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Skin: Integumentary

Professional Nursing

Epidermis: composed of several thin layers. contains melanocytes (melatonin) and keratinocytes (keratin) - waterproof layer.
Dermis: composed of a thick layer of skin. contains collagen, elastic fibers, nerve fibers, blood vessels, sweat and sebaceous glands, and hair follicles.
Subcutaneous Tissue: composed of a fatty layer of skin. contains blood vessels, nerves, lymph, and loose connective tissue filled with fat cells.
Melanocytes (melanin): a pigment that gives the skin its color and protects form ultraviolet radiation.
Keratinocytes (keratin): waterproof layer of protein that gives it tough protective quality.
Protection: intact skin prevents invasion of the body of bacteria.
Thermoregulation: facilitates heat loss and cools and warms the body when necessary.
Perspiration: cools the body through evaporation also prevents perspiration to inhibit cooling.
Vasodilation: increase he blood supply to the skin surface facilitating in heat loss through radiation and conduction.
Vasoconstriction: decrease blood supply to prevent heat loss.
Intentional Wound: involves a wound that is the result of planned therapy
Unintentional Wound: involves a wound that is the result of unexpected trauma
Open Wound: involves a break in skin integrity or mucous membrane
Closed Wound: involves no break in skin integrity or mucous membrane
Superficial Wound: involves only the epidermal layer of skin
Penetrating Would: involves penetration of the epidermal and dermal layers of skin and deeper tissues or organs
Clean Wound: uninfected wounds in which the respiratory, gastrointestinal, genital, and/or urinary tracts are not entered
Clean/Contaminated Wound: uninfected wounds in which the respiratory, gastrointestinal, genital, and/or urinary tract have been entered
Contaminated Wound: open, traumatic or surgical wounds involving a major break in sterile technique
Infected Wound: old, traumatic wounds containing dead tissue and wounds with evidence of a clinical infection (e.g., purulent drainage)
Laceration: involves tearing apart of tissues resulting in irregular wound edges
Abrasion: Involves scraping or rubbing the surface of the skin by friction. Open wound involving skin
Contusion: Involves a blow from a blunt object resulting in a closed wound with swelling, discoloration, bruising, and/or eccymosis
Incision: Involves cutting the skin with a sharp instrument
Puncture: Involves penetration of the skin and, often, the underlying tissues by a sharp object, metal fragment of bullet
Pressure Ulcer: localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of: pressure or pressure in combination with shear and/or friction. Also known as “decubitis, pressure sores, bedsores”
Localized ischemia: deficiency in blood supply, areas deprives of O2 and nutrients = death
Reactive hyperemia: pressure relief – bright red flesh
Vasodilatation: extra blood flow to area
Friction: Force acting parallel to skin surface. Removes superficial layers – prone to breakdown
Shearing Force: Friction & pressure. Fowler’s position - sacrum
Pressure Ulcer Stages: First indication is blanching of the skin over the area under pressure.
Ischemia: make skin appear paler in the area where circulation is adequate
Hyperemia: when pressure is relieved, blanchable reddening of the skin when pressure is removed. Blood floods the area with blood to nourish and remove wastes form the cells.
Normal: skin appears healthy and well.
Suspected Deep Tissue Injury: (hard to suspect in pts with dark skin tones). Purple localized area of discolored intact skin/blood-filled blister: damage of underlying soft tissue from pressure/shear. Presents as painful, firm, mushy, boggy, warmer, or cooler area compared to adjacent tissue. Deep tissue injury.
Stage 1: Non blanchable erythema – potential ulceration. Intact skin with redness of localized are usually over a bony prominence.
Stage 2: Partial thickness loss of dermis presenting as shallow open or shiny ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. The ulcer is superficial presents as an abrasion or blister.
Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. May include undermining and tunneling. Involves damage or necrosis of subcutaneous tissue.
Stage 4: Full thickness tissue loss with exposed bone, tendon or muscle. Slough and eschar may be present on some parts of he sound bed. Often includes undermining and tunneling.
Unstageable: Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, green or brown) and/or eschar (tan, brown, black) in the wound bed.
A Stage 3 Pressure Ulcer: requires debridement through wet-to-dry dressings, surgical intervention, or proteolytic enzymes
Wound Healing by Primary Intention: Approximated (closed) skin edges, Minimal granulation tissue, Early suturing, Minimal scarring,Minimal tissue loss, Rapid healing, Minimal risk of infection
Wound Healing by Secondary Intention: Open skin edges (cannot approximate), Extensive granulation tissue, No suturing, Extensive scarring, Extensive tissue loss, Delayed healing, Extensive risk of infection
Wound Healing by Tertiary Intention: Open skin edges that are sutured later, Moderate granulation tissue, Delayed suturing, Moderate scarring, Moderate tissue loss, Delayed healing, Moderate risk of infection
Homeostasis: Occurs immediately after initial injury. Involved blood vessels constrict and blood clotting begins. Exudate is formed causing swelling and pain.
Homeostasis: cont Increased perfusion results in heat and redness. Platelets stimulate other cells to migrate to the injury to participate in other phases of healing.
Inflammatory Phase of Wound Healing: Initiated immediately after injury. Bleeding is controlled (hemostasis). Fibrin acts to start cellular repair. Histamine increases blood supply eukocytes ingest bacteria and debris, and macrophages (phagocytosis) clean the wound bed for healing.
Proliferative Phase of Wound Healing: Extends from day 2-4 to about 21 post-injury Connective tissue cells (fibroblasts) – migrate into wound in 24 hrs after injury & synthesize collagen Adds tensile strength to wound As collagen ↑’s wound strength ↑’s
Granulation: Capillaries grow across wound ↑ing blood supply. Fibroblast move from bloodstream into wound depositing fibrin. Capillary network develops – tissue becomes translucent red color – fragile and bleed easily.
Eschar: Dead Cells.
Maturation Phase of Wound Healing: Begins about day 21 up 1 to 2 yrs after injury. Fibroblasts continue to synthesize collagen. Scar becomes stronger. Repair area never as strong as original tissue.
Keloid: Hypertrophic scar. Abnormal amount of collagen laid down – dark skinned
In which one of the following phases of wound healing is new tissue built to fill the wound space, primarily through the action of fibroblast? Proliferation Phase.
Homeostasis: involved blood vessels constricts and blood clotting begins.
Inflammatory Phase: white blood cells move to the wound.
Maturation Phase: collagen is remodeled forming a scar.
Hemorrhage: Massive bleeding – slipped stitch, dislodged clot, erosion of blood. Internal hemorrhage - swelling/distension in area of wound. Hematoma – collection of blood underneath skin.
Fistula: caused by an abscess or infection where tissue layers do not close but tunnel into adjoining tissues
Infection: Indications are redness, warmth, swelling, pain, fever, increased WBC. Susceptible time of injury, during surgery, post-op.
Dehiscence: is the partial or total separation of wound layers as a result of excessive stress on wound that are not healed.
Evisceration: is the most serious complication of Dehiscence.
Exudate: Material such as fluid and cells that have escaped from blood vessels during inflammatory process. Deposited in tissue or on tissue surface.
Serous: watery and clear fluid.
Purulent: contains pus.
Serosanguineous: clear blood tinged.
Sanguineous (hemorrhagic): large amounts of blood.
Red: proliferative stage of healing- reflects color of normal granulation.
Yellow: characterized by oozing; needs to be cleansed.
Black: covered with thick eschar; requires debridement.
Color classification of open wounds: Red = Protect; Yellow = Clean; Black = Debride
Open system: Penrose drain soft and flexible without a collection device. It promotes drainage passively form the area of grater pressure in the wound or surgical incision.
Closed system: Jackson-Pratt drain Hemovac drain closed drainage: drainage tube that may be connected an electrical suction device or have a built in reservoir to maintain constant low suction.
Wound pouching: is a specialized pouch designed toerless and drain fistulas, wounds and it regular or multiple stomas.
Wound Dressings: *Administer analgesic 30 minutes prior to dressing change if it is uncomfortable* Provide physical, psychological, and aesthetic comfort. Remove necrotic tissue Prevent, eliminate, or control infection. Absorb drainage
Wound Dressings: cont Maintain a moist wound environment. Protect wound from further injury. Protect skin surrounding wound. Follow manufacturer’s guidelines for specific dressing.
Which one of the following wound complications is caused by over-hydration related to urinary and fecal incontinence? Maceration
Necrosis: dead tissue present in wound that delays healing.
Edema: swelling at a wound site that interferes with blood supply to the area.
Desiccation: process in which the cells dehydrate and die.
Created by: mr209368