Test #4 - Skin/Tissue Integrity Flashcards
What are the top 2 layers of skin and their functions?
- Epidermis = outer layer, used for protection, permits absorption of topical meds
- Dermis = inner layer of skin, provides strength/support & protection of muscles, bones, and organs. Contains collagen, blood vessels, and nerves, fibroblasts for collagen formation.
What are the fx of the epidermis and dermis when the skin is injured?
- Epidermis resurfaces the wound and restores barrier against invasion of organisms.
- Dermis restores collagen
Stage 1 pressure injury
non-blanchable erythema of the skin caused by superficial (top-down) shear or friction. Looks red
Blanchable hyperemia
skin blanches (turns light in color) when pressure w/finger is applied and erythema returns when you remove your finger
Nonblanchable erythema
area of redness does not turn light in color when pressure is applied and is consistently red/pink in color
How to check for pressure injuries in patients w/darkly pigmented skin
Inspect an adjacent or opposite area of the body for comparison. Check consistency (firm or boggy), sensation (pain), edema, warmer/cooler temperature. Edema can appear taut and shiny
BRADEN Scale risk factors: pressure injury development
- Sensory perception
- Moisture
- Physical activity
- Mobility
- Nutrition
- Friction/shear
Stage 2 pressure injury
- Partial thickness skin loss w/exposed dermis
- Wound bed is pink/red, moist
- Granulation tissue, eschar, slough NOT present
Stage 3 pressure injury
- Full thickness skin loss
- Adipose (fat) is visible
- Granulation tissue, slough, eschar ARE present
- Undermining/tunneling may occur
Stage 4 pressure injury
- Full thickness skin loss and tissue loss w/exposed muscle, tendon, ligament, cartilage, or bone
- Undermining/tunneling may occur
- Slough, eschar ARE present
Deep-Tissue pressure injury
- Persistent, non-blanchable deep red, maroon, purple discoloration
- CANNOT see necrotic, subcutaneous, granulation tissue or fascia, muscle, other underlying structures
Unstageable pressure injury
- Obscured full thickness skin and tissue loss
- Tissue damage unknown due to slough or eschar covering area
Primary Intention wound healing process
- Closed, well-approximated wound
- Surgical incision, sutured, stapled wound
- Healing by epithelialization
- Minimal/fine scar formation
- Low risk of infection
Secondary Intention wound healing process
- Edges NOT approximated
- Surgical wounds w/tissue loss or contamination
- Heals by granulation tissue formation, wound contraction, and epithelialization.
- Stage 2 pressure injury or severe laceration
Tertiary Intention wound healing process
- Closure of wound delayed until infection/risk of infection is resolved
- Req. observation for inflammation
