Skin Integrity And Wound Care

Front 1

factors affecting skin integrity(child)

Back 1

child younger than 2, skin is thinner and weaker than adults; child's skin becomes increasingly resistant to injury and infection

Front 2

factors affecting skin integrity(infant)

Back 2

skin and mucous membranes are injured easily and are subject to infection. careful handling of infants is required to prevent injury and infection of the skin and mucous membranes

Front 3

factors affecting wound healing

Back 3

local factors and systemic factors

Front 4

local factors

Back 4

pressure
dessication
maceration
trauma
edema
infection
necrosis

Front 5

systemic factors

Back 5

occur throughout the body
age
circulation to and oxygenation of tissues
nutritional status
wound condition
health status
immunosuppression
medication use

Front 6

pressure

Back 6

disrupts the blood supply to the wound area
persistent or excessive pressure interferes with blood flow to the tissue and delays healing.

Front 7

desiccation

Back 7

cells dehydrate and die in a dry environment
cell death causes a crust to form over the wound site
and delays healing

Front 8

maceration

Back 8

overhydration of cells related to urinary and fecal incontinence can lead to impaired skin integrity changes in PH

Front 9

trauma

Back 9

Repeated ____ to a wound area results in delayed healing
or the inability to heal.

Front 10

Edema

Back 10

at a wound site interferes with the blood supply to
the area, resulting in an inadequate supply of oxygen and
nutrients to the tissue.

Front 11

Infection

Back 11

Bacteria in a wound increase stress on the body, requiring
increased energy to deal with the invaders.
requires large amounts of energy be spent by the immune system to fight the microorganisms, leaving little or no reserves to attend to the job of repair and healing. In addition, toxins
produced by bacteria and released when bacteria die interfere
with wound healing and cause cell death

Front 12

Necrosis

Back 12

Dead tissue present in the wound delays healing. Dead tissue
appears as slough, moist, yellow stringy tissue, and
eschar appears as dry, black, leathery tissue. Healing of the
wound will not take place with necrotic tissue in the wound.
Removal of the dead tissue must occur for healing to begin

Front 13

Age

Back 13

Children and healthy adults, however, heal more rapidly
than do older adults, in whom physiologic changes caused
by aging result in diminished fibroblastic activity and circulation.

Front 14

Age

Back 14

Older adults are more likely to have one or more
chronic illnesses, with pathologic changes that impede the
healing process.

Front 15

age(infant)

Back 15

loose binding between the layers causes
the layers to separate easily during an inflammatory process
placing infants and small children at risk for impaired skin
integrity.

Front 16

Circulation and Oxygenation

Back 16

Adequate blood flow to deliver nutrients and oxygen and
to remove local toxins, bacteria, and other debris is essential
for wound healing. Certain physical conditions, because of
their effect on circulation and oxygenation, can affect wound
healing.

Front 17

Nutritional status

Back 17

wound healing requires adequate proteins, carbohydrates, fats, vitamins, and minerals,. Calories and protein are necessary to rebuild cells and tissues
A and C necessary for epithelialization and collage synthesis
All phases of the wound healing process are slowed or inadequate in the patient with poor nutritional status and fluid balance.

Front 18

Wound condition

Back 18

affects how quickly and effectively it heals
large contaminated infected wounds or wounds that retain foreign bodies heal slowly sutures needed to close surgical wounds

Front 19

Medications and health status

Back 19

Patients taking corticosteroid drugs or require
postoperative radiation therapy are at high risk for delayed
healing and wound complications.
Corticosteroids decrease inflammatory process, which may delay healing. Radiation
depresses bone marrow function, resulting in decreased
leukocytes and an increased risk of infection. The presence
of a chronic illness (such as cardiovascular disease or diabetes
mellitus) or impaired immune function can impair
wound healing. Chemotherapeutic agents impair or stop
proliferation of all rapidly growing cells, including cells
involved in wound healing

Front 20

immunosuppression

Back 20

Suppression of the immune system as a result of disease
(e.g., AIDS, lupus), medication (e.g., chemotherapy), or age
(e.g., changes associated with advancing age) can delay
wound healing.

Front 21

Pressure Ulcers

Back 21

is a wound with a localized area of tissue
necrosis. Depending on the depth of the ulcer, a pressure
ulcer may be an acute wound or a chronic wound. The
underlying cause is pressure. Most pressure ulcers develop
when soft tissue is compressed between a bony prominence
and an external surface for a prolonged period of time, or
when soft tissue undergoes pressure in combination with
shear and/or friction

Front 22

shear

Back 22

results when one layer of tissue slides over another layer. separates the skin from underlying tissues

Front 23

immobility

Back 23

Patients who spend long periods of time in bed or seated
without shifting their body weight properly are at great risk
for development of a pressure ulcer (Hess, 2008). Individuals
who are ambulatory usually do not develop this type of
injury because no part of the body experiences prolonged
pressure.

Front 24

at risk for pressure ulcers

Back 24

immobility
Nutrition and hydration
moisture
mental status
age

Front 25

Friction

Back 25

occurs when two surfaces rub against each others
the injury resembles an abrasion, also can damage superficial blood vessels directly under the skin. a patient who lies on wrinkled sheets is likely to sustain tissue damage

Front 26

nutrition and hydration

Back 26

Protein–calorie malnutrition predisposes a person to pressure
ulcer formation because poorly nourished cells are
damaged easily. Protein deficiency leading to a negative
nitrogen balance, electrolyte imbalances, and insufficient
caloric intake also predisposes the skin to injury. Other deficiencies
can increase risk. For example, vitamin C deficiency
causes capillaries to become fragile, with resultant
poor circulation to the area. The condition of the teeth or fit
of dentures may also exacerbate the problem of inadequate
dietary intake. Dehydration as well as edema can interfere
with circulation and subsequent cell nourishment.

Front 27

Moisture

Back 27

Primary sources of skin moisture include perspiration, urine,
feces, and drainage from wounds (Butler, 2006). Prolonged
moisture on the skin reduces the skin’s resistance to trauma,
particularly damage from friction and shear. When skin is
damp, less friction is required to blister and abrade skin.
Additionally, the moisture associated with urinary and fecal
incontinence is believed to increase the risk for skin damage
due to the chemical irritation from the ammonia in the urine.
Ammonia also raises the alkalinity of the skin pH, altering
the function of the normally acidic skin. A more alkaline pH
promotes premature shedding of skin cells and decreases the
skin’s defense against bacteria, which results in enhanced
growth of pathogens, such as yeast and staphylococci.

Front 28

Mental status

Back 28

The more alert an individual is, the more likely he or she is
to protect skin integrity by relieving pressure periodically
and maintaining adequate skin hygiene. Apathy, confusion,
or a comatose state can diminish these self-care abilities and
increase the likelihood of skin breakdown.

Front 29

Age

Back 29

Older adults are at a greater risk for pressure ulcer formation
because the aging skin is more susceptible to injury. Chronic
and debilitating diseases, more common in this age group,
may adversely affect circulation and oxygenation of dermal
structures. Other problems, such as malnutrition and immobility,
compound the risk of pressure ulcer development in
older adults.

Front 30

Stage 1 of Pressure Ulcers

Back 30

Intact skin with nonblanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible
blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer, or cooler as compared to
adjacent tissue. Stage I may be difficult to detect in individuals with dark skin tones. Stage I may indicate “at risk” persons.

Front 31

Stage II of Pressure Ulcers

Back 31

Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. Presents as a shiny or dry
shallow ulcer without slough or bruising (which indicates suspected deep tissue injury). May also present as an intact or open/rupture
serum-filled blister. This stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration, or excoriation.
(

Front 32

Stage III of pressure ulcers

Back 32

Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed. Bone/tendon is not visible or
directly palpable. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The
depth of a stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput, and malleolus do not have subcutaneous
tissue, and stage II ulcers at these locations can be shallow. In contrast, areas with significant adipose tissue can develop
extremely deep Stage III pressure ulcers.

Front 33

Stage IV
.

Back 33

Full thickness tissue loss with exposed bone, tendon, or muscle. Exposed bone/tendon is visible or directly palpable. Slough or eschar
may be present on some parts of the wound bed. Often include undermining and tunneling. The depth of a stage IV pressure ulcer
varies by anatomical location. The bridge of the nose, ear, occiput, and malleolus do not have subcutaneous tissue and these ulcers
can be shallow at these locations. Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon, or joint
capsule), making osteomyelitis possible

Front 34

Unstageable

Back 34

Full thickness tissue loss in which the base of the ulcer is
covered by slough (yellow, tan, gray, green, or brown) and/or
eschar (tan, brown, or black) in the wound bed. Until enough
slough and/or eschar is removed to expose the base of the
wound, the true depth, and therefore stage, cannot be determined.
Stable (dry, adherent, intact, without erythema, or
fluctuance) eschar on the heels serves as “the body’s natural
(biological) cover” and should not be removed.
From

Front 35

Albumin level and abnormal levels for pressure ulcer

Back 35

3.2 mg/dL (normal, 3.5–5 mg/dL).

Front 36

Prealbumin and abnormal levels for pressure ulcer

Back 36

19 mg/dL (normal 16–40 mg/dL)

Front 37

levels for risk of pressure ulcer if body weight?

Back 37

decrease of >15%

Front 38

Total lymphocyte count  and abnormal pressure ulcers levels

Back 38

1,800/mm3 (normal,
1,000–4,000/mm3)

Front 39

Hemoglobin

Back 39

A1C >8% (normal 6%)

Front 40

• Glucose 

Back 40

120 mg/dL (normal 70–120 mg/dL)

Front 41

moisture

Back 41

makes the skin more susceptible to injury
can create an environment in which microorganisms can multiply and the skin is more likely to blister, suffer abrasions and become macerated

Front 42

serous drainage

Back 42

composed primarily of clear, serous portion of the blood and from serous membranes
serous drainage is clear and watery

Front 43

Sanguineous drainage

Back 43

consists of large numbers of red blood cells and looks like blood
bright-red sanguineous drainage is indicative of fresh bleeding, whereas darker drainage indicates older bleeding

Front 44

serosanguineous drainage

Back 44

a mixture of serum and red blood cells.
it is light pink to blood tinged

Front 45

purulent drainage

Back 45

made up of white cells
liquefied dead tissue debris, and both dead and live bacteria.
thick often has a musty or foul odor and varies in color such as dark yellow or green.

Front 46

debridement

Back 46

removal of devitalized tissue and foreign material

Front 47

dressing

Back 47

protective covering placed over a wound

Front 48

eschar

Back 48

wound let open to the air heal more slowly because wound drying produces this or a scab

Front 49

penrose drain

Back 49

provides sinus tract
after incision and drainage of abscess in abdominal surgery
soft and flexible
does not have a collection device
empties into absorptive dressing and promotes drainage passively with the drainage moving from the area of greater pressure in the wound or surgical site , to the area of less pressure, the dressing.
not sutured in place

Front 50

Jackson-Pratt drain

Back 50

decrease dead space by collecting drainage
after gallbladder surgery

Front 51

Hemovac drain

Back 51

decrease dead space by collecting drainage
after abdominal orthopedic surgery

Front 52

Jackson-Pratt drainage
or Hemovacs

Back 52

closed drainage system may be connected to an electrical suction device
tube is usually sutured to the skin

Front 53

closed drainage system

Back 53

prevent microorganisms from entering the wound from saturated dressings.

Front 54

granulation

Back 54

pink-red tissue