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85 Cards in this Set
- Front
- Back
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Epidermis
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The outer portion of the skin. Made up of four or five layers, of which the most important are the inner and outer layers
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Stratum Corneum
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The outermost layer of the epidermis. Composed of numerous thickness of dead cells. Functioning as a barrier, it restricts water loss and prevents fluids, pathogens, and chemicals from entering the body.
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Stratum Germinativum
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The innermost layer of the epidermis. Continually produces new cells, pushing the older cells toward the skin surface. Keratinocytes, melanocytes, and Langerhans cells are located here.
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Keratinocytes
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Protein-containing cells that give the skin strength and elasticity
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Melanocytes
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Are deeper in the skin. They produce melanin
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Melanin
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A pigment that gives skin its color and provides protection from ultraviolet light.
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Langerhans cells
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Are mobile. Their function is to phagocytize (engulf) foreign material and trigger an immune response.
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Dermis
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Lies below the epidermis and above the subcutaneous tissue. It is made of irregular fibrous connective tissue that provides strength and elasticity to the skin and is generously supplied with blood vessels. Sweat glands, sebaceous (oil) glands, ceruminous (wax) glands, hair and nail follicles, sensory receptors, elastin, and collagen
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Subcutaneous Layer
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Composed primarily of connective and adipose tissue. It provides insulation, protection, and reserve of calories in the event of severe malnutrition. Sex hormones, genetics, age, and nutrition also influence the distribution of subcutaneous tissue.
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Age-Related Variations
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Age affects the condition and structure of the skin.
-In infants: they are born with vernix, and caseosa, that protects their skin, their subcutaneous layer is not fully developed. -In older adults: regeneration of skin take twice as long The strong bond between the epidermal and dermal layer decreases as the dermal layer loses elasticity as a result of changes in its collagen fibers. |
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Xerosis
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Itchy, red, dry, scaly, cracked, or fissured skin) is a problem form up to (85%) of older adults and can be a threat to the integrity of their skin.
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Impaired Mobility
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Immobility causes an increase in pressure and may lead to skin breakdown. Impaired mobility is caused by conditions that require complete bed rest or that seriously limit activity.
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Nutrition and Hydration
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Skincondition reflects overall nutritional status, while nutritional intake affects the skin.
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Protein
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Is necessary to maintain the skin, repair minor defects, and preserve intravascular volume.
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Cholesterol
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Abnormally low cholesterol levels predispose patients to skin breakdown and inhibit wound healing.
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Calorie Intake
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If calorie intake is inadequate, the body used proteins for energy (catabolism); they re then unavailable for building and maintenance functions
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Diminished Sensation
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Diminished sensation is less able to sense pressure or dangerous surfaces- less likely to notice and seek help
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Diminished Cognition
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Higher risk of skin breakdown because they are not aware of the need to reposition
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Impaired Circulation
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Impaired arterial circulation restricts activity, produces pain, and leads to muscle atrophy and development of this tissue that is prone to ischemia and necrosis. Results in engorged tissues with high levels of metabolic waste products that are prone to edema, ulceration, and breakdown, delay of wound healing.
Main causes of chronic wounds. |
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Medications
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Side effects and idiosyncratic reactions to medication can affect skin integrity and wound healing.
These medications: Blood pressure, anti-inflammatory, anticoagulants, chemotherapeutic agents, antibiotics, psychotherapy drugs, several herbal products |
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Moisture on the Skin
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Exposure to moisture leads to Maceration (softening of the skin) and increases the likelihood of skin breakdown. Incontience and fever are the most common sources of moisture.
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Exoriation
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Denuding
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MASD
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Moisture-Associated Skin Damage
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Dermatitis
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Inflammation of the skin
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Fever is a risk factor for skin breakdown for two reasons
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One, it leads to sweating, which can cause maceration
Two, it increases the metabolic rate, thereby raising the tissue demand for oxygen. AN increased demand for oxygen is difficult to meet if there is any circulatory impairment or tissue compression secondary to pressure |
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Contamination of a wound
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refers to the presence of microorganisms in the wound
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As bacteria begin to increase in number, a wound is said to be
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Colonized, though the microorganisms are causing no harm
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A wound becomes critically colonized when
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The bacteria begin to overwhelm the body's defenses
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Infection
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Implies the microorganisms are causing harm by releasing toxins, invading body tissues, and increasing the metabolic demand of the tissue
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Lifestyle habits affect skin integrity like
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Tanning, hygiene habits, regular exercise, nutritious diet, smoking, and body piercings
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Wounds
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Are a disruption in the normal integrity of the skin. Intentional or unintentional.
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How are wounds classified
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According to length of time the wound has existed, as well as the condition of the wound.
Skin Integrity, Length of Time for Healing, Level of Contamination, Depth of Wound. |
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Skin Integrity
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The simplest wound classification system is based on the integrity of the skin
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Closed Wound
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If there are no breaks in the skin.
Contusion (bruises) or tissue swelling from fractures are common closed wounds |
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Open Wound
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If there is a break in the skin or mucous membrane.
Open wounds include: abrasions, lacerations, puncture wounds, and surgical incisions. A Compound fracture may lead to an open wound caused by the projection of bone. |
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Acute Wounds
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Expected to be of short duration.
-These heal spontaneously, and easily complete the phases of wound healing (inflammation, proliferation and maturation) |
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Chronic Wounds
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Wounds that exceed the expected length of recovery.
-Healing is usually interrupted by infection, continued drama, ischoemia, or edema. Also slowed from underlying disease -Wounds include; pressure, arterial, venous, and diabetic ulcers |
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Clean Wound
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Uninfected wounds with minimal inflammation.
-They can be open or closed. Do not include; gastrointestinal, respiratory, or genitourinary tracts. |
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Clean-Contaminated Wounds
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Surgical incisions that enter the gastrointestinal, respiratory, or genitourinary tracts. There is an increased risk of infection but not obvious infection.
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Contaminated Wounds
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Include open, traumatic wounds or surgical incisions in which a major break in asepsis occurred. Risk for infection is high fir these wounds.
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Infected Wounds
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When bacteria counts in the wound tissues are above 100,000 organisms per gram of tissue. The presence of "beta-hemolytic streptococci" in any number is considered an infection. (Do not mistake epithelial tissue for infection)
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Signs of Wound Infection
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Erythema and swelling around the wound, fever, foul order, severe or increasing pain, large amount of drainage, or warmth of the surrounding soft tissue.
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Superficial Wounds
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Involve only the epidermal layer of the skin.
-Result of friction, shearing, or burning. |
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Partial-thickness Wounds
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Extend though the epidermis but not though the dermis.
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Full-Thickness Wounds
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Extend into the subcutaneous tissue and beyond.
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Penetrating
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Sometimes added to indicate that the wound involves internal organs.
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Physiological Wound Healing Process
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Epithelial, endothelial, and inflammatory cells, platelets, and fibroblasts migrate into the wound to bring about tissue repair and regeneration.
-The process is same regardless of the type of injury or the types of tussles involved. |
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Regenerative/Epithelial Healing
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When the wound only affects the epidermis and dermis. No scar forms. Partial-thickness wounds heal by regeneration.
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Primary Intention Healing
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When a wound involves minimal or no tissue and has edges that are well approximated (closed), or primary (first) intention healing takes place. Little scaring is expected. A clean surgical incision heals by this method.
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Secondary Infection
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1) Involves extensive tissue loss, which prevents wound edges from approximating
2) Should not be closed (because it is infected) |
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Granulation Tissue
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A form if connective tissue with an abundant blood supply.
(Left open wounds heal from the inner layer filling with granulation tissue) |
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Tertiary (Third) Healing
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Also called delayed primary closure, occurs when two surfaces of granulation tissue are brought together.
Used when the would is clean-contaminated or contaminated. Requires strict aseptic technique. Creates less scaring than secondary but more than primary intention healing. |
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Stages of Would Healing
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Inflammatory, proliferative, and maturation.
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Inflammatory Phase-Cleansing
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Lasts from 1 to 5 days and consists of two major processes: hemostasis and inflammation
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Hemostasis
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At the time of injury, tissue and capillaries are destroyed, causing blood and plasma to leak into the wound. Area vessels constrict to limit blood loss. Platelets are activated and aggregate to slow bleeding. The clotting mechanism is activated to form a blood clot.
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Inflammation
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Characterized by edema, erythema, pain, temperature elevation, and migration of white blood cells into the wound tissues.
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Phagocytosis
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When macrophages engulf bacteria
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Fibroblasts
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Connective tissue cells
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Collagen
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A protein substance that adds strength to the healing wound
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Proliferative Phase-Granulation (aka regeneration)
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Phase occurs from day 5 to 21. Cells develop to fill the would defect and resurface the skin. Fibroblasts migrate to he wound where they form collagen. New bolo and lymph vessels sprout from the existing capillaries at the edge of the wound. The result is formation of granulation tissue. Then epithelialization occurs
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Epithelialization
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As a clot or scab is dissolved, epithelial cells begin to grow into the wound from surrounding healthy tissue and seal over the wound.
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Maturation Phase-Epithelialization (aka remodeling)
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The final phase of the healing process. Begins in the second or third week and continues even after the wound has closed. The next 3 to 6 months, the initial collagen fibers are broken down and remodeled int organized structure, increasing the tensile strength. A Scare is only 80% as strong as the original tissue.
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Adhesive Strips are used for
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Closing superficial low-tension wounds, a wound that has been closed subcutaneously, or giving additional support after sutures or staples have been removed.
They are kept in place until they begin to separate from the skin on their own |
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Sutures aka Stiches
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-Absorbent sutures are used deep in the tissues
-Nonaborben sutures require removal |
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Surgical Staples
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Made of titanium, provide a fast, easy way to close an incision. Associated with lower risk of infection than sutures. Should not be used on hands, feet, neck, or face.
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Surgical Glue
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Safe or use in clean, low-tension wounds. Good for skin tears.
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Negative Pressure Wound Therapy
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Promotes healing by secondary and tertiary intention. Using a pump, negative pressure is placed on a wound packed with foam or gauze dressing to create a vacuum.
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Surgical Options
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Extensive debridement, skin grafts, secondary closure of the would, and flap techniques are used for complicated wounds
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Hyperbaric Oxygen Therapy
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The administration of 100% oxygen under pressure to a wound site. HBOT increases oxygen concentration in the tissue, stimulates the growth of new blood vessels, and enhances white blood cell action
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Platelet-drived Growth Factor
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Augments the inflammatory phase of wound healing and accelerates collagen formation in the wound
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Exudate
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Fluid that oozes as a result of inflammation
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Serous Exudate
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Typically from clean wounds. Watery in consistency and contains very little cellular matter. Consists of serum, straw-colored fluid that separates out the blood when a clot is formed
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Sanguineous Exudate
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Seen with deep wounds or wounds in highly vascular areas. It is bloody drainage. It indicated damage to the capillaries.
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Serosanguineous Drainage
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In new wounds, combination of bloody and serous drainage
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Purulent Exudate
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Thick, often malodorous, drainage that is seen in infected wounds. Contains pus. Usually yellow in color.
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Pyogenic
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Pus forming
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Hemostasis
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Cessation of bleeding
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Most common complication of healing
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Hemorrhage, infection, dehiscence, evisceration, and fistulas
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Hemorrhage
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Highest risk is 24 to 48 hours after surgery or injury.
Internal Bleeding External Hemorrhage |
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Dehiscence
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Rapture of one or more layers of a wound. Most likely to occur in the inflammatory phase. Common causes are poor nutrition, inadequate closure of the muscles, or wound infection. Fatty tissue does not heal readily.
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Evisceration
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Is total separation of the layers of a wound in which internal viscera protrude though the incision.
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Fistula
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Is an abnormal passage connecting two body cavities or cavity and the skin. Resulting from infection. Most common sites are the gastrointestinal and genitourinary tracts.
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State the function of skin
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Protection of the internal organs, unique identification of an individual, thermoregulation, metabolism of nutrients and metabolic wastes products, and sensation.
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List the factors that affect the integrity of the skin
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Age-related variations, impaired mobility, nutrition and hydration, diminished sensation or cognition, impaired circulation, medications, moisture to the skin, fever, contamination or infection, and lifestyle
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List the necessary data that should be included in dressing change documentation
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-Appearance and location of the wound and surrounding tissue
-Pain level -Medicated? -Method of cleansing -Description of area where the culture was taken -Dressing reapplied to wound -Education provided to patient |
