Chapter 32: Skin Integrity & Would Healing

Epidermis

outer portion of the skin

The epidermis has 5 layers but ___ are the most important

2

The epidermises most important layers are the

1. stratum corneum (outermost)

2. stratum germinativum (innermost)

Stratum corneum is composed of

numerous thicknesses of dead cells

Stratum corneum functions

1. barrier

2. restricts water loss

Stratum germinativum continually produces

new cells, pushing older cells towards the skin surface

Keratinocytes

protein-containing cells that give skin strength and elasticity

Melanocytes

produce melaning

Langerhans cells

mobile cells that phagocytize foreign material and trigger immune response

Dermis

layer below the epidermis and above the subcutaneous tissue

Dermis is made up of

irregular fibrous connective tissue

Dermis functions

1. strength

2. elasticity

Dermis contains

1. blood vessels

2. sweat glands

3. sebaceous glands (oil)

4. ceruminous glands (wax)

5. hair/nail follicles

6. sensory receptors

7. elastin

8. collagen

Subcutaneous layer is made up of

1. connective tissue

2. adipose tissue

Children are born with varrying amounts of ___ which protects the skin

vernix caseosa

In women experiencing puberty, high estrogen levels can cause

1. softening of the connective tissue

2. striae and darkening of the skin

85% of adults experience xerosis, which is

itchy, red, dry, scaly, cracked or fissured skin

Subcutaneous tissue layer thins in

older adults because of loss of lean body mass

Low cholesterol levels can predispose pts to

1. skin breakdown

2. inhibit wound healing

If calorie intake is inadequate, the body uses ___ for energy

protein

Healing can be delayed without proper amounts of

1. vitamin c (absorbic acid)

2. zinc

3. copper

Poor skin tugor can be triggered by

dehydration

Edema can result from

overhydration

Pts with diminished sensation are more likely to suffer from

1. burns

2. pressure injury

Pts with imapired cognition are at greater risk for

1. pressure injury

Vascular system brings oxygen rich blood to tissues and

removes metabolic waste products

Impaired arterial circulation

1. restricts activity

2. produces pain

3. leads to muscle atrophy

4. leads to thin tissue

Impaired venous circulation causes tissues to engorge and contain

high levels of metabolic waste products

Impaired venous circulation causes skin to be susceptible to

1. edema

2. ulceration

3. breakdown

One of the main causes of chronic wounds is

circulatory impairment

Medications that can impair skin integrity or delay healing include

1. blood pressure medications

2. anti-inflammatory meds

3. anticoagulants

4. chemotherapeutic agents

5. particular antibiotics, psychotherapeutic drugs

6. antifungal and anticonvulsants

7. several herbal products

Blood pressure medications can impair integretity and healing b/c they

decrease the amount of pressure needed to occlude flow flow, which increases risk for ischemia (poor oxygenation)

Anticoagulants can cause issues w. wound healing b/c they can cause

extraversion of blood into subcutaneous tissue, therefore minimal pressure or injury can cause hematoma

Several herbal products (e.g. those containing Lavendar and tree oil) can cleanse the skin but also

dry out the skin

Steven-Johnson syndrome

severe rash and skin peeling triggered by certain antibiotics and antifungals, anticonvulsants, and psychotherapeutic drugs

Common sources of moisture that lead to maceration

1. incontinence

2. fever (sweat)

Bowel incontinence can lead to the __ of superficial skin layers

excoriation/denuding

Fever increases metabolic rate, which increases

the tissue demand for oxygen, which is difficult to meet if there is circulatory impairement

All chronic wounds are considered

contaminated

Colonization

microorganisms begin to increase in number but cause no harm

Critical cocolonization

bacteria begins to overwhelm the body’s defenses

Infections

microorganisms are causing the body harm by releasing toxins, invading body tissues, and increasing the metabolic demand on tissue

Wounds are classified by

1. length of time the wound existed

2. condition of the wound

Closed wound

no breaks in the skin (e.g. contusions/bruises, tissue swelling)

Open wound

break in skin or mucous membrane (e.g. puncture wounds, lacerations, abrasions)

Acute wounds

short duration wounds that are healed w.o complicaiton

Three phases of wound healing

1. inflammation

2. proliferation

3. maturation/remodeling

What happens during the proliferation phase

fibroblasts produce new collagen, create new blood vessels, and repair avascular epithelial tissue

Chronic wounds

wounds that exceed the expected length of recovery, usually caused by infection, trauma, ischemia, or edema

Chronic wound e.g. are

1. pressure injury

2. diabetic ulcers

3. arterial ulcers

Clean wounds

uninfected wounds w. minimal inflammation; can be opened or closed

Abrasions

scrape of the superficial layers of the skin

Abscess

localized collection of pus resulting from invasion from a pyogenic bacterium or other pathogen

In order for an abscess to heal, you must

open and drain it

Contusion

closed wound caused by blunt trauma

Contusions are also referred to as

bruises or ecchymosis

Crushing

wound caused by force leading to compression or disruption of tissue, but no to little break of the skin

Crushing wounds are often associated w.

fractures

Excoration

superficial wound often caused by excessive scratching or mechanical force

Incision

open, intentional wound caused by sharp instrument

Laceration

torn open skin or mucous membranes

Laceration wounds have ___ margins

jagged

Penetrating

open wound where the causing agent lodges itself into body tissue

Puncture

open wound caused by sharp object

In puncture wounds, the tissue surrounding the entry point ___

collapses

Tunnel

wound with an entry and exit point

Clean-contaminated wounds

surgical incisions that enter the GI, respiratory, or genitourinary tract

there is a greater risk for infection, but no obvious infection

Contaminated wounds

open, traumatic wounds or surgical incisions where a major break in asepsis has occurred

Infected wounds

wounds where the bacteria in the wound is above 100,000 organisms per gram of tissue

The presence of ___ in any amount is a sign of infection

beta-hemolytic stretococci

Areas with poor circulation often heal quickly (T/F)

False

Superficial wounds

involve only epidermis of skin

Partial thickness wound

extent through the epidermis, but not through the dermis

Full thickness

extent to the subcutaneous tissue and beyond; can involve internal organs

Types of chronic wounds

1. pressure injury

2. arterial ulcers

3. venous stasis ulcers

4. diabetic foot ulcers

Pressure injuries tend to be located over

bony prominences

Arterial ulcers are caused by

inadequate circulation of oxygenated blood blow to the tissue, which can lead to tissue ischemia and dmg

Arterial ulcers are often found on

1. lower leg

2. ankles

3. toes

4. side of foot

Venous stasis ulcers are caused by

incompetent venous valves, deep vein obstruction, or inadequate calf muscle function, which causes venous pooling, edema, and impaired circulation of the skin

Venous stasis ulcers are usually located on

1. inner ankle

2. lower part of calf

Diabetic foot ulcers are caused by

narrowing of the arteries that leads to reduced oxygenation to the feet, which causes delayed wound healing and tissue necrosis

Diabetic foot ulcers mainly occur on ___ surfaces

plantar

Venous stasis ulcers are usually shallow and have ___ wound margins

irregular

Arterial ulcers often appear '“punched out,” small, round and have ___ borders

smooth

Regenerative/epithelial healing

takes place when a wound only affects the epidermis and dermis; no scarring

In regenerative/epithelial healing, the new skin can be distinguished from the intact skin (T/F)

False

Primary intention healing occurs when

a wound involves minimal or no tissue loss and has edges that are well approximated

Secondary intention healing occurs when

1. wound involved extensive tissue loss that prevents wound edges from approximating

2. should not be closed (e..g due to infection)

Wounds that heal by secondary intention heal more ___, are more prone to infection, and develop more scar tissue

slowly

Secondary intention healing heal from the inner layer to the surface by fillin in with ____

tissue

Granulation tissue is abundant in

blood supply

Tetriary intention healing occurs when

two surfaces of granulation tissue are brought together

Tertiary wound healing can be used when the wound is

clean-contaminated or contaminated

Initially, wounds healing via tertiary intention are allowed to heal by ___ intention

secondary

Tertiary intention healing requires strict __ technique

aseptic

Tertiary healing creates less scarring than ___, but more than ____

secondary; primary

Inflammatory phase is also known as cleansing and it lasts approximately

1 to 5 days

Inflammatory phase consists of two major processes

1. hemostasis

2. inflammation

Hemostasis

area vessels near injury constrict to limit blood loss and platelets aggregate to slow bleeding; clotting mechanisms are also activated to form clots

Inflammation is characterized by

1. edema

2. erythema

3. pain

4. temp. elevation

5. migration of WBCs into wound tissue