Skin Integrity (Final) Flashcards by Gabriella Arias

Epidermis

stratum corneum

stratum germinativum

How well did you know this?

Not at all

Perfectly

Age affecting skin integrity

older adult skin is less elastic, drier, reduced collagen, areas of hyperpigmentation, more prone to injury

How well did you know this?

Not at all

Perfectly

Mobility status affecting skin integrity

SKIN BREAKDOWN

increased pressure
shearing and friction (moving patients)

How well did you know this?

Not at all

Perfectly

Nutrition/hydration affecting skin integrity

PROTEIN: maintains the skin, repair minor defects, preserves intravascular volume

vitamin C, zinc and copper for formation of collagen

more fluids, calories, cholesterol

How well did you know this?

Not at all

Perfectly

Sensation level affecting skin integrity

diminished sensation leads to increased risk for pressure and breakdown

How well did you know this?

Not at all

Perfectly

Impaired circulation affecting skin integrity

negatively affects tissue metabolism

less oxygenation to tissues, ischemia, increased risk of pressure ulcers!

How well did you know this?

Not at all

Perfectly

Meds affecting skin integrity

side effects like itching or severe rashes

blood thinners, inhibits wound healing!

How well did you know this?

Not at all

Perfectly

Moisture affecting skin integrity

leads to maceration

incontinence, sweating (fever)-depletes moisture, increases metabolic rate

How well did you know this?

Not at all

Perfectly

Infection affecting skin integrity

impedes healing

How well did you know this?

Not at all

Perfectly

Lifestyle affecting skin integrity

tanning
bathing
piercings and tats

How well did you know this?

Not at all

Perfectly

Cognition affecting skin integrity

may not resposition and may not recognize any dangers

How well did you know this?

Not at all

Perfectly

Classification of wounds

• open/closed
• acute/chronic
• clean/contaminated/infected
• superficial/partial or full thickness
• penetrating

How well did you know this?

Not at all

Perfectly

Regeneration

in epidermal (or dermis) wounds, no scar

epithelial healing!

How well did you know this?

Not at all

Perfectly

Primary (First intention)

clean surgical incision/edges approximated, minimal scarring

mininal/no tissue loss, easily closed

How well did you know this?

Not at all

Perfectly

Secondary

wound edges not approximated, tissue loss (prevents wound edges from approximating), heals from inner layer to surface

wouldn’t shouldn’t be closed in cases of infection or animal bites

How well did you know this?

Not at all

Perfectly

Tertiary

granulating tissue brought together, delayed primary closure of wound edges

when a wound is allowed to heal by secondary intention and suture the surface only when no signs of infection are seen

How well did you know this?

Not at all

Perfectly

Phases of wound healing

hemostasis
inflammation
proliferation
maturation (tissue remodeling)

How well did you know this?

Not at all

Perfectly

Wound closures

adhesive strips
sutures
surgical staples
surgical glue

Serous exudate

straw colored, watery

Sanguineous exudate

bloody drainage

Serosanguineous exudate

mix of bloody and straw colored fluid

red, watery, clear

Purulent exudate

yellow, contains pus, thick odor

Purosanguineous exudate

contains blood and pus, red-tinged

Complications: Hemorrhage

internal/external; profuse or rapid loss of blood and bruising

Complications: Infections

red, swelling, warmth, odor, purulent discharge, fever, tenderness or pain

Complications: Dehiscence

MEDICAL EMERGENCY!!! rupture/separation of 1+ layers of wound

Complications: Evisceration

MEDICAL EMERGENCY!!! total separation of all layers of a wound with internal viscera protruding through incision

Complications: Fistula formation

abnormal passive connecting 2 body cavities/cavities in the skin

Braden scale

sensory perception, moisture, activity, mobility, nutrition, and friction/shear **total score less than 18=risk**

Wound assessment (Nursing Interventions)

• location • size • undermining/tunneling • appearance (color) • odor • drainage • redness • swelling • pain • nutritional status • output

Lab Data

blood studies wound cultures (*swabbing, needle aspiration, tissue biopsy*)

Nursing Interventions: Drains

Jackson-Pratt, Hemo-vac

Nursing Interventions: Debriding a wound

wet/dry mechanical hypotherapy (*removes tissue and can reopen wound*) enzymatic, autolysis (**moisture-retentive dressings aid**), biotherapy (*applying maggots*), sharp

Leech therapy

BIOLOGICAL WOUND DEBRIDEMENT can be used to “detox” wound **predominantly used to increase blood flow**

Other nursing interventions

• cleansing/irrigating • applying negative pressure wound therapy • dressing a wound (*gauze/transparent film, hydrocolloids/hydrogels*) • supporting/immobilizing a wound (*binders/bandages*) • applying heat and cold • monitor wound, nutrition, hydration and weight

Pressure injuries

15% OF HOSPITALIZED CLIENTS! caused by unrelieved pressure to an area, resulting in ischemia **USE PUSH TOOL**

Preventing pressure ulcers

reposition every 2 hours barrier cream nutrition elevate heels off the bed Braden scale prevention skin care and moisture control therapeutic mattresses (*sand/air filled*) client and family teaching

Risk factors of pressure injuries

• mobility, activity and sensation (*time and pressure*) • intrinsic factors like nutrition, age, circulation, underlying health status (*tissue tolerance*) • extrinsic factors like friction, shearing, and moisture (*tissue tolerance*)

Stage 1 pressure ulcer

red, non-blanchable, INTACT!, no open areas

Stage 2 pressure ulcer

OPEN, blistered, partial thickness loss of epidermis and dermis, superficial

Stage 3 pressure ulcer

full thickness loss, ADIPOSE visual, damage/necrosis, may extend into fascia, may see granulation tissue

Stage 4 pressure ulcer

full thickness loss, extensive destruction, tissue necrosis/damage to bone, muscle/support structures like tendons and ligaments

Unstageable pressure ulcer

presence of eschar (black/necrotic) or if deep tissue like a bruise