Skin/wound Flashcards
Functions of the skin:
protection temperature regulation psychosocial (self esteem) sensation vitamin D production immunologic absorption (topical medications) elimination (sweat)
p. 958
Factors affecting skin integrity:
resistance to injury varies (age, amount underlying tissue, illness conditions)
nourished/hydrated body cells resist injury
adequate circulation necessary to cell life
p.958
Developmental considerations in infant/child:
Less than 2y.o. skin is thinner and weaker than adult
easily injured
subject to infection
p.958
Developmental considerations in aging adult:
epidermal cell maturation is prolonged thin skin easily damaged circulation/collagen/elasticity is impaired ^ risk tissue damage from pressure
p.958
dehydration can occur from these situations:
fluid loss from fever, vomiting, diarrhea
skin appears loose/flabby
p958
Jaundice is characterized by:
excessive bile pigments in the skin
resulting in yellowish skin color
skin is often itchy/dry
^ risk for scratching/open lesion
p958
wound definition:
break or disruption in the normal integrity of the skin and tissues
p958
Factors placing an individual at risk for skin alterations:
lifestyle variables (sexual practices/occupation/body piercing)
Age
changes in health state (dehydration/malnutrition)
illness (DM)
diagnostic measures (GI cleansing)
therapeutic measures (bed rest/cast/medications/therapy)
p959
Wound classifications: intentional/unintentional:
Intentional: planned invasive therapy or treatment (surgery/IV therapy/lumbar puncture) edges are clean bleeding controlled decreased risk of infection ^ for healing
Unintentional: accidental (unexpected trauma/injury/burns) Edges jagged uncontrolled bleeding ^ risk of infection longer healing time
p960
Wound classifications: open/closed:
Open: intentional/unintentional (incisions/abrasions) surface is broken/bleeding/tissue damage ^ risk for infection delayed healing
Closed:
result from blow/force/strain (ecchymosis/hematoma)
soft tissue damage/ internal injury/hemorrhage
surface not broken
p960
Wound classifications: Acute/Chronic:
Acute:
heal within days to weeks
edges well approximated
risk infection lessened
Chronic: healing process impeded edges not approximated ^ risk infection healing time delayed remain in inflammatory phase of healing
p961
Wound repair classifications:
primary intention
secondary intention
tertiary intention
p961
primary intention is:
well approximated edges
wounds with minimal tissue damage
p961
secondary intention is:
edges not well approximated large open wounds (burns) sometimes contaminated take longer to heal form more scar tissue
p961
tertiary intention is:
wounds left open for several days
allow edema or infection to resolve
fluid to drain
and then are closed
p961
Types of wounds:
incision contusion abrasion laceration puncture penetrating avulsion chemical thermal irradiation pressure ulcers venous ulcers arterial ulcers diabetic ulcers
p961
phases of wound healing:
hemostasis
inflammatory
proliferation
maturation
pp 962-963
factors affecting wound healing:
LOCAL FACTORS pressure desiccation maceration trauma edema infection excessive bleeding necrosis biofilm
SYSTEMIC FACTORS age circulation oxygenation nutritional status medications health status immunosuppression
pp 963-965
wound complications:
infection hemorrhage dehiscence evisceration fistula formation
pp 965-966
Dehiscence is:
the partial or total separation of wound layers was a result of excessive stress on wounds that are not healed.
p.965
Evisceration is:
is the most serious complication of dehiscence– complete separation with protrusion of viscera through incisional area
p965
increase in the flow of fluid from wound between postoperative day 4/5 may be a sign of what?
impending dehiscence
p966
What would you do if your patient is experiencing dehiscence?
cover the wound area with sterile towels moistened with sterile 0.9% sodium chloride solution and notify provider
p.966
Is dehiscence or evisceration of an abdominal incision an emergency?
YES!
Place the pt in low fowlers position and cover the exposed abdominal contents (with sterile towels moistened with sterile 0.9% sodium chloride solution)
DO NOT leave the pt alone
notify PCP immediately
p966
Pressure ulcer development/factors:
- external pressure that compresses blood vessels
- friction and shearing forces that tear and injure blood vessels and abrade the top layer of skin
pp 966-967
Risks for pressure ulcer development:
immobility nutrition and hydration moisture mental status age
p 967-968
Eschar is:
a thick, leathery, scab or dry crust that is necrotic and must be removed before the stage can be determined
except for stable eschar on the heels
Suspected deep tissue injury:
underlying soft tissue damage from pressure/shear
purple or maroon
intact skin
painful/firm/boggy/warm/cool than adjacent skin
Stage I:
Intact skin
non-blanchable redness
painful/firm/soft/warmer/cooler than adjacent skin
may indicate “at risk”
Stage II:
partial thickness loss of dermis shallow/open ulcer red/pink wound bed without slough or bruising May be: intact/open/rupture serum-filled blister
Stage III:
full thickness tissue loss
subcut fat may be visible
NO bone/tendon/muscle
may include undermining/tunneling
Stage IV:
Full thickness loss
palpable/visible bone/tendon/muscle/surrounding structures
slough/eschar present
includes undermining/tunneling
Unstageable:
full thickness tissue loss
base of ulcer covered by slough/eschar
cannot be determined until cleaned up
How long after surgery should wound have “closer to normal appearance?”
1 week– with edges healing together.
p 974
Venus pressure ulcers:
lower leg- shin/ankle, pooling of blood, moist/exudate/slough, irregular border, surrounding brown skin (brawny)
Arterial pressure ulcers:
lower leg- toes/feet, injury-lack of blood, dry, “punched out” round, neurotic, surrounding pale skin
Appearance of infected wound:
wound is swollen, deep red, hot on palpation, drainage is increased and purulent, sometimes edges dehiscence,
