Skin Integrity And Wound Care

Front 1

1. Outer layer is dead cells, Basal layer replaces outer layer, 3rd layer protects underlying areas from dehydration and certain chemicals

Back 1

Epidermis

Front 2

Provides strenght,k mechanical support and protection.
Mostly connective tissue
Collagen, blood vessels, nerves

Back 2

Dermis

Front 3

Easily torn, reduced elasticity, decreased collagen, thinning of muscle, slower wound healing, less pading

Back 3

Aging Skin

Front 4

Localized unjury to the skin and underlying tissue, usually over a body prominence, as a result of pressure/shear/friction.

Back 4

Pressure Ulcer
Pressure sore
Decubitus Ulcer
Bedsore

Front 5

Decreased mobility
Decreased sensory percept.
Fecal or unrinary incont.
Poor Nutrition
Decreased level of conscious

Back 5

Risk for Pressusre Ulcer

Front 6

Force exerted parallel to skin from gravity and resistance btw client and surface

Back 6

Shear

Front 7

force of two surfaces moving across one another.

Back 7

Friction
(sheet burn)

Front 8

This softens skin and can come from wound drainage, excessive perspiration, fecal or urine.

Back 8

Moisture

Front 9

1. Skin Intact, nonblanchable redness
2. Partial skin loss (abrasion, blister, shallow craer)
3.Full thickness tissue loss, visible fat, bone, tendon (not muscle)
4. Full thidkness tissue loss with exposed bone, muscle, tendons

Back 9

Pressure Ulcer Classification
1. Stage I
2, Stage II
3. Stage III
4. Stage IV

Front 10

Red, moist tissue composed of new blood vessels; indicates healing

Back 10

Granulation Tissue

Front 11

Tissue Ischemia
Hyperemia
Blanching
Tunneling
Undermining

Back 11

Terminology for pressure ulcers

Front 12

Strings substance attached to wound bed

Back 12

Slough

Front 13

Black or brown necrotic tissue

Back 13

Eschar

Front 14

Wound drainage, needs to be removed for healing

Back 14

Wound Exudate

Front 15

Status of skin integrity
Cause of wound
Severity of tissue injury
Cleanliness
Descriptive qualities

Back 15

Classifications of wounds

Front 16

1.Usually easy to clean and repair.`
2. Healing delayed

Back 16

Acute Wounds
Chronic wounds

Front 17

Epithelialization; closed wound
minimal scarring

Back 17

Primary intention (healing)

Front 18

Wound edges not approximatged
Heals by granulation and epithelialization

Back 18

Secondary Intention (healing)

Front 19

Wound left open
Closure delayed until infection resolved

Back 19

Tertiary intention (healing)

Front 20

Shallow with loss of epidermis
Maybe some loss of dermis
Heal by regeneration
Clean surgical wound

Back 20

partial-thickness wounds

Front 21

-Inflammatory response
-epithelial proliferation and
-migration (cells need moisture to heal quickly)
-Reestablshment of the epidermal layers

Back 21

healing of partial-thickness wounds

Front 22

Extend into dermis
Heal by scar formation
(pressure ulcers)

Back 22

Full-thickness Wounds

Front 23

Inflammatory
Proliferative
Remodeling

Back 23

Full-thickness woundrepair phases

Front 24

Redness, edema, warmth, throbbing
Wound cleaning by WBCs
Collagen repair

Back 24

Inflammatory Phase

Front 25

Granulationtissue fills the wound
Wound contracts
Resufacing by epithelialization

Back 25

Proliferative Phase

Front 26

Collagen scar gets stronger
May take months

Back 26

Remodeling Phase

Front 27

-Hemmorage
-Infection (inhibits healing)
-Dehiscence (Partial or total separation of wound layers)
-Evisceration (Protrusion of visceral organs throught the wound opening
-Fistula formation(abnormal passage btw two organs - btw organ and outside of body

Back 27

Wound Healing Complications

Front 28

Occur as an initial spontaneous manifestation a pathological process (insect bite, pressure ulcer)

Back 28

Lesion

Front 29

Color, location, texture, size, shape, type, grouping, distribution
Exudate
Measure height, widtgh depth
Palpate

Back 29

Lesion Assessment

Front 30

If it is wet, dry it.
If it is dry, wet it

Back 30

Dressing Lesions

Front 31

-Harbors insects or worms
-Good hygene
-Careful selection fo sexsual partners

Back 31

Infestations
Lice, Scabies, Ticks, Fleas

Front 32

Itching, excoriation, erythema, petechiae

Back 32

Lice

Front 33

Wavy, brown, threadlike lines on the body - puritis - secondary infections

Back 33

Scabies

Front 34

-Chronic deep vein insufficiency
-Stasis of blood in the venous systme of the legs
-Open, necrotic lesion from lack of O2and nutrients to tissue - Results in prolonged healing - increased risk of infection

Back 34

Venous Stasis Ulcer
(occurs around the medial aspect of the ankle)

Front 35

-protein, Vit. C, A, zinc
-Debridement, wet to dry dressings, enzyme ointments
-Antibiotics
-Protection of site

Back 35

Venous Stasis Ulcer Management

Front 36

-Prolonged ischemia to the tissues - skin becomes shiny,thin, taut - loss of hair to lower legs - diminished pulses - skin cool - ulcers seen on toes, foot or lateral malleoulus, may become gangrenous

Back 36

Aterial leg Ulcer
(dangle leg over side of bed to increas perfusion at night and decrease pain)

Front 37

-Walking - Prevent skin cracking - Keep ulcer clean and dry (sterile dressing) - Not heat or cold - keep hells elevated - Precutaneous transulminal balloon angioplasty ( must restore perfusion for ulcer to heal)

Back 37

Management of Aterial Leg Ulcer

Front 38

Norton Scale - Physical condition, Mental condition - Activity - Moblitly - Incontinence -
Lower score = higher risk

Back 38

Norton Scale Risk Assessment

Front 39

Sensory Perception - moisture - acgtivity - moblility - nutrition - friction and shear -
Lower score - higher risk
Most common scale used

Back 39

Braden Scale
Pressure Ulcers

Front 40

Costs healthcare 2.2 to 3.6 billion a year - increases length of hospital stay from 12 to 30 days -over 1 million affecgted - costs more to treat than to prevent

Back 40

Pressure Ulcers

Front 41

Nutrition - Infection - Tissue perfusion ( must hqave O2 to heal) - Age -Psychosocial impact of wounds ( body image)

Back 41

Factors Influencing Pressure Ulcers formation and wound healing

Front 42

Always be on the lookout for _________.
Blanching, abnmormnall reactive hyperemia, induration

Back 42

Skin Breakdown

Front 43

Superficial - partial-thickness wound

Back 43

Abrasion

Front 44

Bleeds more depending on the depth and location.(scalp laceration)

Back 44

Laceration

Front 45

Danger is internal bleeding and infection.

Back 45

Puncture Wound

Front 46

Amount - Color - Odor -Consistency

Back 46

Charactaristics of wound drainage

Front 47

Wound Drainage
1. straw colored
2. Bloody Drainage
3.Mix of bloody and straw-colored
4. Yellow with pus

Back 47

1. serous
2.sanguineous
3. seroussanguineous
4. Purulent

Front 48

1. Skin blisters
2. Adhesions following surgery
3. nose
4. yellow or green from boils or absess
5.presence of RBCs

Back 48

1. serous
2. Fibrinous
3. Catarrhal
4. Purulent
5. Hemorrhagic

Front 49

COACH
Color - Odor - Amount - Consistency - How the clinet tolerates it

Back 49

Charting body fluids

Front 50

Penrose
Hemovac
Jackson-Pratt
Wound-VAC

Back 50

Drains

Front 51

-Risk for infection - Imbalanced nutrition (less) - Acute or chronic pain - imolpaired physical mobility - risk for imparied skin integrity - Ineffective tissue perfusion

Back 51

Nursign DX

Front 52

Topical skin care, turn every 1-2 hours, support bony surfaces by decreasing pressure with pillows etc.

Back 52

Implementation for wounds

Front 53

Mechanical
Autolytical
Chemical
Surgical

Back 53

Debridment

Front 54

Used after microvascular surgery when venous blood flow is restricted
Used to reduce blood congestion
Osteoarthritis (pain relief) - purpura fulminanas - hematomas - systgemic lupus- ear infection

Back 54

Leech Therapy

Front 55

Freshf water worm with 3 jaws used for suction device.
-sucks 5 - 15 ml f blood over 20 - 45 min.
-saliva inhibits thromin and induces vasodilaton

Back 55

Leeches

Front 56

Gauze -dry or moist
Hydrocolloid - (protects wound from surface contamination)
Hydrogel (moist surface)
Wound VAC (neg. pressure)

Back 56

Dressings

Front 57

Removes exudates, use sterile technique with 35 mL syringe and 19 g needle

Back 57

Irrigation

Front 58

Portable units that exert a safe, constant, low pressure vacuum to remove and collect drainage.

Back 58

Drainage Evacuation

Front 59

Cleanse wounds with

Back 59

Noncytotoxic solution