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Nursing

Skin Integrity and Wound Healing

QuestionAnswer
Skin layers Epidermis (outer), dermis, subcutaneous tissue
Skin appendages Hair, nails, sweat glands, sebaceous glands
Functions of the skin: protection Intact skin- protects against physical and chemical injury. Melanin- protects against sun's ultraviolet rays. Sebum- acidic ph, retards microbial growth. Skin flora- inhibits growth of pathogens.
Functions of the skin: metabolism Skin synthesizes Vit D from sun
Functions of the skin: Thermoregulation dilation and constriction of blood vessels, vasoconstriction causes shivering which warms, sweating cools the body via evaporation
Functions of the skin: Sensation Sensitivity to pain, heat, and cold prevents injury
Functions of the skin: Communication Facial expression and physical appearance
Characteristics of normal skin Color, temperature, moisture, texture and thickness, odor, turgor (hydration status)
Factors affecting Integumentary Function Circulation, nutrition, condition of epidermis, allergy, infections, abnormal growth rate, systemic diseases, burns
Mechanical forces affecting integumentary function Friction: skin rubbing against firm surface. Shear: layers of tissue rub together. Pressure. Abrasion: skin rubs against hard surface. Laceration: open wound/cut usually involved with knives. Puncture wound: sharp, pointed object goes thru tissue
Pressure Ulcers Pressure intensity blanching: turns lighter in color. Pressure duration. Tissue tolerance.
Risks for Pressure Ulcers Sensory impairment, impaired mobility, alteration in LOC, shear and friction, moisture
Stage I Pressure Ulcer Persistent red, blue or purple tones; no open skins area.
Stage II Pressure Ulcer Partial-thickness skin loss; presents as an abrasion or blister.
Stage III Pressure Ulcer Full-thickness skin loss with damage or necrosis of subq tissue; presents as a deep crater
Stage IV Pressure Ulcer Full-thickness skin loss with extensive destruction; necrosis or damage to muscle, bone, or other structures.
Unstageable Pressure Ulcer Full-thickness loss covered by slough or eschal
Manifestations of altered integumentary function Pain, pruritus: itching, rash: characteristics, distribution, lesions
Hemostasis Stage of Wound Healing Vasoconstriction and clot formation
Inflammatory Stage of Wound Healing Vasodilation and phagocytosis. Localized redness, edema and pain. Up to 3 days.
Proliferative Phase of Wound Healing 3-24 days. Wound fills in with granulation tissue. Collagen mixes with granulation tissue and supports re-epithelialization.
Maturation Phase of Wound Healing Up to 2 years depending on extent of wound. Collagen scar continues to gain strength for several months.
Primary Wound Healing Describes a wound closed by approximation of wound margins or by placement of a graft or flap, or wounds created and closed in the operating room.
Secondary Wound Healing Describes a wound left open and allowed to close by epithelialization and contraction
Tertiary Wound Healing Useful for managing wounds too heavily contaminated for primary closure but appear clean & well vascularized after 4-5 days of open observation. Over this time, the inflammatory process has reduced bacterial concentration of wound to allow safe closure
Individual Factors affecting wound healing Age, obesity, smoking, medications, stress
Systemic Factors affecting wound healing Nutrition and fluids: Protein/albumin, Vit A & C, Zinc. Circulation and oxygenation: DM and shock. Immune cellular function.
Local Factors affecting wound healing Nature of the injury. Presence of infection. Local wound environment.
Complications of Wound Healing Hemorrhage, interstitial fluid loss, hematomas, infection, fistula- an abnormal connection b/w an organ and vessel, dehiscence- splitting of wound, evisceration- organ outside of body
Five cardinal signs of localized injury/infection 1. Redness 2. Heat- increased blood 3. Edema- fluid and cells accumulate 4. Pain- from change in ph, chemicals, swelling 5. Altered function
Subjective Data Normal skin status, hx of skin problems, injuries, wounds, risk identification: infections, pressure ulcer risks
Objective Data Physical exam: inspection of skin- color, temp, turgor, odor, and integrity. Diagnostic tests and procedures. Nutritional status.
Wound Assessment Type, location, size. Traumatic or stable. Character of drainage. Closure-staples and sutures. Palpation of wounds
Nursing diagnosis Impaired skin integrity, impaired tissue integrity, risk for impaired skin integrity, risk for infection, imbalanced nutrition: less than body requirements, pain
Implementation Health promotion, Prevention of pressure ulcers: positioning and skin care, use of pressure reducing surfaces. Pt teaching: hygiene, protection from sun, pressure ulcer prevention.
Implementation: Acute Care Prevent and manage wounds. Remove nonviable tissue, manage wound exudate, protect wounds (dressing), monitor lab values, nutritional support, teach pt appropriate wound care.
Created by: senmark