Nursing fundamental skin integretity
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| Functions of the Skin | Protection,Body temperature regulation,,Psychosocial,Sensation
Vitamin D production,Immunological,Absorption,Elimination
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| Factors Affecting the Skin | Unbroken and healthy skin and mucous membranes defend against harmful agents and Resistance to injury is affected by age, amount of underlying tissues, and illness.
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| Factors Affecting the Skin Continued | Adequately nourished and hydrated body cells are resistant to injury and Adequate circulation is necessary to maintain cell life.
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| Developmental Considerations | Infant’s skin and mucous membranes are easily injured and subject to infection. A child’s skin becomes increasingly resistant to injury and infection. The structure of the skin changes as a person ages.
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| Developmental Considerations | The maturation of epidermal cells is prolonged, leading to thin, easily damaged skin.
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| Causes of Skin Alterations | Very thin and very obese people are more susceptible to skin injury Fluid loss during illness causes dehydration and Skin appears loose and flabby.
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| Other Causes of Skin Alterations | Excessive perspiration during illness predisposes skin to breakdown. Jaundice causes yellowish, itchy skin. Diseases of the skin cause lesions that require care
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| Types of Wounds | Intentional or unintentional,Open or closed,Acute or chronic
Partial thickness, full thickness, complex
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| What is the first line of defense against microroganism? | Intact Skin
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| Type of Asepsis in wound healing | surgical sespsis
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| Wound Healing | The body responds systematically to trauma of any of its parts.
An adequate blood supply is essential for normal body response to injury. Normal healing is promoted when wound is free of foreign material.
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| Principles of Wound Healing (cont.) | The extent of damage and the person’s state of health affect wound healing.
Response to wound is more effective if proper nutrition is maintained.
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| Wounding healing in Inflammatory Phase | Begins at time of injury. Body prepares wound for healing
through Hemostasis (blood clotting) occurs
Vascular and cellular phase of inflammation
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| What is Hemostasis of wound healing | Occurs immediately after initial injury. It Involved blood vessels constrict and blood clotting begins. Exudate is formed causing swelling and pain. Increased perfusion results in heat and redness
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| Hemostasis continued | Platelets stimulate other cells to migrate to the injury to participate in other participate in other phases of healings.
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| Inflammatory Phase | Follows hemostasis and lasts about 4 to 6 days. WBCs move to the wound. Macrophages enter wound area and remain for extended period.They ingest debris and release growth factors that attract fibroblasts to fill in wound.
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| proliferaton phase | start 2-3 days from wound and continues up to 2-3 weeks. Capillaries grow across wound.
A thin layer of epithelial cells forms across wound Granulation tissue forms a foundation for scar tissue development.
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| Maturation Phase | 3 weeks to 6 months after injury.Collagen is remodeled.
New collagen tissue is deposited.
Scar becomes a flat, thin, white line.
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| Factors Affecting Wound Healing | Age—child & healthy ads heal more rapidly
good Circulation and oxygenatin. adequate Nutritional status.Wound condition—specific condition of wound affects healing
Health status—corticosteroid drugs and postoperative radiation therapy delay healing
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| Wound Complications | Infection,Hemorrhage,Dehiscence and evisceration,Fistula formation
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| Hemorrhage | bleeding
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| Dehiscence | wound opened up
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| evisceration | wound open and organs poped up
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| Fistula formation | organ next to skin and goes outside
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| 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
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| Mechanisms in Pressure Ulcer Development | External pressure compressing blood vessels
and Friction or shearing forces tearing or injuring blood vessels
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| Stage I of pressure ulcers | —non-blanchable erythema of intact skin
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| Stage II of pressure ulcers | II—partial-thickness skin loss
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| Stage III of pressure ulcers | full-thickness skin loss; not involving underlying fascia
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| Stage IV of pressure ulcers | —full-thickness skin loss with extensive destruction
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| Unstageable of pressure ulcers | —base of ulcer covered by slough and or eschar in wound bed
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| Measurement of a Pressure Ulcer | Size of wound,Depth of wound,Presence of undermining, tunneling, or sinus tract
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| Cleaning a Pressure Ulcer | Clean with each dressing change, Use careful, gentle motions to minimize trauma. Use 0.9% normal saline solution to irrigate and clean the ulcer.
Report any drainage or necrotic tissue.
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| Wound Assessment | Inspection for sight and smell. THen Palpation for appearance, drainage, and pain
Sutures, drains or tube, and manifestation of complications
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| Presence of Infection | Wound is swollen,deep red in color,feels hot on palpation,Drainage is increased and possibly purulent. Foul odor may be noted.
Wound edges may be separated with dehiscence present
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| Purposes of Wound Dressings | Provide physical, psychological, and aesthetic comfort.
Remove necrotic tissue and prevent, eliminate, or control infection. Absorb drainage and Maintain a moist wound environment. Protect wound from further injury and Protect skin surrounding wound.
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