wound care Flashcards
tissue integrity
the ability of the human body to regenerate and maintain normal physiologic functioning. the skin, cornea and subc tissue, and mucous membranes act as defense mechanisms for the body
largest organ system of body accounting for about 15% of total body wight
skin
skin main function
protection
providing barrier from injury, ultraviolet radiation and heat
skin plays a crucial role in
sensory percreption such as touch, pain, pressure, and vibration
skin regulates
temperature and protects the body against temperature changes
- eliminates waste and supports the underlying structures and synthesis of vitamin d
epidermis
outer layer of the skin composed mainly of keratinocytes and other cells, such as melanocytes, Merkel cells and lanerhans cells
dermis
largest portion of skin
- main function to sustain and support epidermis by providing strength and flexibility; made of connective tussye with capillaries; blood vessels; lymoth vessels; nerves; sweat and sebaceous glands; hair roots; elastic fibers; and collagen
subcutaneous tissue
subc fat that insulates the body, absobs shock and pads the internal organs and structures
risk factors for development of pressure injuries and wounds
- age
- mobility issues
- weight
- spina bifida, cerebral palsy, other chronic conditions such as liver, renal diseases, cancer and malnutrition
as adults skin becomes
thinner, elasticity is lost, sub c fat becomes thinner, blood supply is more sulggish and the skin becomes less hydrated. therefore, shear, friction, pressure can cause problems
pressure injury
- localized damage to skin, underlying tissue as a result of a pressure in combination with shear
pressure injuries are most often
over bony prominences but can also be a result of a pressure caused by a medical device, such as urinary catheters, oxygen tubing, endotracheal tubing, drains.
- most susceptible are held, toes, sacrum, hips, elbow, shoulders, back of head
stage 1
nonblanchable erythema of intact skin
stage 2
partial thickness skin loss with exposed dermis
stage 3
full thickness skin loss
stage 4
full thickness skin and tissue loss
unstageable
obscured full thickness skin and tissue loss
deep tissue pressure injury
persistent nonblancable deep red, maroon or purple discoloration
TIME ( how pressure injuries shoudl be described)
T: tissue integrity- describe how the tissue looks, the wound color, and if there is dead netcrotized tissue present
I: inflammation or infection- s/s of infection present, redness, warmth, swelling, discharge, and swelling
M: moisture- wound is dry or moist and if the wound is macerated
E: edge of wound- describe the wound edges
DIDNT HEAL (factors influencing wound healing)
D= diabetes I= infection D= drugs N= nutritonal problems T= tissue necrosis H= hypoxia E= extensive tension A= another wound L= low temperature
hemosatic/ inflammatory
damaged tissue releases cytokines which trigger a process called hemostasis; blood coagulates, and the wound starts to heal
- plasma leaks into surrounding tissue and causes swelling
proliferative
- new collagen fibers are formed
- nee wound bed is created
- capillaries start growing
- wound edges begin pulling closer and new granulation tissue grows
remodeling
stronger collagen replaces soft gelatinous collagen; however this tissue is much weaker than the orginal tissue and is susceptible to reinjury
primary healing or first intention
occurs in clean lacerations and surgical incisions; closed with skin ahesives or sutures
secondary healing or second intention
wound healing that happens when the wound is left open to heal
delayed primary closure
combination of primary and secondary healing, where the wound is left open for 5-10 days before it is closed with sutures
skin redness
usually referred to as blanchable or nonblanchable erythema
- non-blanchable erythmea is redness that does not go away when pressure is applied and is a sign that structural damage has occurred to the skin
methods for measuring wound size
- tracing wound circumference
2. measuring length and width of the wound
acute wounds
develop as a result of injury and typically are a result of trauma
chronic wounds
develop over time from acute wounds that do not progress in healing
surgical debridement
- accumulated debris and dead tissue are removed with a scalpel or scissors
- debridement decreases the number of bacteria in the wound and stimulates the rebuilding of the wound bed by contraction and epithelialization
major complications of wounds are
infections dehiscences- wound comes apart evisceration- even further process hematomas/seromas fistulas- different layers connect in the wrong spot
