Test 3 Flashcards
Functions of the skin
Protection
Body temp regulation
Psychosocial
Sensation
Vitamin D production
Immunologic
Absorption
Elimination
Factors affecting the skin
Unbroken and healthy skin and mucous membrane defend against harmful agents
Resistance to injury is affected by age, amount of underlying tissue and illness
Adequately nourished and hydrated body cells are resistant to injury
Adequate circulation is necessary to maintain cell life
Skin younger than 2
Thinner and weaker
Infants skin
The skin and mucous membranes are easily injured and subject to infection
A child’s skin becomes increasingly resistant to injury and infection
Skin and aging
The structure of the skin changes, the maturation of epidermal cells is prolonged, leading to thin, easily damaged skin
Circulation and collagen formation are impaired leading to decreased elasticity and increased risk for tissue damage from pressure
Causes of skin alteration
Very thin and obese people are more susceptible to skin injury
- fluid loss during illness causes dehydration
- skin appears loose and flabby
Excessive perspiration during illness predisposes skin to breakdown
Diseases of the skin such as eczema and psoriasis may cause lesions that require special care
Unintentional wound
Caused by an accidental fall or accident
Intentional wounds
Made by a healthcare professional like for surgery
Open wound
Like a cut, something that breaks the skin
Closed wound
Does not break the skin, like a bruise
Acute wound
Lasts for < 30 days
Goes through normal steps of healing
Chronic wound
Lasts for months or years
Partial thickness wound
Damages the epidermis and sometimes the dermis but does not go past the dermis
Full thickness wound
Damage goes past the epidermis and dermis and into the subcutaneous tissue
Could go to bone
Complex wound
Could be all of the above, partial and full
Difficulty healing
Principles of wound healing
Intact skin is the first line of defense against microorganisms
Careful hand hygiene **
Body responds systematically to trauma of any parts
Adequate blood supply is essential for normal body response
Normal healing is promoted when the wound is free of foreign material
Principles of wound healing
Intact skin is the first line of defense against microorganisms
Careful hand hygiene **
Body responds systematically to trauma of any parts
Adequate blood supply is essential for normal body response
Normal healing is promoted when the wound is free of foreign material
Extent of damage and state of health affects healing
Response to wound is more effective is proper nutrition
Need to know how person got wound**
Phases of wound healing
Hemostasis
Inflammatory
Proliferation
Maturation
Hemostasis
Immediately after initial injury
Involved blood vessels constrict and blood clotting begins
Exudate is formed, causing swelling and pain
Increased perfusion results in heat and redness
Platelets stimulate other cells to migrate to the injury to participate in other phases of healing
Inflammatory phase
Follows Hemostasis and lasts about 2-3 days
WBCs, mostly leukocytes and macrophages, move to wound
Macrophages enter the wound area and remain for an extended period
They ingest debris and release growth factors that attract fibroblasts to fill in the wound
Patient has a generalized body response
Proliferation phase
Lasts for several weeks
New tissue is built to fill the wound space through the action of fibroblasts
Capillaries grow across the wound
Think layer of epithelial cells forms across the wound
Granulation tissue forms a foundation for scar tissue development
Granulation tissue
Beefy red marbled tissue
Pink would mean you want more blood supply
Maturation phase
Final stage of healing, begins about 3 weeks after the injury, possibly continuing for months or years
Collagen is remodeled
New collagen tissue is deposited
Scar becomes a flat, thin, white line
Healed but never looks 100%
Local factors affecting wound healing
Pressure
Desiccation
Maceration
Trauma
Edema
Infection
Excessive bleeding
Necrosis
Presence of biofilm