skin power point Flashcards
Factors Affecting Skin Integrity
Integrity
Age
Mobility status
Sensation level
Impaired circulation
Medications (itching, rashes, sun sensitivity, allergies)
Fever (causes warm, wet areas- bacteria like this)
Infection
Lifestyle
Nutrition / Hydration
Nutrition / Hydration that affect skin integrity
Protein (building blocks)
Vitamin C (boosts collagen)
Zinc (anti-inflammatory properties)
Dehydration (skin needs to be moist, water helps to flush away toxins and carry nutrients to the skin’s cells
Wound Classification Skin integrity
Open wound: an actual break in the skin Closed wound: skin is still intact (bruising)
Wound Classification Wound Depth:
Superficial wound: involves only the epidermis
Partial-thickness wound: involves the epidermis and dermis
Full-thickness wound: involves epidermis, dermis, subcutaneous tissue, and possibly muscle orbone
Wound Classification Amount of Contamination
Clean: has no infection and the risk for infection is low
Clean contaminated: involves a surgery that involves organ systems likely to contain bacteria, higher infection risk
Contaminated: result from break in sterile technique, from perforation, trauma, accident, highest risk of infection
Infected: shows clinical signs of infection (warmth, redness, purulent drainage)
other factors Affecting Wound Healing
Oxygenation
tissue perfusion
Diabetes
Wound Healing phases
Inflammatory phase: the first phase, lasts about three days, include coagulation cascade
Proliferative phase: filling of wound bed with new (granulation) tissue
Maturation phase: remodeling phase; can last up to a year, collagen is deposited, and scar tissue forms
Complications of Wound Healing
Infection
Fistula formation
Dehiscence
Evisceration
what is Fistula formation
abnormal connection between organs in the body
Dehiscence is
opening of wound
Evisceration is
opening of wound AND protrusion of organs through the incision (put sterile gauze on and contact surgeon immediately)
calculating the total body surface affected by burns
HEAD and NECK= %
right or left arm= %
entire trunk= %
gronin= %
LEG right or left= %
HEAD and NECK= 9%
right or left arm= 9% each
entire trunk= 36%
gronin= 1%
LEG right or left= 18% each
the 4 types of burns
superficial thickness
partial
intermediate thickness
full-thickness
fourth degree
superficial thickness burns is on
surface
partial burns extend to
epidermis
intermediate-thickness
epidermis and dermis
full-thickness burns extend to
to lower dermis
4th degree burns extends to
bones and muscle
Pressure Injuries are caused by
Caused by long duration of pressure
medical devices
friction and shear
sensory loss
moisture
poor nutrition
Pressure Injury Classification
stage 1
stage 2
stage 3
stage 4
unstageable
deeptissue
stage 1 Pressure Injury looks
intact, non blistered skin with non blanchable erythema
stage 2 Pressure Injury are
partial-thickness wound that involves the epidermis and/or dermis but does not extend below the level of the dermis
stage 3 Pressure Injury are
full-thickness wounds that extend into the subcutaneous tissue but do not extend through the fascia to muscle, bone, or connective tissue
stage 4 Pressure Injuries are
full-thickness wounds that are deeper than Stage III and involve exposure of muscle, bone, or connective tissue
Unstageable Pressure Injuries are
full-thickness wound in which the amount of necrotic tissue in the wound bed makes it impossible to assess the depth
Deep Tissue Pressure Injuries looks like
an area of intact skin that is purple or maroon
Interventions related to wound care
◦ Wound cleansing and irrigation
◦ Solution should be at room temperature or warmed
◦ Irrigation force should be strong enough to be effective without damaging new tissue
◦ Debridement
◦ Sharp
◦ Mechanical
◦ Enzymatic
◦ Autolytic
◦ Biologic
Interventions to preserve skin integrity
Turning and positioning every 2 hours
Skin hygiene
Interventions related to wound care dressings
◦ Dressings
◦ Gauze dressings
◦ Transparent films
◦ Hydrocolloid dressings
◦ Foams
◦ Alginates
◦ Gels
Heat and cold application information and requirements
Reduces pain, improves circulation, and reduces swelling
May require a doctor’s order
Complications
what is required from doctor orders when applied heat/ cold applications
◦ Type of application
◦ Length of the treatment
◦ Frequency
◦ Body part to be treated
Complications of heat/ cold applications
Loss of the body’s normal ability to sense temperature extremes, which may result in damage to tissue
