Wound and Skin Care Flashcards
What are the structures of the skin
Epidermis, dermis, subcutaneous
What are the functions of the skin?
Protection
Body temp regulation
Vitamin D prod
Sensation
Immunologic
Absorption
Elimination
T or F younger people have more resistance to skin injury
T
T or F does the skin need to be adequately nourished
T
T or F the skin does not need adequate circulation
F
T or F in children under 2 y/o the skin is thinner and weaker than adults?
T
T or F an infant’s skin and mucus membranes are injured and infected easily
T
In older adults what happens to their skin?
Epidermis gets thinner, collagen formation impaired, subcutaneous fat is decreased
Who is the most susceptible to skin injury in adults?
very thin or obese people
What does dehydration do to the skin?
Cause break down
T or F pt with jaundice are more likely to scratch and cause lesions?
T
T or F eczema and psoriasis do not cause lesions
F
What are the principles in wound healing?
- intact skin is the first line of defense against infection
- hand hygiene is required
- the body responds systematically to trauma of any of its parts
- an adequate blood supply is essentail for normal body response
- normal healing is promoted when the wound is not covered
- extent of damage and pt helath will effect healing
- proper nutrition
Phases of wound healing
- hemostasis
- inflammatory
- proliferation
- maturation
hemostasis
blood vessels constrict
blood clotting
exudate formed (pain and swelling)
increased perfusion
decreased platelets
inflammatory phase
after hemo
1-2 days
WBC move to wound (macrophages)
ingest debris
fibroblasts fill wound
exudate
generalized body response
Proliferation
repair phase
many weeks
new tissue fills wound space
capillaries grow into wound
granulation and scar tissue
Maturation
3 weeks after injury
collagen shows up and compresses blood vessels
new scar
T or F children and healthy adults heal faster
t
What drugs delays healing?
corticosteroid drugs and postoperative radiation therapy delay healing
What are some wound complications
infection, hemmorrhage, dehiscence and evisceration, fistula formulation
Where are the most common places for pressure ulcers
bony prominences
What are the mechanisms in pressure injury development
external pressure
friction or shearing
microclimate
what is external pressure
compression of blood vessels
friction or shering is what
forces tering or injuring blood vessels
microclimate is what
temperature and moisture of the skin
Stage 1 pressure injuries
nonblanchable erythema of intact skin
Stage 2 pressure ulcer
partial-thickness skin loss with exposed dermis
Stage 3 pressrue ulcer
full thickness skin loss; not involving underlying fascia
Stage 4
full-thickness skin and tissue loss
Unstageable
obscured full-thickness skin and tissue loss
Deep tissue pressure injury
persistent nonblacnchable deep red, marron, or purple discoloration
Skin assessment
inspect and palpate
head to toe
bony prominences
How often do you do a skin assesment
acute care: every shift
long-term settings: weekly for 4 weeks
home health: each visit
Types of drainage
serous - clear normal
sanguineous - bloody (indicates site is bleeding)
serosanguineous - clear and bloody (normal)
purulent - thick yellow, green, brown (infection)
Exudate is
pus
How can the nurse prevent pressure injuries
- assess at risk pts daily
- cleanse the skin
- maintain higher humidity, use moisturizers
- protect skin from wetness (incontinence)
- proper positioning/turning
- appropriate support surface
- nutritional supplements
- improve mobility and activity
When dressing a wound it is important to
- know if you need to add moisture or remove moisture
- protect surrounding skin from the wound
- remove any damaged or necrotic tissue
Types of drains
penrose (open hose)
jackson pratt and hemovac (closed system)
