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Kozier Chapter 36

Skin Integrity and Wound Care

QuestionAnswer
EPIDERMIS Outermost cell layer of skin
DERMIS middle layer of skin beneath epidermis, composed of CT, Blood and Lymph vessels, sweat glands, hair follicles
SUBCUTANEOUS TISSUE or Hyypodermis-3rd layer, contain fat
Intentional Wounds occur during therapy. Ie operation, venipuncture
Unintentional Wounds accidentals
Incision sharp instrument, Open wound, deep or swallow
Contusion blow from a blunt instrument, Closed wound, skin appears ecchymotic, bruised because of damage blood vessels
Abrasion Surface scrape, either unintentional or intentional-Open wound involving the skin
Puncture penetration of the skin and often the underlying tissues by a sharp instrument, either intentional or unintentional-Open wound
Laceration Tissue torn apart, often from accident-Open wound; edges are often jagged
Penetrating Wound Penetration of the skin and the underlying tissues, usually unintentional –Open wound
Clean are uninfected wounds there is minimal inflammation and respiratory , GI, genital, and urinary tracts are not entered. Primarily closed wounds.
Clean-Contaminated surgical wounds in which respiratory, GI, genital, or urinary tract has entered. Such wounds show no evidence of infection
Contaminated wounds include open-fresh accidental wounds and surgical wounds involving a major break in sterile technique or a large amt of spillage from GI. Contaminated wounds show evidence of inflammation
Dirty/infected wounds include wounds containing dead tissue and wounds with evidence of a clinical infection, such as purulent drainage.
Partial-Thickness confined to the skin-dermis and epidermis
Full-thickness involving the dermis, epidermis, subcutaneous tissue, possibly muscle and bone; require CT repair
Ischemia deficiency in blood supply to tissue. Tissue is compressed bw 2 surfaces, surface of the bed and bony skeleton
Created by: moxleyjulene