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134 Cards in this Set
- Front
- Back
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Functions of skin:
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-1st line of defense
-prevents excess fluid loss -provides sensory perception -synthesis & activation of Vit D thru sunlight |
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Partial thickness wounds:
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-are shallow involving loss of epidermis and possible partial loss of dermis
-epidermis can regenerate -example: blister or scratch |
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Full thickness wounds:
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-extends into the dermis or deeper
-heals by scar tissue -example: stab wound, surgical scar |
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Inflammation Phase
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-controls bleeding, establishes clean wound bed
-blood clot forms, WBCs migrate to area & clean up debris -fibrin clot serves as matrix for cellular repair |
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Epithelial Proliferation
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wounds epithelial cells regenerate and migrate across wound surface from the edges
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Why should you keep a wound moist?
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cells can only migrate across a moist surface
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Proliferation (Granulation) Phase:
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-wound fills with granulation tissue & surface is re-epithelialized
-Fibroblasts migrate to site and secrete collagen -wound appears pink, grainy -collagen becomes organized, strengthens site, forms scar -wound is very fragile |
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Fibroblast
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immature connective tissue cells
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Remodeling Phase / Scar contracture
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-remodeling of callagen, contraction & strengthening of scar
-appears pale, avascular -area regains about 2/3 of orig. strength |
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Phagocytosis is?
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WBS eat debri
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Leukocytosis is?
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Increase in WBCs
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Cellular Response
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Specialized WBCs (1st neutrophils, then monocytes) move to site of injury to clean debris
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Vascular Response Phase
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-Start immediately, conts 4-6 days, peaks in 6-8 hours
-release of histamine & other chemicals causes vasodilatation & redness |
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Hyperemia
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redness
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Hemostasis
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blood vessels constrict to slow bleeding
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Capillary Permeability
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protein and cells enter interstitial spaces, fluid accumulates
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Exudate formation
(wound drainage) |
caused by release of chemical mediators (vascular changes & exudates of fluid & cells from blood vessels)
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Functions of drainage
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-dilution of toxins produced by bacteria & dead cells
-transport WBCs, plasma protein, antibodies to site -transport bacteria, dead cell, debris from site |
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Nature and amount of exudate depends on
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-tissue involved
-intensity and duration of inflammation -presence of microorganisms |
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Serous
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Mild imflammation
Example: blister Serum- watery, low protein |
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Serosanguinous or Sanguinous
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-red
-Hemorrhagic-due to capillary damage -occurs with severe inflammation / injury |
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Ecchymosis
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bruising
bleeding under skin |
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Purulent
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Pus
Yellow, tan, green, brown |
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When does Pus occur?
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-Thicker, WBCs, dead tissue, & bacteria
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Pyogenic
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bacteria produce pus
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Mucus (mucous)
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thick fluid secreted by mucous membranes and glands
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Regeneration
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replacement of lost cells & tissue with cells of the same type
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Primary Infection
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-wound closed with sutures, staples, etc
-least scarring |
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Secondary Infection
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-left open to fill in with granulation tissue
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Tertiary Infection
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delayed primary closure
delayed wound closure |
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Factors affecting wound healing- Infection
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further tissue damage
inflammation |
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Factors affecting wound healing- advanced age
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slow immune respose
imparied circulation |
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Factors affecting wound healing- circulation
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decreased O2 nutrients
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Factors affecting wound healing- smoking
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decreased O2 nutrients
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Factors affecting wound healing- diabetes
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decreased collagen synthesis
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Factors affecting wound healing- drugs
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suppress immune system
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Factors affecting wound healing- anemia
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decreased O2
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Factors affecting wound healing- obesity
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less vascular
put more strain on suture line less blood cell |
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Factors affecting wound healing- decresed mobility
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impaired circulation
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dehiscence
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-wound edges separate
-don't lift -support / split incision when cough |
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evisceration
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-protruding organs or body parts
-sterile gauze, soaked in steril saline, call MD |
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Hypertrophic scars
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excess scar tissue red and raised with in wound edges, decreased in size
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hemorrhage
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-bleeding from wound
-may be internal or external |
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s/sx of internal bleeding
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increased pulse
decreased BP vomiting pain swelling |
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s/sx infection
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warmth
redness drainage pain increased temp increased pulse increased RR 2-3 days after trauma 4-5 dayes post-op |
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adhesions
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bands of scar tissue between or around organs
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Keloids
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-outside orig. incision
-scar overgrowth outside of wound egdes -cosmetic issues -common in darker skin |
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Contracture:
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-excessive shortening of muscle or scar tissue
-causes deformity -might occur with burns |
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Fistulas:
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-abnormal passage between 2 organs OR organ & outside of body
-due to poor wound healing or disease complications |
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What causes a pressure ulcers?
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if pressure exceeds normal capillary pressure and occurs for a prolonged period, tissue ischemia occurs
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Increased risk for ulcers
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poor nutrition
age low BP decreased tissue tolerance immobility decreased sensory perception decreased LOC shearing force moisture edema obesity |
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Pressure Intensity
Pressure Duration |
low pressure over a long period of time or high pressure over a short period can occlude blood flow and nutrients resulting in tissue dealth
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Why shouldn't you massage a pressure ulcer?
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causes more tissue damage
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Which areas are at greatest risk for ulcers?
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heals
hips coccyx sacrum elbows |
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hyperemia
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redness
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Stage One Ulcer
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intact skin
non-blanchable erythema discoloration in darker skin warmth, edema, hardness |
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Stage Two Ulcer
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-Partial thickness
-partial loss of epidermis & dermis -blister looking -considered infected even if no sx |
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Stage Threr Ulcer
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-full thickness
-extends into SQ tissue, but not into muscle -tissue necrosis present |
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Slough
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looks like chicken fat
yellow |
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Eschar
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black hard tissue
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Stage Four Ulcer
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-full thickness
-extends through SQ into muscle with extensive destruction, necrosis -possible damage to muscle, bone, supporting structure |
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When can you not stage a ulcer?
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if necrotic tissue is present
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Venous stasis ulcer
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-necrotic crater-like lesion usually found on lower leg at medial malleoli.
-very slow to heal |
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Arterial ulcers:
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pale, ischemic base, well defined, edges found on toes, heels, lateral malleoli
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Contact Dermatitis:
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caused by exposure to irritant chemical or allergen
(poison ivy, metels, nickel) |
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Atopic Dermatitis (Eczema):
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tendency is inherited causing chronic inflammation from exposure to allergens
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Urticaria (hives):
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type I hypersensitivity reaction (usually caused by something ingested) causing release of histamines (Different sized wheals)
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Psoriasis:
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-Unknown origin
-Chronic rapid turnover of epidermal cells resulting in thickening and scaling, silvery plaques |
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Cellulitis:
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infection of the dermis and subcutaneous tissue; may be caused by Staph or Strep, insect bite
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Acute Necrotizing Fascitis:
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caused by a mixture of microbes including a highly virulent strain of gram positive, group A, beta-hemolytic Strep
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Tinea infections
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fungal infection or mycoses
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Pedis
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athlete’s foot
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Corporis
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ringworm of body
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Capitus
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ringworm of head
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Pediculosis (lice)
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contagious parasites that suck blood
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Scabies
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-contagious, caused by itch mite
-Causes burrows, papules, vesicles; very itchy |
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Basal cell
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can be removed. Most common, least likely to metastasize
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Squamous cell
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removal, may require radiation. May metastasize if untreated
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Malignant Melanoma
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-Excision & removal of surrounding tissue
-A symmetry B orders irregular C olor-varied pigmentation brown, black, tan D iameter > 6mm - pencil eraser |
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Age-Related Skin Disorders
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-Wrinkles
-Skin tears -Senile lentigo or liver spots -Pruritis - itching -Keratosis – overgrowth of horny layer |
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Seborrheic
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yellow-brown scales on trunk, face, scalp
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Actinic or Solar on areas of sun exposure
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Pink or tan scales
Pre-malignant |
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Macule:
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flat, non-palpable change in skin color. (freckle)<1cm
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Papule:
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palpable, circumcised skin elevation (pimple)<1cm
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Nodule:
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small collection of tissue (wart)
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Pigmented nevi –
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flat or protruding lesion usually brown or black due to melanocytes (mole)
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Wheal:
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irregular shape & size reddened, raised area with surrounding redness & edema (hives)
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Vesicle:
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fluid filled lesion (blister, chicken-pox, shingles)
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Pustule:
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pus-filled lesion (acne)
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Ulcer:
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loss of skin surface, varied size. (small crater)
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Plaque:
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scaley, silvery lesions (psoriasis)
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Fissure:
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crack in the skin
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Comedone:
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blackhead
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Petichiae:
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tiny pinpoint hemorrhages
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Purpura:
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black & blue lesions (Prednisone or Coumadin)
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Laceration
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tear in skin (knife cut)
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Abrasion
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scrape of skin (skinned knee)
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Avulsion
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chunk of skin is cut or torn off. May be a flap.
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Inflammation
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is the (normal) nonspecific immune response that occurs in reaction to any type of bodily injury
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Infection
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is the presence and growth of a microorganism that produces tissue damage
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Signs & Symptoms Inflammation
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-Redness
-Warmth -Swelling Decreased function -Fever and increased WBCs can occur with extensive inflammation - |
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Localized Infection SX?
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tenderness
heat redness swelling pain |
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Systemic Infection SX?
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fever
increased HR and RR weakness anorexia V&D enlarged / tender lymph nodes |
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Neutrophils:
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-increase with infections or trauma
-shift to left: immature neutrphils, bands are released |
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Normal WBC should be?
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4,000-10,000/mm3
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Absolute cell counts?
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are % x total WBCs
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Measure wound:
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length- head to toe
width- side to side depth at deepest point |
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Surdical/sharp debride wound:
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quickest method of debridement
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Chemical debride:
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topical enzyme
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Mechanical debride:
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wet to dry dressings
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Autolytic debride:
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occlusive or semi-occlusive dressing products promotes bodys softening of cshar
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Gauze:
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woven & non-woven
wet to moist wet to dry |
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Non-adherent dressings:
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Adaptic
Vaseline Telfa |
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Transparent films
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Tegaderm
Biocciusive |
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Hydrocolloids
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Duederm
Comfeel |
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Absorptive dressings
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Kerlix fluffs
ABDs Surgipads |
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Foams
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Lyofoam
curafoam |
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Hydrogels
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supply moisture to dry wound
cover w/gauze or hydrocolloid |
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Alginates
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Sorban
Algiderm |
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Antmicrobial
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Prisma
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What does a red wound look like?
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Clean, pink or red w/ granulating tissue
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What type of drainage?
(red wound) |
serosanguinous drainage
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Treatment Goal:
(red wound) |
Protect & keep moist
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How would you clean wound?
(red wound) |
Use saline or commercial wound cleanser only
Betadine & H202 considered obsolete, inhibit granulation, cytotoxic Irrigate with NS or in shower or use NS on q-tip or gauze Clean very gently to prevent damaging new tissue |
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What kind of dressing might be used if wound is superficial?
(red wound) |
Transparent dressing will keep surface clean and slightly moist
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If wound is deeper and has moderate drainage?
(red wound) |
Hydrocolloid dressings (Duoderm) used on superficial & partial thickness w/ mod. drainage
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What would it look like?
(yellow wound) |
presence of slough or soft necrotic tissue.
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What type of drainage?
(yellow wound) |
Ivory to yellow-green exudate
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TX Purpose:
(yellow wound) |
purpose to remove (debride) non-viable tissue & absorb exudate
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How would you clean & debride wound?
(yellow wound) |
Can debride w/irrigation, whirlpool
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What kind of dressing might be used?
(yellow wound) |
Absorption dressings (exudate absorbers, alginates for heavy drainage), polyurethane foams, or hydrocolloid
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Dressings to promote softening
(black wound) |
-Hydrogel dressings may help to debride
-Hydrocolloids may soften eschar -Dressings to promote softening -Wet to dry dressings – pull off when dry to debride |
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BLACK WOUND INFO
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-Thick black necrotic tissue called eschar
-Must be removed before wound can heal -Surgical debridement is best if tolerated -Mechanical debridement by Dr. or Nurse |
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Document Wounds
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-Size
-Appearance -Drainage -Drains |
