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