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Skin Integrity
Skin Integrity Fall 19 CCON PN
| Question | Answer |
|---|---|
| Tissue Integrity | the state of structurally intact and physiologically functioning epithelial tissues such as the integument (including the skin and subcutaneous tissue) and mucous membranes |
| Categories of Skin integrity | Trauma or injury or Burn Surgical Incision Loss of perfusion Immunological reaction Infections and infestations Thermal or radiation injury Lesions, Incisions, Pressure Injuries |
| Tissue integrity can be open, closed or both | Both |
| Layer that is Dense connective tissue Strong and elastic Blood vessels, nerves, hair follicles, fibroblast, glands Hair and nails—dead keratin with no blood supply or nerve endings | Dermis (corium) |
| Skin layer that: Line cavities or passageways of the body that open to the outside Made up of epithelial tissue over a deeper layer of connective tissue Protect against bacterial invasion Secrete mucus Absorb fluids and electrolytes | Dermis |
| Skin functions | Protection Absorption Secretion Excretion |
| Function of skin that is the First line of defense against bacteria and other organisms; protects against thermal, chemical, and mechanical injury Sebaceous glands make the skin waterproof | Protection |
| Function of the skin which allows for touch, pain, heat, and cold | Sensation |
| Function of the skin that allows that constricts or dilates blood vessels and activates or deactivates sweat glands | Temperature regulation |
| Excretion and secretion | Sweat glands help maintain the homeostasis of fluids and electrolytes Sweat glands: organs of excretion, secrete nitrogenous waste Sweat glands in axillae and external genitalia secrete fatty acids and proteins Sebum lubricates the skin and hair Sebum |
| Wounds with Contusion (bruise) Hematoma Sprain | Closed Wound |
| Types of Open wounds | Incision Laceration Abrasion Puncture Penetrating Avulsion Ulceration |
| Characteristics of Partial-thickness wounds | Superficial wounds Heal more quickly by producing new skin cells Fibrin clot forms framework for growing new cells |
| Characteristics of Full-thickness wounds | No dermal layer present except at margins of wounds All necrotic tissue must be removed Wound heals by contraction |
| What are the three distinct phases of wound healing | Inflammatory phase Proliferation or reconstruction phase Maturation or remodeling phase |
| How long does wound healing last | 1 to 4 days |
| Wound healing begins immediately with: | edema |
| Macrophages continue to clear the wound of debris, stimulating fibroblasts, which synthesize collagen New capillary networks formed to provide oxygen and nutrients to support the collagen and for further synthesis of granulation tissue Tissue is deep | Begins on third or fourth day; lasts 2 to 3 weeks |
| Final phase begins about 3 weeks after injury May take up to 2 years | Collagen is lysed (broken down) and resynthesized by the macrophages, producing strong scar tissue Scar maturation, or remodeling Scar tissue slowly thins and becomes paler |
| Surgical Incision has 3 intentions: | Primary, Secondary and Tertiary |
| 11 Factors Affecting Wound Healing | Age Peripheral vascular disease (PVD) Decreased immune system function Reduced liver function Decreased lung function Nutrition Lifestyle Medications Anti-coagulants Infection Wound infections slow the healing process Chronic illnesses |
| A wound with little tissue loss Edges of the wound approximate, and only a slight chance of infection | Primary intention |
| A wound with tissue loss Edges of wound do not approximate; wound is left open and fills with scar tissue | Secondary intention |
| Occurs when there is delayed suturing of a wound Wounds sutured after granulation tissue begins to form | Tertiary intention |
| Wound Complications | Hemorrhage and Infection |
| May occur if hemorrhage is internal | hypovolemic shock |
| Signs and symptoms of hemorrhage | Decreased BP; increased pulse rate; increased respirations; restlessness; diaphoresis; cold, clammy skin |
| Wound infections may occur | During surgery or postoperatively. Traumatic wounds are more likely to become infected |
| Primary organisms responsible for infection | S. aureus, E. coli, S. pyogenes, Proteus vulgaris, and P. aeruginosa |
| Localized infection | Abscess |
| Abscess | an accumulation of pus from debris as a result of phagocytosis |
| Inflammation of tissue surrounding the wound, characterized by redness and induration | Cellulitis |
| An abnormal passage between two organs or an internal organ and the body surface | Fistula |
| A canal or passageway leading to an abscess | Sinus |
| The spontaneous opening of an incision A sign of impending dehiscence may be an increased flow of serosanguineous drainage into the wound dressing | Dehiscence |
| Protrusion of an internal organ through an incision | Evisceration |
| Interventions if evisceration occurs | Place the patient in supine position Soak the dressings in sterile normal saline Place large sterile dressings over the viscera Notify the surgeon immediately Prepare the patient for return to surgery Keep NPO |
| Sutures and staples Silver wire clips Large retention sutures Steri-Strips Dermabond | Wound closures |
| A synthetic, noninvasive glue | Dermabond |
| Classifications of open wounds | Red wounds Yellow wounds Black wounds |
| Clean and ready to heal; protective dressing should be used | Red wounds |
| Have a layer of yellow fibrous debris and sloughing; need to be continually cleansed and have an absorbent dressing | Yellow wounds |
| Need debridement of dead tissue, usually caused by thermal injury or gangrene | Black wounds |
| Function and types of Drains and Drainage Devices | Provide an exit for blood and fluids that accumulate during the inflammatory process May be active or passive Penrose drain Plastic drainage tubes can be connected to a closed drainage system Hemovac and Jackson-Pratt |
| Penrose drain | a flat rubber tube |
| Procedure for using a Jackson-Pratt–type drainage device | Apply slight suction to the drainage tube to help evacuate wound fluids. Fluid is measured at the end of each shift and amount drained is entered on the I&O record |
| Protective coverings placed over wounds | Dressings |
| Prevent microorganisms from entering the wound Absorb drainage Control bleeding Support and stabilize tissues Reduce discomfort | Function of dressings |
| Removing necrotic tissue from a wound so that healing can occur | Debridement |
| May be enzymatic (an enzyme is used to liquefy dead tissue) | Debridement |
| Debridement that uses wet-to-dry dressings or whirlpool treatments | Mechanical debridement |
| Used to secure dressing | Stretch gauze such as Conform, Kerlix, Kling Mesh netting Elastic bandage Montgomery straps Binders Tape |
| An abdominal binder after surgery might be used with this type of incision | A large incision |
| Also called vacuum-assisted closure (VAC) | Negative Pressure Wound VAC |
| Involves applying a suction device to a special wound dressing to institute negative pressure at the wound site, drawing the edges together | Negative Pressure Wound VAC |
| Remove fluid from the wound, allowing increased blood flow, and thereby oxygen and nutrients, to be delivered to the wound | Negative pressure and suction with Negative pressure wound VAC |
| Vascular Ulcers | Ulcers that are chronic, or long term, breaches in the skin caused by problems with the vascular system |
| Cleaning Vascular Ulcers | Clean ulcers at each dressing change. Use only normal saline; then cover ulcer with a dressing |
| 3 Stages of dressing vascular ulcers | Stage l Stage II (noninfected) Stage III (draining ulcers) |
| In this stage thin film dressings are used to protect vacular ulcers from shear | Stage I |
| In this stage a hydrocolloid dressing is used | Sstage II |
| In this stage an absorbent dressing is used | Stage III |
| With these ulcers nonocclusive dressing is always used | Infected ulcers |
| Oxygen chamber treatment | used to treat nonhealing wounds occasionally |
| Used to accelerate wound healing | Electrical stimulation |
| Impaired skin integrity Risk for infection Acute pain Activity intolerance r Disturbed body image Deficient knowledge Anxiety | Common Nursing Diagnoses for Patients with Wounds |
| related to surgical incision (or trauma) | Impaired skin integrity |
| Common Nursing Wound Diagnoses for Patients related to nonintact skin or impaired skin integrity | Risk for Infection |
| Common Nursing Wound Diagnoses for Patients related to infected wound | Acute pain |
| Common Nursing Wound Diagnoses for Patients related to pain and malaise from wound infection Disturbed body image related to wound appearance Deficient knowledge related to care of wound Anxiety related to need to perform wound care | Activity intolerance |
| Common Nursing Wound Diagnoses for Patients related to wound appearance | Disturbed body image |
| Common Nursing Wound Diagnoses for Patients related to care of wound | Deficient knowledge |
| Common Nursing Wound Diagnoses for Patients related to need to perform wound care | Anxiety |
| Suture and Staple Removal | Sutures often removed by the physician, cut and pulled through the skin with Sterile technique should be used Staple removal requires a special instrument Steri-Strips applied after removal of sutures or staples Parts of sutures left under the skin |
| Applied to support the incision after suture removal | Steri-Strips |
| May be performed when injury is involved and debris or a caustic substance is present in the eye | Eye irrigation |
| Used to remove cerumen or foreign substances | Ear irrigation |
| May be ordered for infections or surgical preparation | Vaginal irrigation |
| May be used to: Relieve pain, reduce congestion, relieve muscle spasm Reduce inflammation and swelling Provide comfort, elevate body temperature | Hot and Cold Applications |
| Can be dry or moist Usually requires physician’s order | Hot and Cold Applications |
| Pad that is applied for a heat treatment | Aquathermia pad |
| To decrease swelling; prevents edema For joint injuries or areas requiring decreased blood flow To decrease pain Decreases cellular activity, leading to numbing | Effects of cold compress |
| Used in the form of compresses, ice bags, collars, or hypothermia blanket | Cold Applications |
| Wound edges well-approximated Wound is clean and dry without redness or swelling Patient states that pain is gone Patient states that energy has returned; is up walking in the hall Return demonstration of dressing change properly performed | Examples of Goals for Patients with Wounds |
| Collaborative interventions in wound therapy | Pharmacotherapy Wound care Phototherapy Surgical interventions Nutritional support |
| Pharmacotherapy in wound therapy | Antibiotics, steroids, emollients, chemotherapy agents |
| Involved in Wound care & wound therapy | Cleansing and dressings |
| Use of Excisions (scalpel or laser), debridement, skin grafts in wound therapy | Surgical interventions |
| Types of Nutritional support in wound therapy | Protein, vitamin A, and vitamin C are critical |
Created by:
TutorDavis17
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