Week 4 Skin Integrity and Wound Assessment Flashcards
Skin functions
- Protects
- Regulates
- Receives sensation
Factors affecting skin integrity
Resistance to injury of skin and mucous membranes varies among people
- Age
- Amount of underlying tissues (thin)
- Conditions
- Some medications
- Impaired circulation
- Nutritional state
Adequate ____ is necessary to maintain cell life
Circulation
Skin gland secretions peak during
Adolescence and continues until about 50
Age related skin changes
- Skin more easily injured
- Less capacity to insulate
- Sensation is reduced
- skin becomes drier
-ealing time delayed - Uneven pigment
- Loss of skin elasticity
Loss of epidermis only
Superficial
Involves the dermis and epidermis
Partial thickness
Involves the epidermis, dermis, subcutaneous fat, muscle, and sometimes bone
Full thickness
How many phases are there of wound healing?
3
Inflammatory phase
Phase 1 (0-3 Days)
Proliferative phase
Phase 2 (3-24 Days)
Maturation phase
Phase 3 (24-365 Days)
Contributing factors to impaired healing
- Unstable diabetes mellitus
- Venous or arterial disease
- Ageing
- Infection
Maceration
pH of skin
Oedema
Inadequate O2 and blood
Necrosis
Dead tissue which must be removed
Wound not progressing through stages of healing in a timely manner
Chronic wound
Chronic wounds due to___ factors
Intrinsic and extrinsic
Exudate
- Contains nutrients, energy and growth factors for metabolising cells
- Contains high quantities of WBCs
- Cleanses the wound
- Maintains a moist environment
- Promotes epithelisation
Exudate
Clear, straw coloured
Serous (normal)
Exudate
Clear, pink
Haemoserous (normal)
Exudate
Red
Sanguinous (trauma to blood vessels)
Exudate
Yellow, grey, green
Purulent (Infection)
A technique which aims to prevent pathogenic microorganisms from being introduced to susceptible sites by hands, surfaces/equipment
Aseptic
Preventing contamination of susceptible sites by hands, surfaces/equipment
Non-touch
Identifying the risk of contamination and choosing the right field and technique
Technique
Technically simple, short in duration (<20 min) involving relatively few and small key sites and parts
Standard ANTT
Main general aseptic field and non-sterile gloves
Standard ANTT
Technically complex surgery involving extended time periods with large open key sites or large or multiple key parts
Surgical ANTT
Main critical aseptic field, sterile gloves and barrier precautions
Surgical ANTT
Open wounds, including insertion and puncture sites
Key SITES
Parts of procedure equipment coming into direct or indirect contact with other key parts, any liquid infusion or key sites
Key PARTS
Clinical manifestations of wound infection
- Localised heat
- Erythema
- Fever
- Odour
-Increased exudate - Increased pain
- Slow healing
- Cellulitis
Wound cleansing
- Normal saline used
- Cleanses bacteria from wound
- Assists debridement
- Adhere to ANTT principles
When should you swab a wound for testing?
After cleansing, but before antibiotics
Used when Key parts/sites are large or numerous and can’t be easily
protected by covers or caps or can’t be handled with a non-touch technique
Critical aseptic field
The phases of wound healing occur in the following order:
Inflammatory, Proliferative, Maturation.
Most superficial layer of the skin and provides the first barrier of protection from the invasion of substances into the body
Epidermis
Connective tissue layer between the epidermis and subcutaneous tissue
Dermis
Removal of infected and necrotic tissue
Debridement
The partial or total rupturing of a sutured wound
Dehiscence
Loss of the superficial layers of the skin
Excoriation
Dead tissue in wound usually cream or yellow in colour
Slough
Material, such as fluid and cells, that has escaped from blood vessels during the inflammatory process and is deposited in tissue or on tissue surfaces
Exudate
Young connective tissue with new capillaries formed in wound healing process
Granulation tissue
A collection of blood in a tissue, an organ or a space due to a break in the wall of a blood vessel.
Haematoma
Indicates freedom from infection or pathogenic material.
Asepsis
Aims to prevent pathogenic organisms, in sufficient quantity to cause infection, from being introduced into susceptible body sites by the hands of staff, surfaces of equipment.
Aseptic technique
Smaller parts of equipment that must be protected and kept sterile during an aseptic procedure
Micro critical aseptic field
Simple aseptic field where there may be a small number of key parts and small key sites
General aseptic field
