Skin Integrity & Wound Care. Ch 32 Flashcards
Dermis
Second layer, Elastic connective tissue, contains nerves, hair follicles, glands, blood vessels
Epidermis
Top outermost layer, regenerates quickly
Subcutaneous tissue
The underlying layer that anchors the skin layers to the underlying tissues of the body
Functions of the skin
- Protection
- Temp regulation
- Psychosocial. Pg 919
- Sensation
- Vit D production
- Immunological
- Absorption. (Increase use in medicinal patches)
- Elimination
Age related skin changes
- Skin becomes thin, easily injured, less insulating, sensation of pain and pressure is reduced
- decrease in sweat gland activity, skin becomes dryer, pruritis (itching)
- healing time is delayed
- amount of melanocytes decline, hair becomes gray-white, uneven skin pigmentation
- collagen fiber is less organized, skin loses elasticity.
- infants skin is easily injures,d subject to infection
Wound
Break or disruption in the normal integrity of the skin and tissue
Wound classification
Intentional and unintentional
Open and closed
Acute and chronic
Partial thickness,full, complex
Examples pg 923
Phases of wound healing
- Hemostasis- occurs immediately, vessels constrict and clotting begins, exudate causes swelling, incr perfusion creates heat, platelets stimulate migration of cells to next phase
- Inflammatory- lasts 4-6 days, WBCs/macrophages move to wound, ingest debris, release growth factors for healing
- Proliferation- w/in 2-3 days, last up to 2-3 wks, regenerative phase, new tissue is built, capillaries grows cross wound, thin layer epi cells and granulation tissue forms.
- Maturation-final stage, begins about 3 wks-6 mos after injury, collagen is remodeled to make skin stronger, new collagen tissue deposited, scar becomes thin, flat, white
Exudate
Plasma and blood components to leak out into the area that is injured forming a liquid
(Homeostasis)
Granulation tissue
Foundation for scar tissue development. Made of thin layer epithelial cells formed across the wound reinstating blood flow
Desiccation
Dehydration
Maceration
Over hydration
Tissue had been soaked in water/fluid
Necrosis
Death of tissue
Two Factors affecting wound healing
Local and Systemic
Local Factors affecting wound healing
Pressure- interferes with blood flow, delays healing
Desiccation- cells dehydrate forming crust cover
Maceration- over hydration
Desiccation-
Trauma-
Edema- interferes with blood supply to the area,
inadequate supply of oxygen and nutrients
Infection-toxins produced by bacterial death
interfere with healing and cause cell death
Necrosis- dead tissue; must be removed for
healing to occur
Systemic factors affecting wound healing
- Age- older adults are more likely to have one or more chronic illnesses impeding healing. Infants and young children at risk due to loose skin binding.
- Circulation and oxygen- (smoking) adequate blood flow delivers nutrients and oxygen to remove local toxins, bacteria, and other debris.
- Nutritional status-body requires adequate proteins, carbs, fats, vitamins, minerals
- Wound Condition- size, presence of infection, foreign bodies.
- Medications- corticosteroids decrease the inflammatory process, radiation depresses bone marrow function, chronic illnesses, chemotherapy, prolonged antibiotics
- Immunosupression-diseases (aids,lupus), medication (chemo), age
- Health status - diabetes
Wound complications
Infection, hemorrhage, dehiscence and evisceration, fistula formation
Dehiscence
Partial or total separation of wound layers as a result do excessive stress on wounds that are not healed.
Picture of open surgical wound sutures have come apart
Evisceration
The wound completely separates with the protrusion of the viscera through the incisional area.
(Picture of intestine coming through incision)
Fistula
An abnormal passage from an internal organ to the outside of the body or from one internal organ to another
Pressure ulcer
Wound with localized area of tissue necrosis. Acute or chronic
Most occur in older adults as a result of aging, chronic illnesses, immobility, malnutrition, fecal and urinary incontinence, and/or altered consciousness
Factors in pressure ulcer development
External Pressure- ischemia, hypoxia, edema,
inflammation, then necrosis and ulcer formation
Friction and Shear- two surfaces rub against each
other. Skin breakdown, wear and tear of tissue
layers.
Ischemia
Deficiency of blood in a particular area
Difference between friction and shear
Friction- looks like an abrasion, superficial blood vessels damaged
Shear- one layer of tissue slides over another layer. Separates the skin from underlying tissue. Vessels can tear decreasing circulation
Risks for pressure ulcer development
Immobility, nutrition and hydration, moisture, mental status, age
Pressure ulcer stages
Suspected: purple or maroon localized area.
Stage 1: intact skin, nonblanchable redness, usually over bony prominence
Stage2: partial thickness loss of dermis, presents as shallow open ulcer
Stage 3: full thickness tissue loss, undermining
Stage 4: full thickness tissue loss with exposed bone, tendon, muscle
Eschar
Thick, leathery scab or dry crust that is necrotic and must be removed before stage can be determined.
**eschar in the heels serves as body’s natural cover and should not be removed
Risk assessment scales
Norton Scale
Braden Scale
Debridement
Removal of devitalized tissue and foreign material
Additional techniques to promote wound healing
Fibrin sealants, negative pressure wound therapy, growth factors, oxygen therapy, heat and cold therapy, other treatment options for pressure ulcers-> surgery
Intentional wound
Result of planned invasive therapy or treatment, purposely created for therapeutic purposes,
Edges are clean, bleeding usually controlled, risk for infection is decreased, healing is facilitated
Unintentional wounds
Accidental, occur from unexpected trauma, contamination is likely, wound edges are jagged, multiple traumas are common, high risk for infection, longer healing time
Open wound
Skin surface is broken, provides portal of entry for microorganisms
Closed wound
Results from blow, force or strain caused by trauma, skin surface is not broken, soft tissue is damaged
Factors affecting skin
- Unbroken healthy skin defend against invaders
- Resistance injury affected by age, illness, underlying tissue
- adequately nourished cells resistant to injury
- adequate circulation necessary to maintain cell life
Causes if skin alteration
- very thin and obese people more susceptible
- jaundice
- diseases of the skin
Principles of wound healing
- Intact skin first line of defense
- Surgical asepsis used for acting for the wound
- Body responds systematically to trauma
- Adequate blood supply is important for normal injury response
- Wound healing is promoted when wound is free of foreign material
- extent of damage to a persons state of health
- response is improved with proper nutrition, protein
