Skin Integrity and Wound Care

Flashcards covering the key vocabulary and concepts related to skin integrity, wound care, and pressure injuries as discussed in the lecture.

Epidermis

The outermost layer of the skin providing a protective barrier.

Dermis

The layer of skin between the epidermis and subcutaneous tissue, containing blood vessels, nerve endings, and glands.

Subcutaneous tissue

The layer of tissue beneath the dermis, primarily composed of adipose tissue.

Sebaceous gland

Glands in the skin that secrete an oily substance called sebum.

Eccrine sweat gland

Sweat glands distributed over the entire body, primarily for thermoregulation.

Wound Healing - Hemostasis Phase

The immediate response to injury involving blood vessel constriction and clotting.

Wound Healing -Inflammatory Phase

Phase lasting 2-3 days where WBCs migrate to the wound, causing pain, heat, redness, and swelling.

Wound Healing - Proliferation Phase

Phase lasting several weeks involving granulation tissue formation and requiring adequate nutrition and oxygen.

Wound Healing - Maturation Phase

Phase lasting weeks to years where collagen is remodeled and a scar develops.

Desiccation

Dehydration of a wound which impacts wound healing.

Maceration

Overhydration of a wound which impacts wound healing.

Necrosis

Death of tissue which impacts wound healing.

Serous drainage

Clear and watery drainage composed primarily of the clear, serous portion of the blood and from serous membranes.

Sanguineous drainage

Drainage consisting of large numbers of red blood cells and looks like blood.

Serosanguineous drainage

A mixture of serum and red blood cells which is light pink to blood tinged.

Purulent drainage

Drainage made up of white blood cells, liquefied dead tissue debris, and both dead and live bacteria. It is thick, often has a musty or foul odor, and varies in color.

Wound complications

Hemorrhage, dehisence, evisceration, fistula formation

Hemorrhage

Excessive internal or external blood loss

Dehiscence

Partial or total separation of wound layers as a result of excessive stress on wounds that are not healed.

Evisceration

internal organs are pertruding

Fistula formation

abnormal passage from an internal organ or vessel to the outside of the body, or from one internal organ vessel to another.

Braden Scale

predicts pressure sore risk by measuring sensory perception, moisture, activity, mobility, nutrition, friction, and shear.

Stage 1 Pressure Injury

Non-blanchable erythema of intact skin.

Stage 2 Pressure Injury

Partial-thickness skin loss with exposed dermis.

Stage 3 Pressure Injury

Full-thickness skin loss not involving underlying fascia.

Stage 4 Pressure Injury

Full-thickness skin and tissue loss.

Unstageable Pressure Injury

Obscured full-thickness skin and tissue loss.

Deep Tissue Pressure Injury (DT)

Persistent non-blanchable deep red, maroon, or purple discoloration.

Risk factors for pressure injury

Poor skin hygeine, diabetes, fractures, previous pressure injuries, significant obesity, increased body temperature

Performing pressure injury assesment

Braden scale, mobility, nutritional status, moisture/incontience, appearance of existing pressure injury, pain assessment, diagnosing

Effects of applying heat

Dilates leripheral blood vessels, increases tissue metabolism, reduce muscle tension, relives pain

Effects of applying cold

Constructs peripheral blood vessels, reduce muscle spasms, promotes comfort

Proper body mechanics

use of proper body movement in daily activities

Purpose of upper body mechanics and assistive devices

Help prevent back injuries

Ambulating a patient

Dangling, 1 nurse asist, 2 nurse asist

Variables leading to nack injury in healthcare workers

Uncoordianted lifts, lifting when fatigued, not using assivtive devices when lifting

Protective postiining

Supine, prone, sims, high foulers, lateral movement, trendelenburg/reverse

Diet to promote wound healing

Well balanced meals, high in protein, high in vitamins

Nursing interventions to prevent pressure injuries

Frequent repositioning, skin assessment, pressure reliving devices, braden scale, minimize friction

Open systems

Gauze, penrose drain

Closed systems

Jackson-pratt, hemovac, t-tube

NERDS (assessment of wound infection)

nonhealing wound, exudative wound, red and bleeding wound, debris in the wound, smell from the wound

Wound documentation

Type, measurement, description

General skin care principles

Minmize skin moisture, cleanse skin when needed, use skin moisturizer as needed, avoid friction