Skin Integrity and Wounds Flashcards
Epidermis
- protective waterproof layer of keratin
- cells have no blood vessels of their own
- regenerates easily and quickly
Dermis
- elastic tissue made mainly of collagen
- nerves, hair follicles, glands, immune cells, blood vessels
Subcutaneous
- anchors skin layers to underlying tissue
functions of skin
- protection
- body temp regulation
- psychosocial
- sensation
- immunologic
- vitamin d prodution
- absorption
- elimination
factors affecting skin integrity
- unbroken, healthy skin and mucous membranes defend against harmful agents
- resistance to injury affected by age, amount of tissue, illness
- adequately nourished/hydrated cells resistant to injury
- adequate circulation
developmental considerations
skin
- maturation of epidermal cells is prolonged, leading to thin, easily damaged skin
- circulation and collagen formation are impaired, leading to ⬇️ elasticity and increased risk for tissue damage from pressure
causes of skin alterations
- very thin and very obese people more susceptible to skin injury especially in skin folds
- fluid loss during illness causes dehydration
- jaundice causes yellow, itchy skin
- diseases of skin (eczema/psoriasis) cause lesions requiring special care
types of wounds
- intentional (surgical) or unintentional (traumatic)
- neuropathic or vascular
- pressure related
- open or closed
- acute or chronic
- partial thickness, full thickness, complex
phases of wound healing
- hemostasis
- inflammatory
- proliferation
- maturation
hemostasis
- immediately after injury
- vasoconstriction, clotting begins
- exudate is formed, causing swelling and pain
- ⬆️ perfusion leads to heat and redness
- platelets stimulate other cells to migrate to site of injury
inflammatory phase
- after hemostasis, lasts 2-3 days
- WBCs move to wound (leukocytes and macrophages)
- macrophages injest debris and release growth factors that attract fibroblasts to fill the wound
- exudate accumulates, pain, swelling, redness
- generalized body response
proliferation phase
- several weeks
- new tissue is built by fibroblasts
- capillaries grow across the wound
- thin layer of epithelial cells forms across wound
- granulation tissue forms foundation for scar tissue
maturation phase
- begins approx 3 weeks after injury, leasts months to years
- collagen is remodeled
- new collagen tissue depositied, compressing the blood vessels which causes a scar
what is a scar?
- flat, thin, white line
- avascular collagen tissue that does not sweat, grow hair, or tan in the sunlight
local factors affecting wound healing
- pressure
- desiccation (dehydration)
- maceration (overhydration)
- trauma
- edema
- infection
- excessive bleeding
- necrosis
- presence of biofilm
systemic factors affecting wound healing
- age: older adults take longest
- circulation/oxygenation
- nutritional status
- wound etiology
- health status: steriods/postop radiation delay healing
- medication use
- adherence to treatment plan
wound complications
- infection
- hemorrhage
- dehiscence and evisceration
- fistula formation
factors involved in pressure injury formation
- urinary/bowel incontinence
- aging skin
- chronic illness
- immobility
- malnutrition
- altered level of consciousness
- neuromuscular disorder/ cns injury
stage 1
stages of pressure ulcers
nonblanchable erythema of intact skin
stage 2
stages of pressure ulcers
partial-thickness skin loss with exposed dermis
stage 3
stages of pressure ulcers
full-thickness skin loss, not involving underlying fascia
stage 4
stages of pressure ulcers
full thickness skin and tissue loss
muscle and bone exposed
unstageable
stages of pressure ulcers
obscured full-thickness skin and tissue loss
deep tissue pressure injury
stages of pressure ulcers
persistent nonblanchable deep red, purple or maroon discoloration
wound assessment
- appearance (size, depth, undermining, tunneling)
- drainage (serous, sanguineous, serosanguineous, purulent)
serous drainage
- comprised of mostly the clear, serous portion of blood and from serous membranes
- clear and watery
- normal sign of healing
sanguineous drainage
- large number of RBC and looks like blood
- bright red or dark red
- normal sign of healing in the beginning, abnormal if prolonged
serosanguineous drainage
- mixture of serum and RBCs
- light pink to blood tinged
- normal, most common type of wound drainage
purulent drainage
- made up of WBCs, dead tissue debris, dead and live bacteria
- thick, foul odor, varies in color (yellow or green)
- not normal, sign of infection
open drains
- gauze: allow healing from base of wound, infected wound
- penrose: soft rubber tube to drain blood and fluid, abd surgery
closed drains
- blake: silicone tube with 4 chambers to drain blood and fluid. cardiac surgery in place of chest tube or JP
- chest tube: mediastinal placement to drain blood after cardiac surgery
- hemovac: portable negative pressure suction device to drain blood and fluid, after abd or orthopedic surgery
- JP: bulb suction device to drain blood and fluid, after breast surgery/masectomy/abd surgery
- T tube: tube placed in common bile duct to collect bile after gallbladder surgery
types of wound dressings
- maintain moisture
- add moisture
- absorb moisture
maintaining moisture wound dressing
- hydrogels, foams, alginate, hydrocolloid, film
- used for ulcers, pressure injuries
adding moisture wound dressing
- hydrogels
- for ulcers, surgical wounds, sensitive skin
absorbing moisture wound dressing
- gauze, absorbent cotton, antimicrobials, negative pressure wound healing
- for burns, skin grafts, diabetic injury
changing wound dressing
- maintain aseptic technique
- remove old dressing
- cleanse wound
- apply new dressing
- secure dressing
types of bandages
- roller bandage
- circular turn
- spiral turn
- figure of eight turn
