integumentary
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| Skin | show 🗑
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| show | is the top layer,composed of stratified epithelial cells
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| Dermis | show 🗑
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| subcutaneous tissue layer | show 🗑
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| show | protection, temperature regulation, psychosocial, sensation, vitamin D production, immunological, absorption, and elmination (water and electrolyte balance).
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| Mucous membranes | show 🗑
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| Mucous membranes | show 🗑
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| Factor that Affects Skin Integrity | show 🗑
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| show | Resistance to injury of the skin andmucous membranes vaires among people
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| show | Adequately nourished and hydrated body cells are resistant to injury
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| show | Adequate ciruclation is necessary to maintain cell life.
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| show | In young children the skin is thinner and weaker than it is in adults
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| show | an infants skin andmucous membranes are easily injured and subject to infection.
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| Developmental Considerations | show 🗑
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| show | very thin and obese people tend to be more susceptible to skin irritations and injury
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| show | fluid loss through fever, vomiting, or diarrhea reduces the fluid volume of the body
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| State of Health | show 🗑
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| State of Health | show 🗑
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| State of Health | show 🗑
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| pruritus | show 🗑
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| Wound | show 🗑
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| Intentional Wounds | show 🗑
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| show | 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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| show | the skin surface is broken, providing portal of entry for microorhanisms. -delayed healing process
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| show | 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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| show | Ex.Surgical incisionm usually heal within days or weeks. The edges are well approximated and less risk of infection
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| show | 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 | show 🗑
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| show | Ex. surgical incision with minimal tissue loss
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| Secondary Intention | show 🗑
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| show | secondary intention
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| Tertiary intention or delayed primary | show 🗑
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| show | highly vascular, red, and bleeds easily
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| Phases of Wound Healing | show 🗑
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| show | 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 | show 🗑
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| show | the accumulation of exudate, increased perfusion cause heat and redness
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| Inflammatory Stage | show 🗑
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| Proliferation, (fibroblastic, regenerative, or connective tissue Stage | show 🗑
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| show | 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 | show 🗑
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| show | Age, circulation, nutritional status, wound condition, health status
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| Local factors Affecting wound healing | show 🗑
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| Wound complication | show 🗑
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| Symptoms of infection | show 🗑
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| Osteomyelitis | show 🗑
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| Sepsis | show 🗑
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| Hemmorrhage | show 🗑
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| Dehiscence and evisceration | show 🗑
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| Fistula Formation | show 🗑
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| Psychological Effects of Wounds | show 🗑
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| Pressure ulcer | show 🗑
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| show | 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 | show 🗑
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| Common Sites of Pressure ulcers | show 🗑
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| Friction/ Shearing | show 🗑
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| Satges of Pressure ulcers | show 🗑
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| Satges of Pressure Ulcers | show 🗑
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| show | Apply soft foam pad to cover and protect, turn Q1-2 hours, DO NOT MASSAGE, most common on heels
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| show | 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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| show | Debridement, mechanical (wet to dry), surgical, autolytic, chemical (enzymatgic), and biological (Maggot therapy) therapys
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| show | debridement, mechanical (wet to dry), surgical, autolytic, chemical, biological
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| Intrinsic Factors | show 🗑
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| show | skin is intact, ishemic tissue injury that develops due to pressure and shear
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| show | document what you see
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| show | 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 | show 🗑
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| show | 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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| show | clear
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| Sangous | show 🗑
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| purulent | show 🗑
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| serosanguous | show 🗑
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| Purpose of Wound Dressings | show 🗑
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| show | Healing, normal granulation
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| show | oozing, needs to be cleansed
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| Black Open Wound | show 🗑
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| show | contains all colors
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| Common Diagnosis of Wound Patient | show 🗑
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