Skin Integrity and Wound Healing FOUNDATIONS 2 TEST 3

Structure of integumentary system

Epidermis

Dermis

Subcutaneous layer

Protection function of the Integumentary system

From physical and chemical injury

sebum

Normal Flora

Metabolism function of the Integumentary system

Vitamin D

Thermoregulation function of the Integumentary system

Dilation and constriction of blood vessels

Elimination function of the Integumentary system

Water electrolytes and wastes

Sensation function of the Integumentary system

Nerve endings in skin provide valuable info and protection

Psychosocial function of the Integumentary system

Facial expressions

Hair distribution

Absorption function of the Integumentary system

Substances absorbed due to vascularity of the skin

Factors that affect integumentary function

Circulation

Nutrition

Condition of the epidermis

Allergy

Infection

Abnormal growth rate

Systemic disease

Abnormal Skin Growth Rate

Psoriasis

Renal Failure effect on skin

itchy

Diabetes effect on skin

peripheral neurpathy

Liver Failure effect on skin

Yellow skin

Manifestations of altered integumentary function

Pain

Pruritus

Rash

Lesion

Intentional wound

Created for therapeutic process under sterile conditions

Unintentional wounds

Non-Therapeutic

Take longer to heal, more tissue trauma.

Types of unintentional wounds

abrasions

Lacerations

Puncture wound

Chemical wound

Exposure wounds

Open wounds

Closed wound

Acute vs chronic wounds

Acute heal as expected and follow normal healing process

Chronic wounds get stuck in inflammatory phase of wound healing

Children younger than 2 years old

- Skin is thinner and weaker

- an infants skin and mucous membranes are easily injured and subject to injection

- becomes increasingly resistant to injury and infection

Elderly developmental considerations

Maturation of epidermal cells is prolonged, leading to thin, easily damaged skin

Circulation and collagen formation are impaired leading to decreased elasticity and increased risk for tissue damage from pressure

Takes 2 months for epidural to regenerate

Pressure Injury causes

Pressure intensity

Pressure duration

Pressure injury risks

Impaired tissue tolerance

Nutrition

Moisture

Age

Friction

Shear

Shear

When two skin layers go in opposite directions

Friction

Two surfaces rub together to get skin beaks

Pressure injury comorbid conditions

- altered level of consciousness

- sensory impairment

- impaired mobility

Common sites for pressure injuries

bony prominences, such as the

-sacrum

-buttocks

-greater trochanter

-elbows

-heels

-ankles

-occiput

-scapulae

Stage 1 pressure injury

Non-blanchable

Erythema of the skin

Closed wound, skin is intact, redness does not go away after being pushed.

Stage II pressure injury

- Partial thickness skin loss

- presents as an abrasion or blister

Stage III pressure injury

- full thickness skin loss with damage of necrosis of SQ tissue

- presents as a deep crater

Stage IV pressure injury

Full thickness skin loss with extensive destruction, necrosis, or damage to muscle, bone, or tendons.

Slough

Yellow, tan, gray, green, or brown

Non Viable tissue

Eschar

Dark brown or black

Crust-like, non-viable tissue.

Unstageable

- full thickness tissue damage

- base of the wound is covered by slough or eschar

Suspected deep tissue injury

- Purple or maroon localized area of intact skin

- Implies deep tissue damage and necrosis, likely to be a 3-4 when the skin opens.

Autolytic Debridement

- use of hydrocolloid or foam dressings

- bodys own enzymes and defensive mechanisms to loosen and liquefy necrotic tissue

Bio-Surgical Debridement

Use of maggots on wound

Enzymatic Debridement

- Application of commercially prepared enzymes

- enzymes are prescribed treatments by a provider

Mechanical Debridement

- use of an external physical force (Drg, h2O2, irrigation)

- painful method of debridement

Sharp / Surgical Debridement

- Use of scalpel

- performed by physicians and advance practice nurse

Hemostasis

Vasoconstriction

Exudate production

Clot formation

Inflammatory

Vasodilation

Phagocytosis

Localized inflammatory response

Lasts 4-6 days

Proliferative stage of wound healing

Last 3-24 days

Fibroblasts and growth factor create collagen and blood vessels

Granulation tissue formation

Maturation stage of wound healing

Can take up to 2 years

Collagen matures

Scar tissue is created

Types of wound

Primary intention

Secondary Intention

Tertiary Intention

Systemic Factors

Age

Nutrition (protein, vitamins A&C, Zinc)

Circulation / Oxygenation

Health status (diabetes, shock, immunosuppression, obesity)

Local Factors

- Moistures (Desiccation, Maceration)

- Trauma

- Edema

- Infection

- Bleeding

- Necrosis

- Biofilm

Complications of wound healing

Hemorrhage

Hematoma

Dehiscence

Evisceration

Infection

Fistula

5 Signs of local infection

Redness

Heat

Edema

Pain

Altered function

Subjective data of skin integrity and wound healing

- Normal skin condition

- Hx of skin conditions and wounds

- psychosocial effects of impaired skin integrity

Typical findings of intact skin

- color

- temperature

- moisture

- texture

- odor

- turgor

Implementation

- health promotion

- prevention of pressure ulcers

- positioning and skin care

- pressure reducing surfaces

- PT teaching

- hygiene and handwashing

- pressure ulcer preventions

- infection symptoms