Skin Integrity & Wound Healing

Flashcards on Skin Integrity and Wound Healing

Integumentary System

Skin, hair, nails, sweat glands, and the subcutaneous tissue.

Function of the Skin

Protection of internal organs, unique identification of an individual, thermoregulation, metabolism of nutrients and metabolic waste products, and sensation.

Epidermis

Thick outer layer of skin, waterproof, contains melanin, and made up of 4-5 layers.

Dermis

Layer below the epidermis, provides strength and elasticity, contains nerves that sense pain, touch, and temperature, blood and lymphatic vessels, bases of hair follicles, and sebaceous and sweat glands.

Subcutaneous Tissue

Adipose tissue and connective tissue that provides insulation, protection, and a reserve of calories.

Infant Skin

fragile skin.

Adolescent Skin

Sebaceous glands enlarge; secretions increase.

Older Adult Skin

70% have skin conditions, sebaceous and sweat glands diminish (dry skin), subcutaneous tissue thins, and dermal layer loses elasticity.

Protein Role in Skin Integrity

Maintain and repair skin.

Low Cholesterol Effect on Skin Integrity

May lead to skin breakdown and inhibit wound healing.

Undernutrition Effect on Skin Integrity

Predisposes to pressure injuries.

Vitamin C, Zinc, and Copper Role in Skin Integrity

Formation of collagen.

Hydration Effect on Skin Integrity

Can make skin prone to injury.

Diminished Sensation

Can affect tactile sensation and may be caused by Peripheral Vascular Disease, Spinal cord injury, Diabetes, CVA, or Trauma/Fracture.

Impaired Cognition

Not aware of need to change position due to Alzheimer’s disease, Dementia, or Altered LOC.

Impaired Arterial Circulation

Restricts activity, produces pain, and leads to muscle atrophy and thin tissue leading to ischemia and necrosis.

Impaired Venous Circulation

Engorged tissues contain high levels of waste products and are susceptible to edema, ulceration, and breakdown.

Pruritus

Itching side effect of Medications.

Dermatoses

Rash side effect of Medications

Photosensitivity

Sensitivity to sunlight side effect of Medications

Alopecia

Hair loss side effect of Medications

Pigmentation changes

Skin discoloration side effect of Medications

Contamination

Microorganisms in the wound (aka chronic wounds)

Colonization

Increase in microorganisms; not causing harm

Critically Colonized

Bacteria overwhelm the body’s defenses; increased drainage, foul odor, wound bed changes, tunneling

Infection

Microorganisms are causing harm, If not stopped = Sepsis

Wound Definition

A disruption to normal skin integrity.

Closed Wounds

No breaks in the skin, examples include contusions and swelling.

Open Wounds

Break in skin or mucous membrane, examples include abrasions, lacerations, puncture wounds, and surgical incisions.

Acute Wounds

Short duration that Heal without complications in healthy persons.

Chronic Wounds

Natural healing interrupted or due to infection, continued trauma, ischemia, or edema; last months to years, examples include pressure injuries, arterial/venous/diabetic ulcers.

Pressure Injuries

Localized areas of injury to the skin and possibly the underlying tissue.

Arterial Ulcers

Occur when there is a non-pressure related blockage of arterial blood.

Venous Stasis Ulcers

Irregularly shaped lesions caused by venous congestion.

Diabetic Foot Ulcers

Occurs when diabetes narrows the arteries, reducing oxygen to the feet and causing slow healing and tissue death.

Clean Wounds

Uninfected with minimal inflammation, closed or open.

Clean-Contaminated Wounds

Surgical incisions that enter the GI, respiratory, or GU tracts, increased risk but NO infection

Contaminated Wounds

Open, traumatic, or surgical with major break in asepsis occurred, risk for infection HIGH

Infected Wounds

100,000 MO’s/gram of tissue

Superficial Wounds

Epidermal layer

Partial Thickness Wounds

Trough the epidermis, but not the dermis

Full Thickness Wounds

Extend to the subcutaneous tissue and beyond

Regenerative / epithelial healing

Wounds affecting the epidermis and the dermis are healed as new cells form skin

Primary (first) intention healing

Edges brought together with minimal or no tissue loss and edges are well approximated.

Secondary intention healing

Involves extensive tissue loss, should not be closed, granulation tissue forms, prone for infection / more scar tissue.

Tertiary intention healing (delayed primary closure)

When wound is clean-contaminated or contaminated, heals by secondary intention first, two surfaces of granulation tissue are sutured together, creates less scarring.

Hemostasis

blood and plasma leak into wound and vessels constrict = limit blood loss, platelets aggregate = blood clot

Inflammation

Signs: Edema, erythema, pain, hotness, migration of WBC’s and within 24 hours phagocytosis begins, Scab is formed.

Proliferative Phase

Fibroblasts migrate to wound and form collagen which Strengthens the wound, New blood and lymph vessels form, Granulation tissue is formed,Wound will shrink; edges pull together.

Maturation Phase-Epithelialization

Collagen fibers are remodeled into scar tissue which are 80% as strong as the original tissue.

Hemorrhage

Profuse loss of blood

Hematoma

Collection of blood under the skin

Dehiscence

Rupture of one of more layers of a wound during inflammatory phase of healing due to poor nutrition, inadequate closure of the muscles, wound infection or increased tension on the suture line.

Evisceration

Total separation of the layers of a wound with internal viscera protruding through

Fistula

Abnormal passage connecting two body cavities or a cavity and the skin

Nursing Interventions for Dehiscence

Bedrest, head of the bed elevated at 20°, the knees flexed and applying a binder to prevent evisceration.

Nursing Interventions for Evisceration

Immediately cover the wound with sterile towels soaked in sterile saline, Keep patient in bed with knees bent, Do not put a binder on the patient, Notify the surgeon and ready the patient for surgery.

Exudate

Fluid that oozes because of inflammation

Serous Drainage

Watery and contains very little cellular matter

Sanguineous Drainage

Bloody drainage

Serosanguineous Drainage

Combination of serous and bloody exudate

Purulent Drainage

Thick, malodorous, pus

Puro sanguineous Drainage

Red-tinged pus

Pressure Injury

Localized injury to the skin and underlying tissue, usually over a bony prominence

Braden Scale Use

Evaluate sensory perception, moisture, activity, mobility, nutrition , friction and Sheer, The lower the score, the more likely the patient will develop a pressure ulcer

Stage I Pressure Injury

Intact skin with non-blanchable redness over a bony prominence

Stage II Pressure Injury

Partial-thickness loss of dermis, open, but shallow with no slough, Intact or ruptured blister

Stage III Pressure Injury

Full thickness skin loss with damage or necrosis of subcutaneous tissue

Stage IV Pressure Injury

Full thickness skin loss with exposed bone/tendon visible; Slough or eschar may be present; Undermining and tunneling are common

Deep Tissue Injury

Area of skin that is intact, but discolored

Unstageable Pressure Injury

Base of wound is obscured