Skin Integrity & Wound Types Flashcards
Layers of skin
Epidermis- avascular
Dermis
SubQ tissue
1st line of defense, largest organ in body
Skin
Factors affecting normal fx of skin
Circulation
Nutrition
Epidermis condition
Abnormal growth
Allergy/infection/ Systemic Diseases
Substance Abuse
Adequate skin perfusion requires four factors
-Heart must pump adequately.
-Volume of circulating blood must be sufficient
-Arteries * veins must be apparent and fx well
-Capillary pressure must be higher than external pressure
break in skin integrity that can be acute, chronic, open, closed
wound
Injury, such as knife, gunshot, burn, or surgical incision; heals within 6 mo
acute wound
Wound that persists beyond usual healing time (>6 mo) or recurs without new injury to the area
chronic wound
Break present in the skin; tissue damage present
open wound
No break seen in the skin, but soft tissue damage evident
closed wound
Closed surgical wound that did not enter gastrointestinal, respiratory, or genitourinary systems; low infection risk
clean wound
Wound entering gastrointestinal, respiratory, or genitourinary systems; increased infection risk
clean contaminated
Open, traumatic wound; surgical wound with break in asepsis; high infection risk
contaminated
Wound site with pathogens present; signs of infection
infected
when tissue layers move on each other, causing blood vessels to stretch as they pass through the subcutaneous tissue
shear force
localized damage to the skin or tissueover a bony prominence, as a result of pressure or pressure. This pressure decreases the blood flow, impairing the supply of nutrients & oxygen to the skin and underlying tissues that form an ulcer as cells die
pressure ulcer
Sitting in urine and stool breaks down skin easier and faster. T or F
True
Wound w/ ragged edges with torn tissue
laceration
a wound caused by shear, friction, or blunt force, resulting in separation of skin layers
skin tear
COntributing factors to pressure injuries
Friction
Shear Force
Moisture
Age/ Declined Mental status
Immobility
Poor Nutrition
over bony prominence, Blanchable skin that is a warning sign for potential breakdown and can be reversed
“At risk” area for pressure ulcer
over bony prominence; non blanchable erythema of intact skin; reportable; measure and document
Stage 1 Pressure Ulcer
Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, can be opened or closedwithout slough or bruising
Stage 2 pressure ulcer
dead/nercrotic tissue that can be various colors
sloth/eschar
deep, crater appearing, full thickness tissue loss where fat is visible, but doesn’t expose bone, tendon, or muscle
Stage 3 pressure ulcer
Wound edges not attached to wound bed
undermining
A narrow channel or pathway that extends from a wound
tunneling
What makes a wound unstageable?
Slough or eschar covering the majroity of the ulcer
rolled, curled under wound edges/ callus
epibole
abnormal hardening of tissue around wound
induration
How to debride wound
Wet-dry dressings
Surgical intervention
Proteolytic enzymes
a medical procedure that removes dead, damaged, or infected tissue from a wound to help the healthy tissue heal
debridement
full-thickness tissue loss with exposed bone, tendon, or muscle
Stage 4 pressure ulcer
a serious bone infection that occurs when bacteria or fungi spread to the bone
osteomyelitis
purple maroon/localized area if discolored intact skin where the soft tissue beneath the skin is damaged by pressure or shear forces
DTI- deep tissue injury
full-thickness skin and tissue loss where the base of the wound is covered by a layer of dead tissue, or eschar,
unstageable pressure ulcer
Stable eschar on heels can be removed. T or F
FALSE- shout NOT be removed from heels
predictor scale for skin breakdown
Braden Scale
wound involving friction of skin
Abrasion
a close wound w/ bleeding in underlying tissues
contusion
a wound involving penetration of skin & underlying tissue
puncture
