Module 12 (Hygiene, Tissue Integrity)

epidermis

outermost layer of skin, made of squamous epithelium organized into four (5 in thick skin), receives nutrition from dermis, avascular

dermis

middle layer, made of connective tissue, nervous tissue, and blood vessels. alerts the body to stimuli

epidermis

outermost layer of skin, made of squamous epithelium organized into four (5 in thick skin), receives nutrition from dermis, avascular

dermis

middle layer, made of connective tissue, nervous tissue, and blood vessels. alerts the body to stimuli

hypodermis/subcutaneous layer

separates dermis from underlying organs, consists of adipose tissue, acts as cushion from physical trauma, insulates the body.

mucous membranes

membranes that line the respiratory, digestive, and urinary tracts (and other areas exposed to the outside environment), act as a physical barrier blocking pathogens from invading the body.

merkel cells

cells in the epidermis that detect light touch, especially in thick skin

langerhans cells

cells in the epidermis that ingest and package foreign antigens to be presented to lymphocytes

what layer of the skin contains cells that help prevent infection?

epidermis

maceration

irritation of the epidermis caused by moisture

dermatitis

red skin irritation that develops due to exposure to irritants such as feces, urine, stoma effluent, and wound secretions

skin tears

loss of top layer of the skin caused by mechanical forces

skin frailty

having at-risk vulnerable skin

conditions that predispose clients to alterations in tissue integrity

sun exposure, age, mobility impairments (spina bifida, cerebral palsy, other chronic diseases)

cellulitis

infection of the superficial layers of the skin, risk in older adults

wound

disruption in normal composition and performance of the skin adn its underlying structures

acute wounds examples

lacerations, surgical wounds, MASD

exudate

fluid consisting of plasma secreted by the body during the inflammatory phase of healing, should decrease and resolve by day 5

normal color of healing surgical wounds

red days 1-3, pink days 5-14, pale pink 15 days +

when is epithelial closure usually seen?

day 4

when are wound closure materials usually removed?

10-12 days, depending on type of surgery

moisture associated skin damage (MASD)

a type of dermatitis that develops when skin is exposed to irritants, predisposition factors include sweating, increased local skin temp, abnormal pH, deep skin folds. predisposes clients to to pressure injury formation

what are chronic wounds

wounds that develop over time as a result of disruption in the wound healing process associated with acute wounds, or due to alterations in blood flow

categories of chronic wounds

venous, arterial, neuropathic

venous wounds

beefy red rounds with regular borders

arterial ulcers

pale wounds due to lack of oxygen, irregular borders

diabetic ulcers

ulcers that occur due to poor circulation caused by diabetes, could form from any wound - take extra care to protect feet in diabetic pts

serous exudate

thin, straw yellow drainage (healthy)

sanguineous exudate

bloody drainage, seen in a fresh wound

serosanguinous exudate

mix of bloody and serous exudate

purulent exudate

pus, indicates infection

puro-sanguineous exudate

exudate that contains pus and blood

pressure injury risk factors

poor circulation, lack of sensation, immobility, moisture

where are pressure injuries most common

bony prominences - heels, toes, sacrum, hips, elbows, shoulders, abc of head

shear forces

when skin and muscles are pulled in opposite directions, occurs when patients sit on an incline, causes trauma to blood and lymph vessels

pressure

a continuous force exerted on or against and object

friction

the force created when two objects rub together

benchmarking

comparing results and outcomes to other sources of similarly retrieved data, used to see if initiatives are successful

stage 1 pressure injury

non blanchable erythema

stage 2 pressure injury

partial-thickness skin loss, may also present as a ruptured serum-filled blister

stage 3 pressure injury

full thickness skin loss, granulation tissue may form, wound edges rolled, dead tissue formed, undermining, fascia/muscles are not visible

stage 4 pressure injury

full thickness skin and tissue loss, fascia → bone are visible, edges rolled, undermining, tunneling, dead tissue

unstageable pressure injury

pressure wound is covered by slough or eschar

deep tissue pressure injury

localized, nonblanchable, deep red/purple. caused by intense or persistent pressure and shearing

device related pressure injury

pressure injury resulting from prolonged pressure from devices that are left in direct contact with skin

MDRPI

medical device related pressure injury, commonly oxygen masks, oxygen tubes, urinary caths, cervical collars, compression stockings

mucosal membrane pressure injury

injury caused by the pressure related to the insertion or placement of a foreign device

HAPI

hospital acquired pressure injury, prolonged hospitalization is risk factor

classifying pressure injuries in darkly pigmented skin

asses adjacent skin that is darker than surrounding skin, palpate for changes in sensation and temperature, skin can appear taut, shiny, or indurated

documenting pressure injuries

include location, stage, size, description of tissue, color, surrounding tissue, edges, undermining/tunnelling, odor, drainage, pain

surgical debridement

the process of surgically removing dead tissue and other debris that can cause infection with a scalpel or scissors

biological debridement

enzymes such as collagenase, papain, bromelain can clear dead tissue and debris

sterile dressing

applied right after surgery and kept 24-48 hours, changed using sterile technique

clean dressing

applied 48 hours after surgery, wound is considered to be colonized from the client’s environment

open dressing

gauze dressings

wet to dry dressing

moistened gauze is packed into wound, clings to tissue that is removed when the gauze dries and is taken out, removes necrotic and new tissue. rarely used in practice today due to infection rates and gauze remaining in wound

semi-open dressing

knight gauze infused with therapeutic ointments, padding and absorbent gauze, final layer of adhesive. does not control drainage and creates risk for poor healing and adjacent tissue breakdown.

semi-occlusive dressings

films (allow moisture to evaporate), hydrocolloid (bacteriostatic, moist wound bed, creates film of bacteria) alginate dressings (highly absorbent, need secondary dressing), hydrofiber (high absorbency, less maceration), foam, polymeric, hydrogel

staples considerations

rapid placement, faster healing, difficulty of removable

sutures considerations

absorbable dissolve within days to weeks, synthetic generate less tissue reaction but associated with prolonged pain and suture sinus

skin adhesive considerations

alternative to sutures and staples, waterproof covering, used for small wounds that have straight edges, peels off in 5-10 days

negative pressure wound therapy (NPWT)

reduce edema surrounding wound, foam applied over wound and suction is applied

passive drain

penrose (open drain made of corrugated rubber, attached with safety pin), relies on gravity to remove accumulated fluid

portable wound bulb section device

active, closed system drain that use negative pressure to suction drainage, contains a plastic bulb

open drain

removes fluid to air, more likely to be contaminated

bottle drain

silicon drain with a bottle that is used for large amounts of drainage

closed drain

sends fluid to closed containment system, less likely to be contaminated

hematoma

accumulation of blood in the body

seroma

collection of serous fluid)

circular portable wound suction device

designed to continuously suction drainage from a wound by providing a low vacuum pressure

when are drains removed

when drainage is less than 30-100 mL per day

nutrients essential for wound healing and tissue strengthening

protein, omega 3 + 6, vitamin C, protein, fortified, high calorie foods.

primary healing (first intention)

type of wound healing that occurs in clean lacerations and surgical sites, fastest to heal

secondary healing (second intention)

wound healing where a wound is left open to heal and is kept moist, but has a higher risk of infection due to direct contact with environment

delayed primary closure (third intention)

combination of primary and secondary healing, wound is left open for 5-10 days before it is closed with sutures, decreases the risk of infection in wounds that were not considered clean

hemostatic/inflammatory phase of healing

first 3-6 days, clotting factors, histamine, you know.

proliferative phase of healing

days 3-24, granulation tissue, epitheliazation

remodeling phase of healing

day 21+, granulation collagen is replaced with stronger collagen, myofibroblasts secrete proteins that pull wound edges together

clinical manifestations of localized infection

cellulitis, redness, warmth, exudate, foul odor

clinical manifestations of systemic infection

fever, chills, nausea, vomiting, hypotension, high blood sugar, high WBC, change in mental status

common SSI

staph aureus, use CHG wipes

wound culture collection steps

label → clean wound (prevent normal skin microorganisms from contaminating the culture) → use sterile cotton applicator, rotate in area of drainage → place in vile → activate culture medium → note if patient is on antibacterial or antifungal therapy

dehiscence

separation of suture line and underlying tissues that occurs when a wound fails to heal properly, caused by poor surgical technique, infection, or foreign particles. 16% mortality rate

evisceration

dehiscence that results in intra abdominal organs protruding through the wound, treated by placing a sterile, saline soaked dressing over the organs before surgery