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Skin Integrity 102
LU Kozier Notes
| Question | Answer |
|---|---|
| clean wounds | surgical wounds but no gut, genital, respiratory areas |
| clean contaminated wounds | surgical in GI, Resp, Genital region |
| contaminated wounds | accident wounds, burst appendix etc... |
| dirty or infected wounds | obvious infection or necrotic tissue |
| incision | sharp instrument (open wound) |
| contusion | bruise, blow from blunt object, closed wound |
| abrasion | scrape, open wound involving the skin |
| puncture | penetration of skin and often underlying tissue, open wound |
| laceration | tissues torn apart, open wound edges often jagged |
| penetrating wound | penetration of skin and underlying tissue (bullet, metal fragment), open wound |
| partial thickness | confined to skin (dermis and epidermis) heal by regeneration |
| full thickness | involving the dermis, epidermis, subcu tissue, and could be muscle, bone and connective tissue |
| pressure ulcers | lesion caused by unrelieved pressure |
| ischemia | deficiency of blood supply to tissue, (localized pressure causes this and leads to pressure sores) |
| Risk Factors for Pressure Ulcers | friction and shearing (usually together), immobility, inadequate nutrition, incontinence, decreased mental status, body heat, age, medical problems, and other issues |
| friction | force acting parellel to the skin surface |
| shearing force | combination of friction and pressure (patient in fowlers position) |
| maceration | tissue softened by prolonged wetting and soaking |
| excoriation | loss of superficial layer of skin |
| Staging Pressure sores | Four stages, once pressure sore is staged it stays that stage even after improvement, cannot be staged till necrotic tissue removed |
| Braden scale | pressure sore risk scale. 23 highest possible score, 17 and below are at risk for sores |
| Stage 1 pressure sore | redness (non blanching) of epidermis and dermis |
| stage 2 | skin loss |
| stage 3 | full thickness to muscle |
| stage 4 | full thickness with damage through muscle, possibly to bone and connective tissue |
| primary intention healing | stitching, glue, stapels etc used. Tissue is approximated (closed) and there is minimal tissue loss |
| secondary intention healing | bottom up healing, edges cannot or should not be approximated. Heals from the inside out, takes longer to heal, scarring is more, risk for infection is higher |
| tertiary healing | wounds left open for 3-5 days, then approximated and closed |
| dehiscence | partial or total rupturing of sutures |
| evisceration | protrusion of internal viscera (organs) through an incision that has ruptured |
| Assessment of wound | control bleeding, prevent infection (clean or flush), dressing (attempt to approximate edges when wrapping), control swelling (ice), |
| assessment of pressure ulcer | location, size, and depth, presence of undermining, stage (if possible), color of wound bed and location of eschar and necrosis, condition of margins, integrity of near skin, signs of infection |
| obtaining a wound culture | assess wound, sterile technique, cleanse the wound (irrigation), swab from one side to the other while spinning, do not swab up pus |
| ace wraps | to return blood to heart, distal to proximal |
| irrigation | usually use NS, 20, 30 or 60 gauge syringe |
| heat | vasodilation, capillary permeability increase, cellular metabolism increase, inflammation increase, sedative |
| cold | vasoconstriction, decrease cap refill, decrease cell metab, slow bacterial growth, decrease inflam., local anesthetic |
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