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34- Skin Integrity & Wound Healing


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what are the 3 layers of the skin?
epidermis, dermis and subcutaneous layer
what is the stratum corneum? what is its purpose?
it is the outermost layer of the epidermis and is composed of dead cells. It functions to restrict water loss, and prevent fluids, pathogens and chemicals from entering the body.
what is the stratum germinativum? what is its purpose?
its the inner most layer of the epidermis and it functions to produce new cells, pushing the old ones to the surface.
What 3 types of cells are in the epidermis? what do they do?
keratinocytes, melanocytes and langerhan cells are in the epidermal layer. Keratinocytes give strenght and elasticity, melanocytes give color to the skin, and langerhands are mobile cells that phagocytize foreign material and trigger and immune response.
What is the function of the dermis? what is it made of?
the dermis provides strength and elasticity to the skin and is generously supplied with blood vessels. It is made of irregular fibrous connective tissue.
In which of the 3 layers of skin are sweat glands, sebaceous glands, ceruminous glands, hair and nail folicles, sensory receptors, elastin and collagen found?!?
In the dermis.
What is the subcutaneous layer of skin? What is it made of? What is its purpose?
its the inner most layer of skin. Its made of connective and adapose tissue. It provides protection and insulation. Its thickness varies from person to person.
what type of nutritional things do you need for healthy skin?
protein, cholesterol, calories, fluid, vitamin C, and minerals. Lack of protein can cause Edema. Cholesterol, fatty acids and linoleic acids provide fuel for wound healing and the maintinance of a water proof barier of the stratum corneum. Vitamin C, zinc and copper are involved in collagen formation.
one of the main causes of chronic wounds is?
circulatory impairment
how do antiinflammatory drugs and blood pressure medications affect wound healing?
anti-inflammatory drugs inhibit wound healing, and blood pressure medications create a risk for ischemia.
maceration definition, and what causes it?
softening of the skin due to exposure to too much moisture. Incontinence and fever are the most common culprates.
excoriation-def. and what causes it?
denuding of superficial skin layers, its caused by feces and their digestive enzymes and microorganisms eating away at the skin.
How is FEVER a risk for skin breakdown? (list 3 ways)
first it leads to sweating which can cause maceration. Second it increases the metabolic rate thereby raising the tissues demand for oxygen setting you up for ischemia or hypoxia, and third it is a sign of infection, which would take away the valuable nutrients needed to repair a wound.
colonized vs. infected?
colonized just means that there are microorganisms that are in there, but they are cuaseing no harm. Infected means that the microorganisms are releasing toxins and causing harm.
how long might a chronic wound last for?
months or years.
a localized collection of pus due to bacterial invasion. it must be opened and drained to heal.
clean wound
may be open or closed, has no contamination
clean contaminated
surgical incisions that enter the GI, respiratiory, or GU tracts. no obvious infection, but increased risk for one.
contaminated wounds
open wounds or surgical incisions in which a major break in asepsis has occured. High risk for infection
infected wounds
evidence of infection such as purulent drainage or necrotic tissue.
how many microorganisms must be present for a wound to be considered infected?
100,000 organisms per gram of tissue.
superficial, partial thickness, full thickness or penetrating wounds. Describe the difference.
superficial involve only the epidermal layer. Partial thickness extend into the dermis. Full thickness go into the subQ tissue and beyond. Penetrating means that it involves internal organs.
Describe primary, secondary, and tertiary intention, as well as regeneration.
regeneration of a wound happens when the wound is superficail. no scar forms and it heals like new :). Primary intention is when there is minimal tissue loss and the edges are well approximated. Little scarring is expected--a clean surgical incision heals by primary intention. Secondary intention has extensive tissue loss, or shoudl not be closed. It heals from the inner layre to the top and is filled with (hopefully) beefy red granulation tissue. Pressure ulcers and infected wounds heal by secondary intention. Tertiary intetion is when two surfaces of granulation tissue are brought together. Initially it heals by secondary intention, but if everything goes well, then they close it up so it heals faster and leaves less of a scar.
what are the 3 stages of wound healing?
inflammatory, proliferative and maturation
describe the inflammatory stage of wound healing
occurs within 24 hours, characterized by edema, pain, erythema, temp elevation, and WBC rushing to the scene. Phagocytes along with fibrin and plasma proteins form a scab at the surface of the wound.
describe the proliforative phase of wound healing
this is the second phase. it occurs from days 5-21. Fibroblasts migrate to teh wound and form collagen. New blood and lymph vessels sprout, granulation tissue is formed. epithelialization occurs.
mautration phase of wound healing
final phase. it begins the scond or third week and continues until it is completey healed.
a scar is only _____% as strong as the origional tissue
80 %
hyperbaric oxygen therapy. it is the administration of 100% oxygen in the wound stimulates the growth of new blood vessels and enhances white blood cell action.
serous exudate
consists of is straw colored and is watery in consistancy. Usually it comes from a clean wound.
Sanguineous exudate
is bloody drainage. its found in deep wounds or highly vascular areas.
Serosanguineous exudate
a combination of bloody and serous drainage. Most commonly found in new wounds
Purulent exudate
contains pus and is yellow in color (though may in some cases be blue green). It is seen in infected wounds.
purosanguineous exudate
it is pus that is red tinged.
when is the risk of hemmorhage the greates?
in the first 24-48 hours following surgury or injury. Usually homeostasis, and cessation of bleeding occurs within a few minutes of the injury.
what are some signs of internal bleeding?
decreased blood pressure, elevated pulse, temperature. hematomas may be present
how soon will you see signs of infection in a clean, and in a contaminated wound?
in a clean wound it may take 4 or 5 days to see the symptoms of infection. In a contaminated wound it may occur within 2 or 3 days.
dehiscence--1) what is it 2) when is it likely to occur? 3) what is it usually associated with? What kind of drainage?
rupture or separation of one or more layers of a wound. It is most likely to occur after the inflammatory phase of healing. It is most likely to occur in people with poor nutrition or inadequatte closure of the muscles, or obese clients (because fatty tissue does not heal readily). It is usually associated with abdominal wounds. usually they will feel a pop or tear-especially after coughing or sneezing or vomiting or straining in any wya. usually there is serosanguineous drainage.
total separation of the layers of a wound in which interal viscera protrude through the incision. it is a serious emergency. Immediately cover the wound with sterile towls or dressings soaked in sterile saline solution, have the patient stay in bed with knees up, and notify the surgeon immediately.
abrnormal passage connecting two body cavities or a cavity and the skin. the most common site is the gastrointestingal and genitouriurinary tracts. (rectum and vagina).
what causes pressure ulcers?
inrelieved pressure that compromises blood flow to an area and results in ischemia. Intrinsic factors, like immobility or impaired sensation. And extrinsic factors like friction, shearing and exposure to moisture.
what causes ischemia
small amounts of pressure over an extended period of time, or large amounts of pressure for a short time will cause tissue ischemia
what are the most common sites for pressure ulcers?
bony promonances
stage I pressure ulcer
nonblanchable erythema. discoloration lasts for more than 30 minutes after the pressure is relieved. In the begining the temp of the skin raises, but later on it cools because the continued pressure interfears with circulation. It is firm at first and later becomes soft and boggy.
stage II pressure ulcer
partial thickness (down to dermis) skin is no longer intact and may appear as an abrasion, blister or shallow crater.
stage III pressure ulcer
full thicknes, down to the subQ tissue, appears as a deep crater, undermining may be present.
stage IV pressure ulcer
full thickness, skin loss with extensive destruction, tissue necrosis or damage to muscle, bone or support structures. Undermining and sinus tracks are common.
black leathery covering comprised of necrotic tissue. It forms when a wound can not go through epithelialization. it must be removed to be staged.
do pressure ulcers ever reverse their stage?
what does a thorough skin assessment include?
a nursing history, physical exam, and diagnostic testing.
what are the six risk factors that the braden scale measures? How is the braden scale scored?
sensory perception, moisture, activity, mobility, nutrition, friction/shear. The lower the score, the more likely the pt is to develope a pressure ulcer. A score of 18 or 16 means you need to intervene.
What is the Norton scale?
it assesses risk based on the patiens physical condition, mental state, activity, mobility and incontinence. For this scale, intervene at 14 or less
if a pt has an abdominal wound that begins to smell of bile or feces, what should you assess it for?
a fistula
when shoudl you give a tetanus shot for a wound?
if the last immunization was 10 years ago or longer, if the wound is contamainated with dirt and debris and the last tenatus shot was 5 years ago, if it is uncertain when the pt had his last tetanus shot.
reactive hyperemia
an area (like a pressure wound) that flushes bright red when pressure is relieved from it. If the redness does not disappear quickly than tissue damage has occured.
how long should the redness last when you remove pressure, for tissue damage to NOT have occured
normally the redness should last about half as long as the duration of the ischemia
what is the PUSH tool?
it is used when a pressure ulcer actually exists, it evaluates them and reports their progression. Surface area, exuate and type of wound tissue are scored and totaled. As the wound heals the score falls.
What are the most common lab work done for skin breakdown?
leukocyte count, serum protein levels, coagulation studies and wound cultures
How do you obtain a wound culture?
by swab, aspiration or tissue biopsy.
what is healthy people 2010 s goal?
their public health objective is to reduce the prevalence of pressure ulcers in nursing homes by 50% by 2010. ...riiiiight :p
what are the things involved in prevention of pressure ulcers?
providing skin care, nutrition, positioning, therapeuitic mattresses and cushions, and patient/family teaching.
when it comes to preventign pressure ulcers where does soap and moisturizer come in?
do not use soap on a regular basis. Apply moisturizing lotion if the pt has dry skin.
what nutrient is most important in skin integrity?
How much protein does a person who is malnourished with a wound need?
2 grams/kg
How often should you reposition someone at risk for pressure ulcers?
every 2 hours
what is teh "rule of 30"
a guide to positioning the pt. elevate the head of the bed 30degrees or less, when the pt is on her side position them at a 30degree angle to avoid direct pressure on the trochanter.
what position should not be used for people wiht pressure ulcers?
high fowlers. you can use fowlers, but maybe semi fowlers is better.
what is the RYB color code system of wound care?
red wounds are ideal and should be kept covered and moist. Yellow wounds -characterized by moisture and slough, need to be cleansed. Black wounds are eschar and need to be debraded.
What site of the body is NOT recomended for eschar debradement?
the heel
how do you cleanse a wound?
do not use liquid or foam skin cleansers or antiseptic solutions. Only use saline or dilute antimicrobial solutions. Use gause soaked in them and apply to wound.
aggressing cleansing method. it is a form of debradement.
how do you irrigate a wound?
use a 35 ML syringe attached to a 19 guage angiocath and deliver the solution at approximately 8 psi. *ideal irrigation pressures range from 4-15 psi.
what are the ways to debrade a wound?
sharp debradement, wet to dry dressings, mechanical debradement, hydrotherapy/whirlpool treatments, enzymatic debradement, autolysis.
What is the advantage of transparent films?
they are semipermeable, so they allow for air exchange while preventing contamination. they allow you to see the wound without removing or disturbing the dressing.
Hydrocolloids should nto be used on what type of wound?
infected wounds, or those with tunneling or tracts because they are impermeable to oxygen and moisture and therefore facilitate the growth of anaerobic bacteria
what is the ideal dressing for sinus tracts or tunneling?
ribbon dressings, or alginates
montgomery straps
the dressings that require frequent change so they have ties (remember in lab, the abdominal dressing)
how do the CDC precautions differ when taking care of someone with a closed wound, as opposed to an open wound with drains?
in a closed wound follow standard precautions, for open wounds follow contact as well as standard precautions.
what do binders do?
they hold a dressing in place and apply pressure to a wound to impede hemmorhage
what are some things to consider when applying heat/cold
highly vascular areas like the fingers, hand and face are very sensitive to temp changes, the feet however are not, so they will have to be VERY carefully monitored. Always avoid direct contact, apply intermittantly every 15 minutes, check requently.
what may application of heat do to the rest of your body? (ie blood pressure, etc)
if applied to a large area of the body, vasodialation occurs and may drop your blood pressure and make you feel dizzy (like me in a hot room :p).
what does moist heat do?
moisture drives the heat in (liek in micro, remember :) ) , making it more effective.
what does the appication of cold cause?
vasoconstriction and localized anesthesia, reduction in cell metabolism, increased blood viscosity and slows bacterial growth. It is used to prevent or limit edema, fevers and sports injuries, and after surgery. It elevates your blood pressure, and can cause tissue damage.

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