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Skin Integrity

Skin Integrity for NU112

The Skin - The largest organ of the body - Surface area of 18 sq Feet
Layers of the Skin - Outer layer - epidermis - Inner layer - dermis
Functions of the Skin - Protection - Sensory - Perception - Temp Regulation - Water Balance - Vitamin D Production - Excretion
Stratum Basale - These are the only cells of the skin that receive nourishment - They divide and push towards the epidermis where they are dead
Turning and Positioning - This has to be done if the cells of the statum basale are cut off from blood too long they will die and a pressure ulcer will form
Pressure Ulcer - Is a wound with a localized area of necrotic tissue - acute or chronic depending on depth - Caused by pressure friction and shear - mostly over a bony prominence
Pressure Ulcer Statistics - 1.5 - 3 million cases per year - 60% or more in hospitals - 18% in nursing homes - 7 - 12% home care - one pressure ulcer can cost 2 to 40 thousands dollars to treat
Factors in Older for Pressure Ulcers - Aging Skin - Chronic Illness - Immobility - Malnutrition - Fecal and urinary incontinence - Altered LOC
Skin Assessment - Extremely Important - Check on admission, transfer, surgery - Every 8 hours - Check weights and albumin levels - Sacrum, coccyx, buttocks, heels, elbows
Factors that Cause Pressure Ulcers - Pressure - Friction - Shear
Pressure - Usually occurs over a bony prominence - pressure is greater than pressure in capillaries - No blood,oxygen, the tissue dies
How long does it take for a pressure ulcer to form - as little as one hour with as little as not moving a person that is vulnerable - damage can occur within 20 min. - Friction can cause immediate damage
Friction - is the resistance to lateral movements between 2 objects - top surface of skin can be torn off or damaged resulting in an abrasion - with pressure added can cause more damage
Causes of Friction - wrinkled pad or sheet - pt. trying to lift themselves in bed - when nurses dont lift to move - when a person is resting and the head of the bed is over 30 degree for a long time
Shear - Results when one layer of tissue slides over another layer. - Separates the skin from underlying tissues
Causes of Shear - pulling on the skin and blood vessels - When skin moves in one direction and bone moves in another - the greater the pressure and shear the less time it takes for a pressure ulcer
Nursing and Shear - Patients who are pulled rather than lifted - pt who are partially sitting up are susceptible because skin sticks to sheet and the underlying body slides down
Immobility and Pressure Ulcers - A person who sits or lies most of the time - unconscious patients - paralyzed patients - surgery related
Nutrition and Pressure Ulcers - Protein malnutrition predisposes people to -
Hydration and Pressure Ulcers - Dehydration and edema can interfere with circulation and make and individual more prone to pressure ulcers because in either state, it is harder for nutrients to reach and nourish the cells
Moisture and Pressure Ulcers - Reduces the skin's resistence to trauma - incontinent causes wet and warm a bad combo - ammonia is caustic to the skin - infection can develop with the warm wet envrion.
Maceration - weakening of the skin due to excess moisture
Moisture Management - Use comm. barriers, barrier film - transparent dessings - promote continence - avoid plastic sheets - breathable clothing - keep peri-wound tissue dry
Mental Status and Pressure Ulcers - more alert patients will shift their position to relieve the pressure and maintain good hygiene - confusion, comatose apathy increases risk for skin breakdown
Age and Pressure Ulcers - Older greater risk for - aging skin more susceptible to injury - debilitating diseases more common in this age group
Blanching - skin appears paler than surrounding area because of poor circulation - could be the first sign of a pressure ulcer
Ischemia - local anemia resulting from poor circulation related to pressure
Reactive Hyperemia - when the pressure is relieved, the body floods the are with blood to nourish and remove wastes from the cells.
Blanching in Dark Skin - Appears blue, red or purple - compare to the skin around it using a flashlight helps - may also look for boggy, stiff, warm, cooler, different from yesterday, pain, itchiness.
Stage I Pressure Ulcer - Intact skin with nonblanchable redness of a localized area usually over a bony prominence
Stage II Pressure Ulcer - Partial thickness loss in the epidermis/dermis - shallow open ulcer with a area pink wound bed - Skin may blister or form an open sore - area around may be red and irritated
Stage III Pressure Ulcer - Full thickness loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through the underlying fascia - Subcutaneous fat maybe visible but bone, tendon ,and muscle are not exposed
Stage IV Pressure Ulcer - Full Thickness tissue loss with exposed bone tendon or muscle
Unstageable Pressure Ulcer - There is a thick layer of eschar over the wound and has to be removed to stage the ulcer
Stage I Treatment - Pressure relieving measures - Frequent turning - pressure relieving devices - Positioning
Stage II Treatment - Keep a moist healing environment, like an occlusive dressing
Stage III Treatment - May require debridement via wet-to-dry dressing, surgical interventions, enzymatic debrider
Stage IV Treatment - Wound Vac - Surgical Measures - Skin Graft
Red in a Wound - Proliferative stage of healing reflects color of normal granulation
Yellow in a Wound - Characterized by oozing, needs to be cleaned - infected
Black in a Wound - needs to be debrided - necrotic tissue
Wound Assessment - Inspect for sight and smell - Palpate for appearance, drainage and pain - determines the status of the wound, - ids barriers to healing and signs of complications
Signs of Infection - Swollen - deep red in color - feels hot - increased drainage - foul odor - wound edges maybe separated with dehiscence present
Wound Drainage - called Exudate - is composed of fluid and cells that escape from the blood vessels are are deposited in or on the tissue surfaces - caused by the inflammatory process
Serous Drainage - clear serous fluid of the blood - clear and watery
Sanguineous Drainage - Large number of RBCs - looks like blood - bright red - new blood - dark red - older blood
Serosanguineous Drainage - mix of serum and RBCs - light pink to blood tinged
Purulent Drainage - Made up of WBCs, liquefied dead tissue and both dead and live bacteria - it is thick, foul smelling and yellow or green depending on the bacteria
Complications of Pressure Ulcers - Sepsis - Infection - cellulitis - Ostomyelitis - Mortality high as 60% within one year
Steps for Wound Healing - Keep the pt comfortable and reposition frequently
Dressing the Pressure Ulcer - Keep moist and surrounding area dry - Moist only on wound surface - dressings that absorb exudate - use moisture-barrier ointment on surrounding skin - use less tape - wet-to-dry for debridement - pack loosely
Optimal Wound Healing - careful selection of dressing - wound irrigating solutions - topical agents - nutrition - improving circulation - vigilant skin assessment
Dry Dressing - Dry gauze dressings are placed on the wound dry and removed dry - purpose: protection from trauma or infection - for wounds that drain excess fluid
Moist to Dry Dressing - Purpose: debride of necrotic tissue in the wound bed - moistened gauze with NS packed in wound and allowed to dry, then removed, taking debris with it - this may damage new tissue growth when the dressing is removed from the wound
Moist Dressing - Purpose: to keep the wound bed moist - Gauze is placed on the wound moist and removed moist - moist gauze to wound bed only, not on edges
Created by: saraken2007