EXAM 1: Skin Integrity and Hygiene

NURS207: Foundations

functions of the skin

protection, regulation, sensation, secretion

infant hygiene risk

dermatitis because of irritants, lotions can block sweat glands and lead to heat rash

4 stages of wound healing

hemostasis, inflammatory, proliferation/granulation, maturation/remodeling

hemostasis: time period

4-10 minutes

hemostasis: process

coagulation, vasoconstriction, platelet plug and clotting factors

hemostasis: treatment

cold, pressure

hemostasis: characteristics

blood coagulates and scab forms

hemostasis: outcome

bleeding stops

inflammatory: time period

4-6 days

inflammatory: goal

activation of cells to destroy bacteria and form granulation tissue

inflammatory: process

vessels dilate, prostaglandin, leukocytes and macrophages

inflammatory: treatment

protect skin, control drainage, protect wound from infection, debride

inflammatory: characteristics

red, swollen, tender, fragile

inflammatory: outcome

bacteria and debris are removed

when is dehiscence high?

inflammatory phase

dishiscence

splitting open the wound after it has already closed

proliferation: time period

14-21 days

proliferation: processes

pre and post epithelialization, fibroplasia, angiogenesis

proliferation: treatment

keep wound clean, keep moist, nutrition

proliferation: characteristics

healthy, red/pink, granulation tissue is fragile, wound bleeds easily

proliferation: outcome

tissue gaps are replaced with granulation tissue

maturation: time period

2-3 eyars

maturation: processes

scar shrinks, thins, becomes less red

maturation: treatment

OTC, silicone

maturation: outcome

scar tissue is reduced and remodeled

how long should it take for a wound to heal?

month

primary intention of wound healing

wound edges are approximated, little tissue loss

secondary intention of wound healing

edges cannot be brought together, more tissue loss, pink/red, healing is done by granulation which creates a bigger scar (bottom-up)

tertiary intention of wound healing (dehiscence)

wound is deep, infected, contains drainage and debris, wound is left open to heal, high risk for infection

wound classification: by cause

intentional vs unintentional

wound classification: open

incisions resulting in bleeding or tissue damage

wound classification: closed

from blow, force, strain, hematomas, under the skin

wound classification: cleanliness

clean, contaminated, infected

wound classification by depth

superficial: limited to epidermis

partial-thickness: into but not through dermis

full-thickness: heals by repair

wound classification by color

red: wound is healing

yellow: slough or infection

black: necrotic

exudate

material that has escaped from blood vessels during inflammatory process

serous

serum, watery, few cells, example is a burn

purulent

pus, leukocytes and dead tissue with debris and bacteria

sanguineous

large amounts of red blood cells, serosanguineous

dessication

drying up and forming a crust

factors that affect wound healing

pressure, dessication, maceration

maceration

wound is too moist

to remove necrotic tissue

debridement, irrigation using a solution to rinse away surface materials and decrease bacteria

wound vacs

cause negative pressure in order to draw wound edges together and remove infectious materials

wound care treatment by color: red

cover, cleanse, be gentle cause granulation tissue is fragile

wound care treatment by color: yellow

contains slough so we cleanse and remove dead tissue, antimicrobial agents can be used

wound care treatment by color: black

covered by eschar, but be debrided

types of wounds: lacerations

jagged tearing of the skin and often contaminated

types of wounds: puncture wounds

caused by a sharp pointed object, can injure an artery, doesn’t bleed a lot

types of wounds: skin tears

friction and shearing separate epidermis and dermis

types of wounds: vascular insufficiency cause

poor nutrition and lack of blood flow, pressure on areas of the body

types of wounds: vascular insufficiency risk factors

decreased sensation, excess moisture from incontinence

types of wounds: arterial ulcers

claudication with activity, pulselessness, pale, cold, shiny, dry, thin, no edema

neuropathic ulcer

most commonly associated with diabetes mellitus and B12 deficiency

chronic wounds

stuck in inflammatory or proliferative phase, remove necrotic tissue

pressure injury stage I

non-blanchable erythema

pressure injury stage II

partial thickness skin loss, blisters form, open sore

pressure injury stage III

full thickness skin loss, damage to the tissue below the skin

pressure injury stage IV

full thickness skin and tissue loss, damage to muscle and bone, sometimes tendons and joints

pressure injury unstageable

wound is covered with slough or eschar so cannot stage

pressure injury: deep tissue

pressure injury under intact skin that is purple or dark red, blood filled blister

complications of wound healing: bleeding/hemorrhage

internal or external, hematoma, seroma

complications of wound healing: infection

SSI, prevent by cleaning and using PPE

complications of wound healing: dehiscence

separation of wound layers

complications of wound healing: evisceration

protrusion of viscera through the incision

complications of wound healing: keloids

overgrowth of scar tissue beyond the area of injury

complications of wound healing: adhesions

bands of scar tissue binding 2 parts of tissue together

complications of wound healing: hernia

part of an organ protrudes through a weak spot in the abdomen

complications of wound healing: contractures

abnormal shortening of scar tissue

complications of wound healing: fistulas

an abnormal passage from an internal organ to the outside of the body