Unit 6 CHAPTER 29 Wounds and Skin Integrity Flashcards
What are the factors that effect Skin Integrity?
-Many different factors can affect the body’s ability to maintain intact and healthy skin. Wounds, which are disruptions that may occur in the skin’s integrity, lead to a loss of the skin’s normal functioning.
-Vascular disease is a comorbid condition that impairs the skin’s ability to obtain required oxygen and nutrients
-Diabetes, another comorbid condition, affects not only the microvasculature but also the skin’s normally acidic pH.
-Other examples of factors that contribute to wound complications are malnutrition involving inadequate proteins, cholesterol, fatty acids, vitamins, and minerals; steroids, nonsteroidal antiinflammatory drugs (NSAIDs), anticoagulants,
- excessive moisture; and external forces (such as pressure, shear, and friction).
Does age play a factor in skin integrity?
Yes!
-Additionally, aging dramatically affects the appearance and functioning of the skin
-. Aging is associated with thinning of the epidermis, dermis, and subcutaneous layers, with a resultant reduction in elastin, collagen fibers, sweat glands, and sebaceous glands.
-These changes lead to sagging or wrinkling of the skin and to the dry, paper-thin appearance of skin often seen in elderly people. It contributes to a reduction in the skin’s ability to serve as both insulation and cushioning, thereby increasing vulnerability to trauma and temperature extremes characteristic of this population.
What is the function of our epidermis?
-largest Organ in the body
-first line of defense
-It regenerates its self every 4-6 weeks\
it has 5 SUBLAYERS
* Stratum corneum
* Stratum lucidum
* Stratum granulosum
* Stratum spinosum
* Stratum germinativum or
basale
What is MARSI?
Medical adhesive-related skin injuries
-Medical adhesive-related skin injuries (MARSIs) occur when superficial layers of skin are removed by medical adhesive, in which erythema and/or other manifestations of skin trauma or reaction—including formation of vesicles, bulla, skin erosion, and epidermal tears—persist longer than 30 minutes after removal of the adhesive. –MARSI not only affects skin integrity but also causes pain, increases risk of infection, potentially increases wound size, and delays healing. Some hospitals have adhesive remover pads that make adhesive easier to remove without damaging the skin.
Factors affecting skin integrity
- Wounds
- Vascular disease
-Vascular disease is a comorbid condition that impairs the skin’s ability to obtain required oxygen and nutrients - Diabetes
-Diabetes, another comorbid condition, affects not only the microvasculature but also the skin’s normally acidic pH. - Malnutrition
-Other examples of factors that contribute to wound complications are malnutrition involving inadequate proteins, cholesterol, fatty acids, vitamins, and minerals; - Age
-Additionally, aging dramatically affects the appearance and functioning of the skin
What is the function of the subcutaneous layer of the skin?
The subcutaneous layer is a layer of adipose tissue, or fat, that, in addition to attaching the dermis to the underlying muscles and bone, delivers the blood supply to the dermis, provides insulation, and has a cushioning effect
How are Wound Classified?
BY
SKIN INTEGRITY
DEPTH
AMOUNT OF CONTAMINATION
HEALING PROCESS
They can be labeled according to the underlying cause; for example, the terms diabetic ulcer, arterial ulcer, and pressure injury are used to describe wounds.
-by a basic description of the integrity of the skin and referred to as either open or closed wounds.
-Wounds are also classified on the basis of wound depth and are termed superficial, or partial thickness, versus deep, or full thickness.
-Wounds can be classified by the presence or absence of contamination or infection.
The length of time that it is taking for the wound to heal results in the terms chronic and acute. For the nurse, it is important to understand what these terms mean and to see where they overlap to better communicate both with the patients and with other members of the health care team.
Skin Integrity
Open and Closed wounds
An open wound is characterized by an actual break in the skin’s surface. For example, an abrasion, a puncture wound, and a surgical incision are types of open wounds.
-frequently seen in pressure ulcers or vascular disease
In a closed wound, as seen with bruising, the skin is still intact. Although any wound that is open puts the patient at greater risk for infection from outside organisms, a closed wound does not necessarily indicate a more benign condition.
Wound depth
Superficial wound
-A superficial wound involves only the epidermis,
Partial thickness wound
- a partial-thickness wound involves the epidermis and the dermis but does not extend through the dermis to the subcutaneous layer.
Healing
-Superficial and partial thickness tend to heal quickly, leaving no scar, unless other outside factors delay the normal healing process.
Full thickness wounds
-A deeper wound, or full-thickness wound, extends through the dermis to the subcutaneous layer and may extend farther, to the muscle, bone, or other underlying structures.
Healing
Full-thickness wounds tend to heal slowly and leave scarring, and they are more likely to become chronic in nature.
Amount of contamination
wounds can be classified as
-clean,
-clean contaminated,
-contaminated,
- infected, or
- colonized
Clean Wound
- A clean wound is one in which there is no infection and the risk for development of an infection is low. For example, a closed surgical incision made in the controlled, sterile environment of the operating room that does not involve bacteria-containing organ systems is considered a clean wound
Clean contaminated
-A clean contaminated wound is similar to a clean wound, but because the surgery involves organ systems that are likely to contain bacteria, the risk for infection is greater.
Contaminated wound
-Contaminated wounds result from a break in sterile technique during surgery; from the perforation of an organ (such as the colon, small bowel, or appendix) before surgery, which allows for spillage of bacteria-laden material into the wound; or from certain types of trauma or accidents, such as penetrating trauma or a fall
Infected wound
-An infected wound shows clinical signs of infection, including redness, warmth, and increased drainage that may or may not be purulent (contain pus), and has a bacterial count in the tissue of at least 105 per gram of tissue sampled when cultured
Colonized Wound
In a colonized wound, one or more organisms are present on the surface of the wound when a swab culture is obtained, but there is no overt sign of an infection in the tissue below the surface. Colonization is common in chronic wounds and may contribute to delayed wound healing.
Healing Process of a wound.
Acute Wound
-A wound that progresses through the phases of wound healing in a rapid, uncomplicated manner is an acute wound.
Healing
This type of wound is said to heal by primary intention.
-heal quickly and minimal scarring
Chronic Wound
-a chronic wound fails to progress to healing in a timely manner, often remaining open for an extended period of time.
Healing
-heals by Chronic wounds commonly heal by secondary intention.
-Secondary intention,
new tissue must fill in from the bottom and sides of the wound until the wound bed is filled with new tissue. Such wounds are often associated with disease processes (such as diabetes or vascular disease) or with other factors that have inhibited proper wound healing.
Tertiary intention
-When a delay occurs between injury and closure, the wound healing is described as tertiary intention.
Phases of wound healing
The three phases of healing
-inflammatory phase, which includes the process of homeostasis,
-the proliferative phase,
- maturation phase.
Inflammatory Phase
The inflammatory phase of healing begins with the body’s initial response to wounding of the skin and lasts about 3 days.
With the initial injury to the skin, bleeding occurs, which triggers what is known as the coagulation cascade and the formation of a clot to stop the bleeding. This process is an important way of preventing blood loss because of the release of numerous growth factors by the platelets involved in clot formation. These growth factors, along with cytokines, which are released during the inflammatory phase, play an important role in wound healing. During the inflammatory phase, there is an increase in pain, redness, warmth, and swelling in the injured area as the blood vessels dilate and leak fluid to the tissue surrounding the injury. Macrophages and neutrophils are drawn to the site of injury and begin the process of cleaning the wound of bacteria and debris. At the end of this phase, the wound bed is clean and ready to begin the actual repair process
Proliferate Phase
The events of the proliferative phase of healing are repair of the defect, filling in the wound bed with new tissue (called granulation tissue), and resurfacing the wound with skin.
Several weeks
* Granulation tissue
Maturation Phase
The last phase of wound healing, the maturation phase, is known as the remodeling phase and can last up to a year. During this time, collagen continues to be deposited and remodeled, and scar tissue is formed and strengthens. Scar tissue is an avascular mass of collagen that gives strength to the repaired wound. However, the strength of the scar is never equal to that of unwounded tissue, achieving only about 80% of its previous tensile strength.
Up to 1 year
* Scar tissue
