foundations Skin Integrity and Wound Care (exam 3)

what is the layers of skin from outer to inner

epidermis, dermis, and sub1

what is the epidermis layer

outer layer, no blood, relies on dermis, and regrows = every month

what is the dermis layer

sweat grows, hair, nerves

what is the sub q layer

fat and connective tissue

what is the function of protection

•From physical & chemical injury

•Sebum

•Normal Flora

what is the function of metabolism

vitamin D

what is the function of thermoregulation

dilation and constriction of blood vessels

what is the function of elimination

•Water, electrolytes, wastes

•By sweat

what is the function of sensation

•Nerve endings in skin provide valuable information & protection

•Can detect pain

what is the function of physchosocial

•Facial expressions

•Hair distribution

what is the function of absorption

substances absorbed due to vascularity of the skin

what are the systemic diseases

PVD

RF

Neuropathy

what is PVD

impaired blood flow

what is RF

toxins come out of the skin and is itchy

what is neuropathy

decreased sensation which can increase infection due to unknown injury

what is pruritus

itching due to toxin build up or histaminic response

what are the manifestations of altered integumentary function

Pain

Pruritus - itching due to toxin build up or histaminic response

Rash

Lesions

what is unintentional alteration

burns, bed sore, accident, abrasions, lacerations which are longer to heal and is more prone to infection

what is intentional alteration

surgical procedure in a sterile condition

what is open alteration

breaking skin integrity

what is closed alteration

bruising or blood under skin

what is acute alteration?

heals better and is short term

what is chronic alteration

long term proclaim, impaired healing, and prone to infection

what is to be consiered with children younger than two

§Skin is thinner and weaker

§An infant's skin and mucous membranes are easily injured and subject to infection

§Becomes increasingly resistant to injury and infection

what is to be considered with the elderly

§Maturation of epidermal cells is prolonged, leading to thin, easily damaged skin

§Circulation and collagen formation are impaired, leading to decreased elasticity and increased risk for tissue damage from pressure.

what causes pressure injuries

§Pressure intensity

§Pressure duration

what are the risk of pressure injuries

§Nutrition

§Moisture

§Age

Friction

hwo is moisture a risk of pressure injuries

skin softness and breakdown

how is friction a risk of pressure injuries

patient slides down bed so you have to keep boosting, shear, impaired mobility, and sensory impairment

what are some comorbid conditions

§Altered level of consciousness

§Sensory impairment

§Impaired mobility

how many stages of pressure injuries are there

4

what is stage 1 of a pressure injury

•Non-blanchable erythema of intact skin

•Stays red

•No breakdown or openings

•Fix - relive pressure, barrier cream, and padding of area

what is stage 2 of a pressure injury

•Partial-thickness skin loss

•Presents as an abrasion or blister

•Skin has been broken

•Fix- keep them off it, clean area, barrier cream, cover the area, and keep it dry

wha tis stage 3 of a pressure injury

•Full-thickness skin loss with damage or necrosis of SQ tissue - see internal structure

•Presents as a deep crater - could tunnel

•Depth, tunneling, continued breakdown, and undermining

•Fix- keep them off it, clean area, often dressing change, and pack wound

what is stage 4 of a pressure injury

•Full-thickness skin loss with extensive destruction, necrosis, or damage to muscle, bone, or tendons

•Years or may never heal

•Fix- extensive cleaning, surgical cleaning, and suction to drain it

what is slough

•Yellow, tan, gray, green, or brown

•Non-viable tissue

•Drainage and moisture

•Has to be removed

what is eschar

•Dark brown or black

•Crust-like, non-viable tissue

•Don't remove

•Requires surgical debrdment to control

•Wont know how deep wound is till removal

what is unstageable

•Purple or maroon localized area of intact skin

•Can eventually open

•Prevent further destruction

what is suspected deep tissue injury (SDTI)

•Purple or maroon localized area of intact skin

•Can eventually open

•Prevent further destruction

what are the types of debridement

autolytic

bio surgical

enzymatic

mechanical

sharp/surgical

what is autolytic debridement

•Use of hydrocolloid or foam dressings

•Body's own enzymes and defensive mechanisms to loosen and liquefy necrotic tissue

what is enzymatic debridement

•Application of commercially prepared enzymes

•Enzymes are prescribed treatments by a provider

•Similar to peroxide

what is bio-surgical debridement

•Use of surgical grade/sterile fly larvae

•Larvae secrete enzyme that liquefies necrotic tissue, then larvae consumes liquid and infectious material in the wound

what is mechanical debridement

•Use of an external physical force (H2O2, Irrigation)

•Painful method of debridement

•Wet to dry dressing

•Takes dead tissue

what is sharp/surgical (eschar) debridement

•Use of scalpel

•Performed by physicians and advance practice nurses

what are the 4 stages of wound healing

•Hemostasis

•Inflammatory

•Proliferation

•Maturation

what happens during hemostasis

§Vasoconstriction

§Exudate production

Clot formation

how does vasoconstriction help

slow down bleeding

how does exudate production help

get bacteria out

how does clot formation help

stop bleeding by a scab over

what happens during inflammatory

§Vasodilation

§Phagocytosis

§Localized

Lasts 4-6 days

how does vasodialation help

bleeding stopped outside and needs more blood flow

how does phagocytosis

WBC eats bacteria

how does localized inflammatory response

redness, swelling, tender, and warm

what happens during the Proliferative stage

§Lasts 3-24 days

§Fibroblasts and Growth Factor create collagen and blood vessels

§Granulation tissue formation

§More susceptible to get pressure injury in same spot even after fully healed

what happens during the maturation stage

§Can take up to 2 years - for significant wounds

§Collagen matures

§Scar tissue is created - or scar

what are the types of wound healing

primary(primary union)

secondary (contraction and epithelization)

tertiary(delayed closure)

what happens during primary intention (primary union)

•Surgical

•Planned

•Well approximated edges

•Best healing

what happens during secondary intention (contraction and epithelization)

•Full thickness loss

• burn, pressure injury, will fill itself with granulation tissue, and will often leave a scar

•Will probably develop and infection because theres more space, its deep, and not closed

what happens during tertiary intention (delayed closure)

•Degreed closure

•Wound remains partially open to allow space for swelling infection

•ICU

•Increased risk for infection, BR- increases pressure injury

•Delayed healing

•Will scar

what are the systemic factors

§Age

§Nutrition

§Circulation/Oxygenation

§Health Status

§Diabetes

§Shock

§Immunosuppression

§Obesity

what are the local factors

§Moisture

§Trauma

§Edema

§Infection

§Bleeding

§Necrosis

§Biofilm

what are the types of nutrition we look for

§Protein,

§Vitamins A & C

§Zinc

what. are the two types of moisture

§Desiccation

§Maceration

what are the types of health statuses we look for

§Diabetes

§Shock - hypotension and tachycardia which decreased blood flow

§Immunosuppression

§Obesity

what is the formation for biofilm

attachement

expansion

maturation

resistance

what are the complications of wound healing

§Hemorrhage

§Dehiscence

§Infection

Fistula

what is hematoma

blood bruising

what is dehiscence

separations or stretching in wound closure you'll see edema or drainage

what is evisceration

wound opens and internal structure is coming out which is covered in saline and gauze f it dries it dies

what is an infection

microbe in wound

what is a fistula

abnormal connection between two organs made by tunneling

what is av fistula

tunnel between venous and artificial system for dialysis patients

what are the five signs of a localized infection

1.Redness

2.Heat

3.Edema

4.Pain

5.Altered Function

what are some subjective datas

§Normal skin condition

§Hx of skin conditions, wounds

§Psychosocial effects of impaired skin integrity

what are some objective datas

§Visual, tactile and olfactory

§Nutritional Status

§Risk Scoring Tools

§Diagnostic Tests