Skin Integrity & Wound Care Flashcards
describe the SKIN ANATOMY
EPIDERMIS;
- the TOP LAYER OF THE SKIN
*come lets get sun burnt
DERMIS;
- the INNER LAYER OF THE SKIN
- COLLAGEN
DERMAL-EPIDERMAL JUNCTION;
- separates the dermis & epidermis
how do pressure injuries occur?
- due to UNRELIEVED PROLONGED PRESSURE
what are other names for PRESSURE INJURIES?
- pressure ulcer
- decubitus ulcer
- bedsore
describe the PATHOGENESIS of PRESSURE INJURIES
- PRESSURE INTENSITY
- PRESSURE DURATION
- TISSUE TOLERANCE
functions of skin
- the LARGEST ORGAN of the body
- serves as a protective barrier
- sensory organ
- synthesizes vitamin D
important focus on older adults
- have an easier breakdown and risk for injury in the skin;
- decreased collagen formation
- thinning muscle and tissue
- decreased skin elasticity
- slower wound healing
who is AT RISK for pressure injuries?
- impaired sensory perception
- impaired mobility
- changes in LOC (dementia patients)
- diabetic/stroke/SCI/hip fracture patients
definition of SHEAR
- the SLIDING MOVEMENT of SKIN and SUBQ. tissue while underlying muscle and bone are STATIONARY
- SKIN + SUBQ. adhere to surface, while bones/muscle slide in direction of body movement
- causes DEEPER FASCIAL LEVEL DAMAGE
definition of FRICTION
- the force of TWO SURFACES moving across from one another
- affects the EPIDERMIS
- painful and red; sheet burn
- often seen in restless patients
definition of MOISTURE:
- allows for more SOFTENED SKIN and creates more SUSCEPTIBILITY
- can cause MOISTURE-ASSOCIATED SKIN DAMAGE (MASD
describe the stages of CLASSIFICATION OF PRESSURE ULCERS
Stage 1: Non-blanchable erythema of intact skin
Stage 2: Partial-thickness skin loss with exposed dermis
Stage 3: Full-thickness skin loss
Stage 4: Pressure Injury: Full-thickness skin and tissue loss
deep tissue pressure injury (DTPI)
- show case of dark marron discoloration
- probable injury to tissue underneath
- can have nonintact/intact skin
- from intense/prolonged pressure
granulation tissue
new healing tissue; pink or red
slough
dead tissue; cream/yellow color
eschar
dead tissue; dry, black and hard
exudate
drainage
what are our WOUND CLASSIFICATIONS
- PARTIAL THICKNESS WOUNDS
- FULL THICKNESS WOUNDS
- PRIMARY INTENTION
- SECONDARY INTENTION
unstageable wound injury
- OBSURED FULL-THICKNESS SKIN and tissue loss
- has tissue damage due to OBSCURED SLOUGH or ESCHAR
- once removed can possibly be classified as either stage 3 or 4
what are some COMPLICATIONS when it comes to wound healing?
- HEMORRHAGE
- INFECTION
- DEHISCENCE
- EVISCERATION
HEMORRHAGE
bleeding out
infection
showcase of fever, odor, purulent drainage, erythema, increased WBC, pain
dehiscence
the opening of the wound
evisceration
the opening of a wound and anatomical structures come out
**MEDICAL EMERGENCY; need covering of saline & surgery
MEDICAL DEVICE-RELATED PRESSURE INJURY (MDRPI):
- where skin or underlying tissues are subjected to SUSTAINED PRESSURE or SHEAR from medical devices or equipment
- injury begins to CONFORM to pattern or shape of the device
mainly seen in face, head, or ear region
what are the TWO MAJOR TYPES OF WOUNDS?
CLOSED;
- surface of skin is INTACT—damage of UNDERLYING TISSUES
- ex. hematomas, stage 1 pressure injuries, contusions
OPEN;
- surface of skin is SPLIT, INCISED, or CRACKED
- exposed underlying tissues
- very high chance of INFECTION DEVELOPMENT
primary intention
- closed wound
- healing undergoes epithelialization - quick, minimal scaring
- seen in hematomas, surgical incisions
secondary intention
- open wound edges
- healing undergoes granulation, tissue formation, wound contraction, & epithelialization
- wounds with tissue loss/contamination
tertiary intention
- open wound (for several days)
- delayed healing process and closing
- contaminated wounds and signs of inflammation
what are factors that influence pressure injury formation & wound healing?
- NUTRITION (vitamins A & C - reduces steroid effects of healing/collagen synthesis
- TISSUE PERFUSION
- INFECTION
- AGE
- PSYCHOSOCIAL IMPACT OF WOUNDS
heat therapy
- allows for VASODILATION
- allows for flexibility
- relaxation of muscles
cold therapy
- use of vasoconstriction
- for inflammation, wound sprains/strains
- often for SOFT TISSUE INJURIES
what types of heat and cold therapies can be applied?
- moist or dry compresses
- warm soaks/cold soaks
- hot and cold packs
**NEVER APPLY DIRECT COLD OR HEAT TO SURGICAL WOUND
**Always start at the LOWEST SETTING
what are the types of EXUDATE?
- SEROUS
- PURULENT
- SEROSANGUINEOUS
- SANGUINEOUS
serous exudate
- clear, watery plasma
purulent exudate
thick, yellow or brown, tan
serosanguineous exudate
pale, pink, watery; mix of clear & red
sanguineous exudate
bright red; sign of active bleeding
tissue perfusion
- perfusion ability of oxygenated blood
- RISK;
- diabetic patients
- peripheral vascular disease patients
