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Nursing Fundamentals > Skin Integrity & Wound Care. Ch 32 > Flashcards

Skin Integrity & Wound Care. Ch 32 Flashcards

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0
Q

Dermis

A

Second layer, Elastic connective tissue, contains nerves, hair follicles, glands, blood vessels

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1
Q

Epidermis

A

Top outermost layer, regenerates quickly

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2
Q

Subcutaneous tissue

A

The underlying layer that anchors the skin layers to the underlying tissues of the body

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3
Q

Functions of the skin

A
  1. Protection
  2. Temp regulation
  3. Psychosocial. Pg 919
  4. Sensation
  5. Vit D production
  6. Immunological
  7. Absorption. (Increase use in medicinal patches)
  8. Elimination
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4
Q

Age related skin changes

A
  • 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
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5
Q

Wound

A

Break or disruption in the normal integrity of the skin and tissue

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6
Q

Wound classification

A

Intentional and unintentional
Open and closed
Acute and chronic
Partial thickness,full, complex

Examples pg 923

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7
Q

Phases of wound healing

A
  1. Hemostasis- occurs immediately, vessels constrict and clotting begins, exudate causes swelling, incr perfusion creates heat, platelets stimulate migration of cells to next phase
  2. Inflammatory- lasts 4-6 days, WBCs/macrophages move to wound, ingest debris, release growth factors for healing
  3. 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.
  4. 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
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8
Q

Exudate

A

Plasma and blood components to leak out into the area that is injured forming a liquid
(Homeostasis)

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9
Q

Granulation tissue

A

Foundation for scar tissue development. Made of thin layer epithelial cells formed across the wound reinstating blood flow

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10
Q

Desiccation

A

Dehydration

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11
Q

Maceration

A

Over hydration

Tissue had been soaked in water/fluid

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12
Q

Necrosis

A

Death of tissue

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13
Q

Two Factors affecting wound healing

A

Local and Systemic

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14
Q

Local Factors affecting wound healing

A

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

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15
Q

Systemic factors affecting wound healing

A
  1. 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.
  2. Circulation and oxygen- (smoking) adequate blood flow delivers nutrients and oxygen to remove local toxins, bacteria, and other debris.
  3. Nutritional status-body requires adequate proteins, carbs, fats, vitamins, minerals
  4. Wound Condition- size, presence of infection, foreign bodies.
  5. Medications- corticosteroids decrease the inflammatory process, radiation depresses bone marrow function, chronic illnesses, chemotherapy, prolonged antibiotics
  6. Immunosupression-diseases (aids,lupus), medication (chemo), age
  7. Health status - diabetes
16
Q

Wound complications

A

Infection, hemorrhage, dehiscence and evisceration, fistula formation

17
Q

Dehiscence

A

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

18
Q

Evisceration

A

The wound completely separates with the protrusion of the viscera through the incisional area.
(Picture of intestine coming through incision)

19
Q

Fistula

A

An abnormal passage from an internal organ to the outside of the body or from one internal organ to another

20
Q

Pressure ulcer

A

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

21
Q

Factors in pressure ulcer development

A

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.

22
Q

Ischemia

A

Deficiency of blood in a particular area

23
Q

Difference between friction and shear

A

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

24
Q

Risks for pressure ulcer development

A

Immobility, nutrition and hydration, moisture, mental status, age

25
Q

Pressure ulcer stages

A

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

26
Q

Eschar

A

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

27
Q

Risk assessment scales

A

Norton Scale

Braden Scale

28
Q

Debridement

A

Removal of devitalized tissue and foreign material

29
Q

Additional techniques to promote wound healing

A

Fibrin sealants, negative pressure wound therapy, growth factors, oxygen therapy, heat and cold therapy, other treatment options for pressure ulcers-> surgery

30
Q

Intentional wound

A

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

31
Q

Unintentional wounds

A

Accidental, occur from unexpected trauma, contamination is likely, wound edges are jagged, multiple traumas are common, high risk for infection, longer healing time

32
Q

Open wound

A

Skin surface is broken, provides portal of entry for microorganisms

33
Q

Closed wound

A

Results from blow, force or strain caused by trauma, skin surface is not broken, soft tissue is damaged

34
Q

Factors affecting skin

A
  • 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
35
Q

Causes if skin alteration

A
  • very thin and obese people more susceptible
  • jaundice
  • diseases of the skin
36
Q

Principles of wound healing

A
  • 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

Nursing Fundamentals (28 decks)

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