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35 Cards in this Set

  • Front
  • Back
Epidermis
-Largely protective function: pathogen entry, injury
-Prevents moisture loss
-Assists with fluid and electrolyte balance
-Assists with thermoregulation
-Harbours normal flora
Dermis
-Thicker layer - supportive and protective function
-Nerve fibres - sensory function
-Blood vessels – assists with thermoregulation and fluid balance , nourishes tissues
-Growth factors for epidermal regulation and dermal repair
Subcutaneous Tissue
-Connective and fat tissue – supportive and protective function
-Fat provides heat insulation for body
-Blood vessels, nerves, lymph tissues
Functions of skin
-Protection
-Sensation
-Thermoregulation
-Growth and repair
-Fluid and Electrolyte balance
Factors Affecting Skin & Tissue Integrity. 8
1. Age
2. Environment
3. Nutritional Status
4. Excercise
5. Personal Hygeine
6.Socioeconomic/sociocultural status
7. Knowledge
8. Health Status
Risk Factors for Skin/Tissue Impairment (P&P, 2006, p. 1020, Box 34-2)
-Immobilization
-Decreased Sensation
-Nutrition and Hydration Impairment
-Secretions and Excretions on the Skin
-Vascular Insufficiency
-External Devices
Factors in Assessing Skin and Tissue Integrity
-Skin & tissue history
-Skin & tissue examination
- mouth, hair, skin
- lesions: distribution, size,shape,color, configuraton
-diagnostic tests
-self care ability
-risk for impairment
MANAGEMENT OF SKIN & TISSUE INTEGRITY
-Planning for optimal skin & tissue integrity
-Implementation
-Evaluation
Restorative Care General Guidelines
-Encourage independence
-Consider client routine
-Select least restrictive modification
-Maintain privacy, comfort, safety
-Ensure medical asepsis
-Apply principles of body mechanics
Rehabilitative Care
Supporting adaptation to chronic conditions
-Self image
-Listening, encourage expression of feelings
-Acceptance
-Referrals prn
-Home care, teaching
Types of Wound Healing
1)Primary Intention (Healing by regeneration)
-Edges of wound are close together, with little or no tissue loss eg. surgical incision
-May be brought together with sutures, staples, clips, or adhesive strips
-Healing takes place quickly, by connective tissue deposition and epithelialization
-Heals quickly, minimal scarring
Types of Wound Healing
2)Secondary Intention (Healing by scar formation)
-Tissue loss is present, edges cannot be brought together eg. pressure ulcer, trauma wound, burn
-Must heal by granulation tissue formation and contraction of wound edges
Phases of Wound Healing
1)Inflammatory Phase (Day 1 – 3)
-Hemostasis >> control of bleeding
-Establishment of clean wound bed by: Influx of WBC’s (neutrophils, macrophages)
-Macrophages release growth factors that attract fibroblasts (synthesize collagen)

2)Proliferative Phase (Day 3 – 24)
-Granulation >> fills wound in
-Angiogenesis >> New capillary growth induced as granulation requires rich blood supply
-Contraction >> brings edges together
-Epithelialization >> resurfaces wound

3)Remodelling Phase (Months)
-Takes place over months to years
-Formation of collagen scar tissue
Factors that Impair Wound Healing
-Infection
-Malnutrition
-Age
-Obesity
-Impaired Oxygenation
-Smoking
-Drugs
-Vascular diseases
-Radiation
-Wound Stress
Pressure ulcer
area of tissue necrosis that develops due to compression of soft tissue between bone and external surface
6 Subscales of the Braden Scale
-Sensory Perception
-Moisture
-Activity
-Mobility
-Nutrition
-Friction & Shear
B. Best Practice: Ways to Manage Pressure
-Education
-Inspection
-Positioning devices
Turning/Positioning/Repositioning:
-Documentation
C. Best Practice: Friction/Shear Reduction
-Education
-Reduce friction injuries by:
-Use of lubricants, protective films, dressings, paddings
-Use of slider sheets, draw sheets for turning and repositioning
-Do not raise head of bed more than 30° except for meals and for 1 hour post meals
-If left with head raised, knees should be slightly flexed to prevent sliding of back and sacral area

-Proper use of TLR
-Consult to OT, PT
-Documentation
Stage 1 Ulcer
-Persistent redness of skin surface, usually over bony prominence
-Skin is unbroken
-Injury is to epidermis
-“Non-blanching erythema”: redness does not blanch when pressure applied, or lasts more than 30 minutes after pressure removed
-May have changes: skin warm or cool, sensation of pain or itching
Stage 1 Ulcer Treatment
-Goal is to prevent progression!
-RELIEVE PRESSURE – protective devices
-Assess and identify cause
-Avoid more exposure to cause of injury (eg. Good TLR, T & P)
-Use 30 degree lateral position in bed
-Protect from friction – Apply dressing
-Limit sitting
-Manage moisture
-Ensure adequate nutrition and hydration
-DO NOT MASSAGE RED AREA
Stage 2 Ulcer
-Epidermis is broken
-“Partial thickness” damage to dermis
-Appears as a shallow, open ulcer with red/pink wound bed
-Or – as an intact or ruptured blister
-No slough
Stage 2 Ulcer Treatment
-Goals: To keep clean, cover and protect area, prevent infection, prevent progression
-Protective dressings used (eg. Opsite, Allevyn)
-Some dressings designed to absorb as well
-Skin lotions to hydrate surrounding skin
-RELIEVE PRESSURE: protective devices
Stage 3 Ulcer
-“Full-thickness” injury: completely through dermis
-Damage or necrosis to depth of subcutaneous tissue – may see fat
-Crater-like ulcer, not usually painful
-May be slough, undermining or tunneling
Stage 3 Ulcer Treatment
-Wound irrigation needed
-Goals: To keep clean, cover and protect area, prevent infection, prevent progression
-Dressings and tx as per physician’s order or WCN
-Relieve pressure and protect surrounding tissues
-Increased emphasis on nutrition: may consult dietician
-Monitor for infection
-May need AB’s – not always successful
-Eclipse bed
Stage 4 Ulcer
-Extends through subcutaneous tissue to underlying structures: muscle, bone, tendons, fascia
-If infected, can lead to septicemia, osteomylitis
-Often presence of dead tissue, eschar
Stage 4 Ulcer Treatment
-Irrigation
-Cover and protect the wound
-Dressings and tx as per physician’s orders
-Relieve pressure and protect surrounding tissues
-Nutrition and hydration NB
AB’s as ordered
-Surgery often needed to remove dead tissue: “debridement”
-Eclipse bed
Debridement. 5
Removal of dead tissue to remove infection,visualize wound bed, and provide clean base for healing:
-Autolytic - dressings
-Mechanical – wound irrigation
-Surgical/Sharp
-Enzymatic
-Biological – Maggot therapy
Preventative Measures in Pressure Wound Development
-Identify high risk patients
-Eliminate pressures
-Use protective devices
-Avoid shearing forces
-Manage moisture
-Promote circulation
-Reduce friction
-Prevent skin irritation
-Maintain nutritional status
Treatment of Pressure Ulcers
-ALL MEASURES TO RELIEVE PRESSURE AND PROTECT AREA
-Keep area clean
-Removal of necrotic tissue to prevent infection
-Use of antibiotics if indicated
-Surgical debridement prn
-Skin grafting
-Amputation if gangrenous
-Nutritional measures
-Dressing changes as appropriate for wound
SHR Dressings- Liquid Skin Barriers
-Provide protection to skin surrounding a wound or on small skin tears
-Increase adhesion of dressing
-Skin Prep – use on intact skin only; contains alcohol so don’t want to use on broken skin
-3M Spray – use if surrounding skin is broken
SHR Dressings-Hydrocolloids
-Duoderm/Duoderm Thin
-Made of an adhesive, gumlike material (eg. Karaya or pectin) with a water-resistant film
-Adds moisture to wounds (gel forming)
-Autolytic debridement
-Slowly liquefies necrotic tissue
-Absorbs wound drainage - small amounts only
-Has a strong odour on removal
-Can be used as preventive dressing to protect high risk friction areas
-Can be used to protect skin around wound if frequent dressing changes
-Can be left on up to 5-7 days
-Occlusive : Not used for infected wounds!
SHR Dressings- Hydrogels
-Water or glycerine-based gel impregnated in gauze or sheet dressing
-Intra-site Gel: comes as a gel in a tube – single patient use
-Hydrogels ensure moisture in wound bed
-Helps soften necrotic tissue for debridement
-Requires secondary dressing over top
SHR Dressings- Foams
-Allevyn and Mepilex
-Management of large amounts of drainage
-Also provides autolytic debridement
-Decreases frequency of changes – can be left on up to 7 days
-Can shower with Allevyn
-Mepilex less absorbent but better for delicate skin
SHR Dressings- Hydrofibers
-Aquacel (Convatec)
-Converts to solid gel when in contact with moisture
-Use for moderate amounts of drainage
-Can be used as packing but not in undermining or tunneling
-Requires a secondary dressing over top
-Change when product has absorbed to its capacity
SHR Dressings- Antimicrobial Products
-Aquacel AG (Silver nitrate) – leave on for 3-7 days
-Iodosorb – leave on for 3 days
-Reduces bacterial count and manages resistant organisms (ie. MRSA, VRE)
-Aquacel AG and Iodosorb also absorb drainage
-Able to debride necrotic tissue
-Requires a secondary dressing over top
-Crushed Flagyl (metronidazole) with Intra-site gel to control odour