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skin integrity overall status of skin.
factors that affect skin integrity for babies thin, fragile, diaper rash, lose heat quickly
factors that affect skin integrity for elders drier, reduced healing, loss of fat, changes in collagen, decreased elasticity
factors that affect skin integrity for people with mobility issues increases pressure on skin which decreases 02 to tissues
factors that affect skin integrity for people with impaired nutrition/hydration poor turgor (elasticity)
factors that affect skin integrity for people with diminished sensation lead to injury due to not feeling the pain or treating the wound.
factors that affect skin integrity for people on medications itches, rashes
factors that affect skin integrity for people with poor circulation effects tissue metabolism; arterial and venous
wound disruption in the normal integrity of the skin and the underlying tissues
wounds are assessed for... appearance, size, drainage, pain, sutures, drains, tubes, complications.
Classification of the wound is done by noting if it is 1______, 2_______, 3________. 1. open or closed 2. acute or chronic 3.clean, contaminated, infected 4. superficial or full thickness 5. is it penetrating
Pressure Ulcer - Stage I persistent red, blue or purple. No open wounds, blanching
Pressure Ulcer - Stage II partial thickness skin loss, presents as abrasion or blister
Pressure Ulcer - Stage III full thickness, crater
Pressure Ulcer - Stage IV full thickness, crater, exposed bone, tendon or muscle
3 phases of wound healing Inflammation Proliferative Maturation
Inflammation Phase Hemostasis and inflammation occur here. Fluids rush to site (edema) to contain infection. Clotting starts here as well.
Proliferation Phase Fibroblasts enter the wound, collagen synthesis occurs, new blood and lymph vessels form and epithelial proliferation and migration continue.
Maturation Phase Collagen fibers are remodeled, tensile strength increases, the wound begins to contract and the wound is "healed"
Three methods of wound healing Primary Secondary Tertiary
Primary Intention tissue properly closed with little tissue reaction, granulation tissue is not visible and scarring is minimal
Secondary Intention From infected wounds or in wounds whose edges have not been properly approximated. Tissue loss is experienced, wound heals from inside out. Usually packed with saline moistened dressings, covered in dry cloth.
Tertiary Intention Deep wounds that have not been sutured early or who have needed resuturing. Deep, wide scar results.
Serous exudates straw colored drainage
sanguineous bloody drainage
serosanguineous mix of bloody and straw colored
purulent yellow, contains pus
Major complications of wound healing Hemorrhage-concealed bleeding beneath skin Infection - wound sepsis Dehiscence - separation of wound edges Evisceration - protrusion of wound contents Fistula formation - abnormal passageway
Factors involved in pressure ulcers Immobility Impaired sensory perception Decreased tissue perfusion Decreased nutritional status Friction/Shear Increased moisture Age-related skin changes
Braden and Norton scales See page 186 Smelzer
Norton Scale assesses 5 things on a scale of ____ to ____ physical condition mental state activity mobility incontinence scale of 1-4
Created by: Marshall3