Skin Integrity And Wound Healing (EXAM 1) Flashcards
Impaired skin integrity
- expensive to treat
- may not be covered by insurance
- lengthens hospital stay
Skin layers
- Epidermis- top (dermal-epidermal junction separates the top 2 layers)
- Dermis
- Subcutaneous layer
Factors influencing skin integrity
- nutrition
- tissue perfusion
- infection/fever
- age (newborns/children) , elderly
- immobility (impaired)
- diminished sensation/cognition
Impaired circulation
Arterial vs Veous
Vascular system brings blood and O2 to tissues and it also removes waste.
Impaired Venous system–> produces edema –> resulting in ulceration and skin breakdown
Impaired Arterial circulation –> produces pain –> results in ischemia & necrosis
Medication types for wound healing
Immunosuppressants
Corticosteroids
NSAIDS
Anticoags
Moisture in skin
Leads to maceration-softening of the skin and ^ likelihood of breakdown
Lifestyle factors that affect skin
- tanning
- hygiene habits (homeless, dementia, low cognition)
- regular exercise
- nutritious diet
- smoking
- body piercing and tattoos
Types of wounds:
Length of time
Condition
Depth
Acute- short, heal spontaneously w/o complications via 3 phases of wound healing (inflammation, proliferation & maturation)
Chronic- long time to heal, wounds typically colonized w/multiple types of bacteria
Condition: clean, clean- contaminated, Contaminated
Depth: Superficial, partial thickness, full thickness (look in book and add definition)
Wound Healing: (3 types)
- Primary intention: (ex: surgical incision. Very clean and suture from inside out)
- Secondary intention: extensive and involves considerable tissue loss. Edges cant be brought together. Granulated from bottom up to heal on it’s own. Leave scar
- Tertiary intention: Resolution has occurred. Wound edges can be brought together (approximated). EX: bigger surgical wounds that may be infected
Wound Healing Process
- Hemostasis- blood/plasma leak into wound
- inflammation
- Proliferative- regeneration (healing phase)
- Remodeling/maturation phase- week 2-3
Dehiscence vs Evisceration
Dehiscence: seperation or splitting open of layers of the surgical wound
Evisceration: Larger wounds where when the incision opens back up the intestines or insides come outside of body.
Types of wound closures:
Adhesive strips: steri-strips. close low tension wounds like skin tears, lacerations, wound already closed at subcutaneous level
Sutures: stitches, most common type of wound closure.
Absorbent suture: used deep in tissue and dissolve
Nonabsorbent stitches: in superficial tissue and require removal
Staples
Wound Vac
Surgical Glue
Wound Drainage: Exudate types (5)
- Serous- from clean wounds, watery-straw, serum
- Sanguineous- bloody. Bright if new, dark if older
- Serosanguineous- combo
- Purulent- thick, maladorous pus
- Purosanguineous- red tinged pus
Pressure Ulcers- pressure sores, decubitus ulcer, or bedsore
Key variable: ISCHEMIA and PRESSURE
* large amt. of pressure for a short amt. of time, OR light pressure for a long period of time.
Pathogensis:
- Pressure intensity
- Blanching
- Pressure duration
- Tissue tolerance
Contributing Factors of Pressure Ulcer Formation
Time & Pressure + Tissue Tolerance
Friction & sheering
Mobility & activity compromise
Nutrition/age/circulation/underlying health
A flush of blood flow to an ischemic area that makes the skin redden
Normal reactive hyperemia
Excessive vasodilation of tissue with induration (hardening- fibrous elements)
Abnormal reactive hyperemia
Stages of Pressure Ulcers (STAGE 1)
Intact skin Not blanchable Painful Firm/soft Warm or cool Discoloration return after 30 minutes of pressure relief
Stages II Pressure Ulcer
Open but very shallow Red/pink wound bed Partial thickness loss of dermis layer No slough of skin tissue May be intact or open/ruptured May look like a serum-filled blister
Stage III pressure ulcer
Deep crater with Full thickness skin loss
Damage or necrosis of subcutaneous tissue
May extend down to but NOT through underlying fascia
No visible bone or tendon
Pressure Ulcer Stage IV
Full thickness with exposed bone and tendon
Necrosis and muscle damage
Slough or Escher may be present
Blink tracking underneath the epidermis (tunneling)
Suspected deep tissue Injury (additional pressure ulcer info)
An area of skin that is intact but discolored or bruised looking.
Painful
Boggy or have a blister present
Unstageable Pressure Ulcer (additional pressure ulcer formation)
Full thickness Skin loss
Base of wound is obscured by slough tan (dead tissue that keeps the wound closed)
Need to open up and debride in order to know what’s goin on underneath
Risk factors for Pressure Ulcer Development (Braden scale)
Impaired sensory perception Impaired mobility/activity Moisture and repeated injections to 1 area Nutrition Shear and friction
