Skin Integrity and Wound Care

Flashcards about skin integrity and wound care.

Epidermis

Outermost layer, regenerates every 4-6 weeks, five sub layers: Stratum corneum, Stratum lucidum, Stratum granulosum, Stratum spinosum, Stratum germinativum or basale

Dermis

Thicker than epidermis, contains sebaceous glands, sweat glands, hair and nail follicles, nerves, and lymphatics

Vascular disease

impairs the skin’s ability to obtain required oxygen and nutrients

Diabetes

affects the microvasculature but also the skin’s normally acidic pH

Medical adhesive-related skin injuries (MARSI)

Occur when superficial layers of skin are removed by medical adhesive (use adhesive remover pads)

Skin integrity

Open or closed

Wound depth

Superficial, partial thickness, or full thickness

Amount of contamination

Clean, clean contaminated, contaminated, infected, or colonized

Healing process

Primary, secondary, or tertiary

Primary intention

Clean incision, early suture, hairline scar

Secondary intention

Gaping irregular wound, granulation, epithelium grows over scar

Tertiary intention

Increased granulation, late suturing with wide scar

Inflammatory phase of wound healing

3 days, coagulation cascade

Proliferative phase of wound healing

Several weeks, granulation tissue

Maturation phase of wound healing

Up to 1 year, scar tissue

Dehiscence and evisceration

Coughing, vomiting, straining; popping sensation with increase in drainage. Teach to splint wound; cover wound with gauze moistened with a sterile normal saline and notify the physician immediately.

Superficial burn

Damage to only the epidermis, with resulting pain and erythema.

Partial-thickness burn

Damage to the epidermis and part or all of the dermis, causing blistering and pain.

Full-thickness burn

Damage epidermis, dermis, and part of the subcutaneous tissue, cause the area to be white or brown, charred, and without sensation.

Stage 1 pressure injury

Non-blanchable erythema of intact skin. An area that is painful and differs in firmness or in temperature from the surrounding tissue

Stage 2 pressure injury

Partial-thickness skin loss with exposed dermis. Intact or ruptured blisters

Stage 3 pressure injury

Full-thickness skin loss, undermining, tunneling

Stage 4 pressure injury

Full-thickness skin and tissue loss, osteomyelitis

Unstageable pressure injury

Obscured full-thickness skin and tissue loss. Cannot be assessed until necrotic tissue (eschar) in wound bed is removed

Deep tissue pressure injury

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

Braden scale / Norton scale

Risk assessment for pressure injuries

Wound assessment

Location, size, presence of undermining or tunneling, drainage (amount, color, consistency, and odor), conditions of wound edges and surrounding tissue, wound bed (type of tissue and color)

Red wound bed

Healthy regeneration of tissue

Yellow wound bed

Presence of purulent drainage and slough

Black wound bed

Presence of eschar that hinders healing and requires removal

Turning and positioning

Every 2 hours (more frequent for high risk patients). Head of the bed should be elevated no more than 30 degrees. Reposition hourly while sitting in a chair

Skin hygiene

Maintains healthy skin, preserve normal skin pH, use a moisture barrier ointment

Sharp debridement

uses a sharp instrument (scalpel, curette, or scissors) to remove necrotic tissue

Mechanical debridement

nonselective form of debridement that removes the necrotic tissue but also can remove or disturb exposed viable tissue (ex. wet/damp-to-dry dressings and whirlpools)

Enzymatic debridement

applies topical agents containing enzymes to remove necrotic tissue

Autolytic debridement

uses occlusive dressings (hydrocolloids and transparent films) and hydrogels, contraindicated in infected wounds

Biologic debridement

uses maggots to break down necrotic tissue

Gauze Dressings Uses

Packing in all types of wounds. Cover dressing. Absorbing exudate from a heavily draining wound

Transparent film Dressings Uses

Wounds that have minimal or no drainage. Autolytic debridement.

Hydrocolloids Dressings Uses

Autolytic debridement. Use with clean, uninfected wounds with small to moderate amounts of drainage.

Foams Dressings Uses

Wounds producing moderate to heavy amounts of exudates.

Alginates Dressings Uses

Highly exudative wounds. Use on bleeding wounds.

Gels Dressings Uses

Wounds that have minimal or no drainage. Autolytic debridement.

Drains

Reduce the chance of infection. Preventing blood, serum, or pus from collecting in the surgical area. Closed or open systems. May or may not be sutured into place