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