory response is good and normal
4-6 Days
Proliferation
New tissue is built to fill the space
Fibroblasts produce collagen and growth facto for blood vessel formation
Granulation tissue forms
Granulation Tissue
Thin layer of epithelia cells that are beefy red and very vascular
Maturation
Collagen matures and continues to be prepared
Avascular scar remains
primary intention
clean incision that will heal quickly with no granulation and well approximated edges
Secondary Intention
Wound without approximated edges. Granulation will occur. More tissue damage occurs. Scar occurs
Tertiary Intention
Delayed closure of a wound
Desiccation
Dryness of a wound
Maceration
Moistness of a wound
Biofilm
Thick slimy self-made film that has bacteria that are resistant to the body’s natural defense mechanisms
hematoma
Popped blood vessel leaking into the body. Localized collection of blood
Dehiscence
Wound edges separate due to excessive stress (edema, infection, weight, vomiting)
Evisceration
Emergency. Organs seeping from a wound/wound opening
Infection
Invasion of wound by microorganisms
Fistula
Abnormal connection between two passageways or organs that do not typically connect
