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Skin is the largest organ of the body
Epidermis is the top layer,composed of stratified epithelial cells
Dermis is the second layer, consists of a framework of elastic connective tissue. Nerves, hair follicles, and blood vessels are located in this layer
subcutaneous tissue layer lies under the dermis and is a heat insulator for the body.
Functions of the Skin protection, temperature regulation, psychosocial, sensation, vitamin D production, immunological, absorption, and elmination (water and electrolyte balance).
Mucous membranes line the cavities that open to the outside of the body,joining the skin.They can be found in dsigestive tract and respiratory passages.
Mucous membranes are insensitive to temperature, except the mouth and rectum, but are sensitive to pressure.
Factor that Affects Skin Integrity unbroken and unhealthy skin and mucous membrane
Factor that Affects Skin Integrity Resistance to injury of the skin andmucous membranes vaires among people
Factor that Affects Skin Integrity Adequately nourished and hydrated body cells are resistant to injury
Factor that Affects Skin Integrity Adequate ciruclation is necessary to maintain cell life.
Developmental Considerations In young children the skin is thinner and weaker than it is in adults
Developmental Considerations an infants skin andmucous membranes are easily injured and subject to infection.
Developmental Considerations The structure of the skin changes as the person ages.The maturation of epidermal cells is prolonged, leading to thin, easily damaged skin.Circulation and collagen formation are impaired leading to decreased elasticiity & increased risk for pressure ulcer
State of Health very thin and obese people tend to be more susceptible to skin irritations and injury
State of Health fluid loss through fever, vomiting, or diarrhea reduces the fluid volume of the body
State of Health Excessive perspiration is often associated with being ill. predisposes for breakdown in the skin folds.
State of Health jaundice a condition cause by excessive bilew pigments in the skin, result in yellowish skin color.
State of Health Diseases of the skin such as eczema and psoriasis have genetic predisposition and often cause lesions that require special care
pruritus Itching
Wound a break or disruption in the normal integrity of skin and tissues
Intentional Wounds result of planned invasice therapy and treatment. Wound edges are clean and bleeding in controlled, the risk for infection is decreased
Unintentional Wounds are accidental trauma, (stabbing, gunshot and burns)wound edges are jagged, multiple trauma and bleeding is uncontrolled. High risk for infection
Open Wound the skin surface is broken, providing portal of entry for microorhanisms. -delayed healing process
Closed Wound results from a blow, force, or straind cause by trauma such as a fall, assault, or accident. Skin surface is not broken but soft tissue is damaged.Ex. Hematoma
Acute Wound Ex.Surgical incisionm usually heal within days or weeks. The edges are well approximated and less risk of infection
Chronic Wound wound edges are often not approximated, risk for infection is increased, and normal healing time is delayed. Remain in the inflammatory phase
Echymosis bruising
Primary or First intention healing Ex. surgical incision with minimal tissue loss
Secondary Intention have edges that are not well approximated.Ex. large open wound
a primary intention that becomes infected will heal by secondary intention
Tertiary intention or delayed primary are wounds that are left open for days to allow dedema or infection to resolve or exudate to drain, then closed
Granulation Tissue highly vascular, red, and bleeds easily
Phases of Wound Healing Hemostasis, Inflammatory, Proliferation, and Maturation
Hemostatsis occurs initially after injury, blood vessels constrict and clotting begins.Then blood vessels dialate and plasma and blood components leak into injured area
Exudate liquid formed at the injured site from blood components and plasma
Swelling the accumulation of exudate, increased perfusion cause heat and redness
Inflammatory Stage last about 4-6 days, WBC's and macrophages move to the injured site.WBC's ingest bacteria, Macrophages ingest debris and release growth factors. Pt has elevated temp & increased WBC's & general malaise
Proliferation, (fibroblastic, regenerative, or connective tissue Stage last for several weeks, capillaries grow bringing oxygena and nutrients to wound
Maturation Phase Final stage begins about 3 weeks after the injury. Collagen is remodeled making the healed wound stronger and a scar is formed
Scar an avascular collagen tissue that does not seat grow hair or tan in sunlight, it eventually becomes flat, thin line.
Systemic Factors Affecting Wound Healing Age, circulation, nutritional status, wound condition, health status
Local factors Affecting wound healing Desiccation-dehydration, Maceration-overhydration,Trauma, Edema, Infection,slough, necrosis(eschar)
Wound complication infection can occur as a result of nosocomial infections. symptoms appear within 2-7 days after injury occured.
Symptoms of infection purulent drainage, pain, redness, and swelling in and around the wound, increased body temp and increased WBC's
Osteomyelitis bone infection
Sepsis prescence of pathogenic organisms in the blood or tissues
Hemmorrhage can result from slipped suture, or a dislodged clot, infection, erosion of the blood vessel by a foreign body. Wound & dressing must be checked 48 hr after surgery and 8 thereafter
Dehiscence and evisceration dehiscence- the partial or total separration of wound layers as a result of excessive stress on wound that are not yet healed. Evisceration- is the most serious complication of dehiscence.
Fistula Formation Fistula is an abnormal passage from an internal organ to the outside of the body or from one internal organ to another
Psychological Effects of Wounds Pain, anxiety and fear,& changes in body image
Pressure ulcer is a wound with a localized area of tissue necrosis.
Factors Affecting Pressure ulcer Development Aging skin, chronic illnesses, immobility, malnutrition, fecal and urinary incontinence, altered level of consciousness, spinal cord and brain injuries, neuromuscular disorders
Extrinsic Factors of Pressure ulcers Crumbs in the bed/chair, pressure from Iv monitor, soiled or wet bed/clothes, poor hygiene/perspirations, irritant, and friction
Common Sites of Pressure ulcers Sacrum,Heel (Adult), Coccyx, Hips, Shoulder, occiput(children), Ears,
Friction/ Shearing tearing or compressing of blood vessels
Satges of Pressure ulcers Stage 1- nonblanchable erythema of intact skin stage-2 partial thickness, skin loss, shallow crater, involves epidermis, dermis or both
Satges of Pressure Ulcers Stage-3 full thickness, skin loss, NOT involving underlying fasciaStage 4- full thickness skin loss with extensice destruction of underlying fascia
Stage 1 intervention Apply soft foam pad to cover and protect, turn Q1-2 hours, DO NOT MASSAGE, most common on heels
Stage 2 intervention Reduce pressure, protect skin, maintain moist wound bed, minimal to moderate absorbant dressing, such as foam, tegaderm, hydrocolloid, monitor drainage and adequate hydration
Stage 3 intervention Debridement, mechanical (wet to dry), surgical, autolytic, chemical (enzymatgic), and biological (Maggot therapy) therapys
Sateg 4 intervention debridement, mechanical (wet to dry), surgical, autolytic, chemical, biological
Intrinsic Factors Spinal cord injury, poor nutrition, use of steroids, low systemic BP, low serum protein level (albumin), smoking, low hemoglobin, and vascualr disease and diabetes
Deep Tissue Injury (DTI) skin is intact, ishemic tissue injury that develops due to pressure and shear
Unstagable ulcer document what you see
Healed ulcers Stage 3 and 4 will only reach 70% tensile strength (elasticity) once healed, pt continues to be high risk
Measurment of an Ulcer lenth x width x depth
Prevention reposition Q 2hours, maintain 30 degress tilt from supine when turning, limit head of bed to 30 degrees or less, use ROM with para and quadraplegics, maintain fluid intake 30ml/kg/day, keep bed dry
Serous clear
Sangous bloody
purulent pus, yellow
serosanguous pink cloudy
Purpose of Wound Dressings provide physical and psychological comfort, remove necrotic tissue, prevent, eleminate, and control infection, absorb drainage, maintain moist wound environment, protect from injury, protect skin
Red Open wound Healing, normal granulation
Yellow open wound oozing, needs to be cleansed
Black Open Wound covered with eschar, requires debridement
Mixed open wound contains all colors
Common Diagnosis of Wound Patient impaired skin integrity, risk for infection, impaired tissue integrity, ineffective tissue perfussion:peripheral Ex. Diabetic Neuropathy
Created by: agoin182