integumentary
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| Skin | is the largest organ of the body
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| Epidermis | is the top layer,composed of stratified epithelial cells
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| Dermis | is the second layer, consists of a framework of elastic connective tissue. Nerves, hair follicles, and blood vessels are located in this layer
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| subcutaneous tissue layer | lies under the dermis and is a heat insulator for the body.
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| Functions of the Skin | protection, temperature regulation, psychosocial, sensation, vitamin D production, immunological, absorption, and elmination (water and electrolyte balance).
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| 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.
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| Mucous membranes | are insensitive to temperature, except the mouth and rectum, but are sensitive to pressure.
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| Factor that Affects Skin Integrity | unbroken and unhealthy skin and mucous membrane
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| Factor that Affects Skin Integrity | Resistance to injury of the skin andmucous membranes vaires among people
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| Factor that Affects Skin Integrity | Adequately nourished and hydrated body cells are resistant to injury
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| Factor that Affects Skin Integrity | Adequate ciruclation is necessary to maintain cell life.
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| Developmental Considerations | In young children the skin is thinner and weaker than it is in adults
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| Developmental Considerations | an infants skin andmucous membranes are easily injured and subject to infection.
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| 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
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| State of Health | very thin and obese people tend to be more susceptible to skin irritations and injury
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| State of Health | fluid loss through fever, vomiting, or diarrhea reduces the fluid volume of the body
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| State of Health | Excessive perspiration is often associated with being ill. predisposes for breakdown in the skin folds.
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| State of Health | jaundice a condition cause by excessive bilew pigments in the skin, result in yellowish skin color.
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| State of Health | Diseases of the skin such as eczema and psoriasis have genetic predisposition and often cause lesions that require special care
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| pruritus | Itching
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| Wound | a break or disruption in the normal integrity of skin and tissues
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| Intentional Wounds | result of planned invasice therapy and treatment. Wound edges are clean and bleeding in controlled, the risk for infection is decreased
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| Unintentional Wounds | are accidental trauma, (stabbing, gunshot and burns)wound edges are jagged, multiple trauma and bleeding is uncontrolled. High risk for infection
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| Open Wound | the skin surface is broken, providing portal of entry for microorhanisms. -delayed healing process
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| 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
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| Acute Wound | Ex.Surgical incisionm usually heal within days or weeks. The edges are well approximated and less risk of infection
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| Chronic Wound | wound edges are often not approximated, risk for infection is increased, and normal healing time is delayed. Remain in the inflammatory phase
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| Echymosis | bruising
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| Primary or First intention healing | Ex. surgical incision with minimal tissue loss
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| Secondary Intention | have edges that are not well approximated.Ex. large open wound
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| a primary intention that becomes infected will heal by | secondary intention
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| 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
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| Granulation Tissue | highly vascular, red, and bleeds easily
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| Phases of Wound Healing | Hemostasis, Inflammatory, Proliferation, and Maturation
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| Hemostatsis | occurs initially after injury, blood vessels constrict and clotting begins.Then blood vessels dialate and plasma and blood components leak into injured area
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| Exudate | liquid formed at the injured site from blood components and plasma
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| Swelling | the accumulation of exudate, increased perfusion cause heat and redness
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| 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
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| Proliferation, (fibroblastic, regenerative, or connective tissue Stage | last for several weeks, capillaries grow bringing oxygena and nutrients to wound
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| Maturation Phase | Final stage begins about 3 weeks after the injury. Collagen is remodeled making the healed wound stronger and a scar is formed
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| Scar | an avascular collagen tissue that does not seat grow hair or tan in sunlight, it eventually becomes flat, thin line.
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| Systemic Factors Affecting Wound Healing | Age, circulation, nutritional status, wound condition, health status
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| Local factors Affecting wound healing | Desiccation-dehydration, Maceration-overhydration,Trauma, Edema, Infection,slough, necrosis(eschar)
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| Wound complication | infection can occur as a result of nosocomial infections. symptoms appear within 2-7 days after injury occured.
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| Symptoms of infection | purulent drainage, pain, redness, and swelling in and around the wound, increased body temp and increased WBC's
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| Osteomyelitis | bone infection
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| Sepsis | prescence of pathogenic organisms in the blood or tissues
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| 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
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| 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.
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| Fistula Formation | Fistula is an abnormal passage from an internal organ to the outside of the body or from one internal organ to another
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| Psychological Effects of Wounds | Pain, anxiety and fear,& changes in body image
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| Pressure ulcer | is a wound with a localized area of tissue necrosis.
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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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| 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
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| Common Sites of Pressure ulcers | Sacrum,Heel (Adult), Coccyx, Hips, Shoulder, occiput(children), Ears,
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| Friction/ Shearing | tearing or compressing of blood vessels
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| Satges of Pressure ulcers | Stage 1- nonblanchable erythema of intact skin stage-2 partial thickness, skin loss, shallow crater, involves epidermis, dermis or both
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| 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
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| Stage 1 intervention | Apply soft foam pad to cover and protect, turn Q1-2 hours, DO NOT MASSAGE, most common on heels
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| 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
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| Stage 3 intervention | Debridement, mechanical (wet to dry), surgical, autolytic, chemical (enzymatgic), and biological (Maggot therapy) therapys
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| Sateg 4 intervention | debridement, mechanical (wet to dry), surgical, autolytic, chemical, biological
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| 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
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| Deep Tissue Injury (DTI) | skin is intact, ishemic tissue injury that develops due to pressure and shear
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| Unstagable ulcer | document what you see
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| Healed ulcers | Stage 3 and 4 will only reach 70% tensile strength (elasticity) once healed, pt continues to be high risk
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| Measurment of an Ulcer | lenth x width x depth
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| 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
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| Serous | clear
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| Sangous | bloody
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| purulent | pus, yellow
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| serosanguous | pink cloudy
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| 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
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| Red Open wound | Healing, normal granulation
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| Yellow open wound | oozing, needs to be cleansed
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| Black Open Wound | covered with eschar, requires debridement
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| Mixed open wound | contains all colors
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| Common Diagnosis of Wound Patient | impaired skin integrity, risk for infection, impaired tissue integrity, ineffective tissue perfussion:peripheral Ex. Diabetic Neuropathy
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