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35 Cards in this Set
- Front
- Back
Epidermis
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-Largely protective function: pathogen entry, injury
-Prevents moisture loss -Assists with fluid and electrolyte balance -Assists with thermoregulation -Harbours normal flora |
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Dermis
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-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 |
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Subcutaneous Tissue
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-Connective and fat tissue – supportive and protective function
-Fat provides heat insulation for body -Blood vessels, nerves, lymph tissues |
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Functions of skin
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-Protection
-Sensation -Thermoregulation -Growth and repair -Fluid and Electrolyte balance |
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Factors Affecting Skin & Tissue Integrity. 8
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1. Age
2. Environment 3. Nutritional Status 4. Excercise 5. Personal Hygeine 6.Socioeconomic/sociocultural status 7. Knowledge 8. Health Status |
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Risk Factors for Skin/Tissue Impairment (P&P, 2006, p. 1020, Box 34-2)
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-Immobilization
-Decreased Sensation -Nutrition and Hydration Impairment -Secretions and Excretions on the Skin -Vascular Insufficiency -External Devices |
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Factors in Assessing Skin and Tissue Integrity
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-Skin & tissue history
-Skin & tissue examination - mouth, hair, skin - lesions: distribution, size,shape,color, configuraton -diagnostic tests -self care ability -risk for impairment |
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MANAGEMENT OF SKIN & TISSUE INTEGRITY
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-Planning for optimal skin & tissue integrity
-Implementation -Evaluation |
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Restorative Care General Guidelines
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-Encourage independence
-Consider client routine -Select least restrictive modification -Maintain privacy, comfort, safety -Ensure medical asepsis -Apply principles of body mechanics |
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Rehabilitative Care
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Supporting adaptation to chronic conditions
-Self image -Listening, encourage expression of feelings -Acceptance -Referrals prn -Home care, teaching |
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Types of Wound Healing
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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 |
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Types of Wound Healing
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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 |
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Phases of Wound Healing
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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 |
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Factors that Impair Wound Healing
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-Infection
-Malnutrition -Age -Obesity -Impaired Oxygenation -Smoking -Drugs -Vascular diseases -Radiation -Wound Stress |
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Pressure ulcer
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area of tissue necrosis that develops due to compression of soft tissue between bone and external surface
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6 Subscales of the Braden Scale
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-Sensory Perception
-Moisture -Activity -Mobility -Nutrition -Friction & Shear |
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B. Best Practice: Ways to Manage Pressure
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-Education
-Inspection -Positioning devices Turning/Positioning/Repositioning: -Documentation |
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C. Best Practice: Friction/Shear Reduction
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-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 |
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Stage 1 Ulcer
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-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 |
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Stage 1 Ulcer Treatment
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-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 |
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Stage 2 Ulcer
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-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 |
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Stage 2 Ulcer Treatment
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-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 |
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Stage 3 Ulcer
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-“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 |
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Stage 3 Ulcer Treatment
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-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 |
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Stage 4 Ulcer
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-Extends through subcutaneous tissue to underlying structures: muscle, bone, tendons, fascia
-If infected, can lead to septicemia, osteomylitis -Often presence of dead tissue, eschar |
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Stage 4 Ulcer Treatment
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-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 |
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Debridement. 5
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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 |
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Preventative Measures in Pressure Wound Development
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-Identify high risk patients
-Eliminate pressures -Use protective devices -Avoid shearing forces -Manage moisture -Promote circulation -Reduce friction -Prevent skin irritation -Maintain nutritional status |
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Treatment of Pressure Ulcers
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-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 |
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SHR Dressings- Liquid Skin Barriers
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-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 |
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SHR Dressings-Hydrocolloids
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-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! |
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SHR Dressings- Hydrogels
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-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 |
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SHR Dressings- Foams
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-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 |
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SHR Dressings- Hydrofibers
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-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 |
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SHR Dressings- Antimicrobial Products
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-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 |