Wounds

Stages of wound healing

Pressure = disrupts the blood supply to the wound area

Desiccation = dehydrated cells die, causing crust to form over the wound site and delay healing

Maceration = overhydration of cells from urinary and fecal incontinence causes impaired skin integrity. this is caused by excess moisture, changes in the pH of the skin, overgrowth of bacteria and infection of the skin, and erosion of skin from friction on moist skin

Trauma = repeated trauma to wound area delays healing or inhibiting healing

Edema = interferes with the blood supply to the wound area, causing inadequate supply of oxygen and nutrients to the tissue.

Infection = bacteria in the wound increases stress on the body, requiring increased energy to deal with the invaders; toxins produced by bacteria death interfere with wound healing and cause cell death

Necrosis = dead tissue appears as slough, moist, yellow, stringy tissue, and eschar appears as dry, black, leathery tissue. healing is inhibited until necrotic tissue is removed

  • yellow = presence of exudate or slough oozing or drainage, cleanse wound with wound cleaner and irrigate

  • black = eschar (necrotic) and can also be brown/grey/tan. debridement needed before healing will occur.

Types of Lesions

Macular lesions = ecchymosis, pressure point, and tinea versicolor

Papular lesions = ache, warts, nevi, insert bites, and early varicella

Pustular lesions = ache, furuncles, and carbuncles

Vesicular lesions = herpes simplex, varicella, and impetigo

Plaque lesions = psoriasis, lichen simplex

Hair assessment:

  • scalp

  • color

  • texture

  • amount

  • distribution

  • lesions

  • flaking

  • parasites

    • aging females: thinner hair, coarser, decrease in body hair, terminal hair growth on chin

Nail assessment

  • paronychia = local infection of the nail

  • clubbing = a nail base that feels spongy with angle of the nail base 180 degrees or greater