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Skin Integrity and Wound Care

Terms in this set (53)

Dermal-epidermal junction
Separates dermis and epidermis
Epidermis
Top layer of skin
Dermis
Inner layer of skin; collagen
Pressure ulcer
Impaired skin integrity related to unrelieved, prolonged pressure
Pathogenesis of Pressure Ulcers
Pressure is the major element in the cause of pressure ulcers. Three pressure-related factors contribute to pressure ulcer development: pressure intensity, pressure duration, and tissue tolerance.
Tissue ischemia
Point at which tissues receive insufficient oxygen and perfusion
Blanching
Occurs when the normal red tones of the light-skinned patient are absent.
Pressure Duration
Low pressure over a prolonged period and high-intensity pressure over a short period are two concerns related to duration of pressure
Tissue Tolerance
The ability of tissue to endure pressure depends on the integrity of the tissue and the supporting structures.
Impaired sensory perception
patients with altered sensory perception for pain and pressure are more at risk for impaired skin integrity than those with normal sensation.
Impaired mobility
Patients unable to independently change positions are at risk for pressure ulcer development.
Alteration in Level or Consciousness
Patients who are confused or disoriented and those who have expressive aphasia or other inability to verbalize or changing levels of consciousness are unalbe to protect themselves from pressure ulcer development.
Shear
The sliding movement of skin and subcutaneous tissue while the underlying muscle and bone are stationary
Friction
The force of two surfaces moving across one another such as the mechanical force exerted when skin is dragged across a coarse surface such as bed linens.
Moisture
The presence and duration of moisture on the skin increases the risk of ulcer formation.
Stage I: Nonblanchable Redness of Intact Skin
Intact skin presents with nonblanchable erythema of a localized area usually over a bony prominence
Stage II: Partial-thickness Skin Loss or Blister
A partial-thickness loss of dermis presents as a shallow open ulcer with a red-pink wound bed without slough.
Stage III: Full-thickness Skin Loss (Fat Visible)
A full-thickness tissue loss, subcutaneous fat may be visible but bone, tendon, or muscle is not exposed.
Stage IV: Full-thickness Tissue Loss (Muscle/Bone Visible)
A full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present and is often undermining and tunneling.
Slough
Stringy substance attached to wound bed (soft yellow or white tissue)
Granulation tissue
Red, moist tissue composed of new blood vessels, the presence of which indicates progression toward healing.
Exudate
Fluid, cells, or other substances that have been discharged from cells or blood vessels slowly through small pores or breaks in cell membranes.
Wound
A disruption of the integrity and function of tissues in the body
Partial-Thickness Wound Repair
Three components are involved in the healing process of a partial-thickness wound: inflammatory response, epithelial proliferation (reproduction) and migration, and reestablishment of the epidermal layers.
Full-Thickness Wound Repair
The four phases involved in the healing process of a full-thickness wound are hemostasis, inflammatory, proliferative, and remodeling.
Hemostasis
A seriesof events designed to control blood loss, establish bacterial control, and seal the defect occurs when there is an injury.
Inflammatory phase
Damaged tissue and mast cells secrete histamine, resulting in vasodilation of surrounding capillaries and exudation of serum and white blood cells into damaged tissues.
Proliferative phase
Filling of the wound with granulation tissue, contraction of the wound, and the resurfacing of the wound by epithelialization. Lasts from 3 to 24 days.
Remodeling
Maturation, the final stage of healing, sometimes takes place for more than a year, depending on the depth and extent of the wound.
Hemorrhage
Bleeding from a wound site
Hematoma
Localized collection of blood underneath the tissues
Infection
The second most common health care-associated infection. Purulent material drains from wound.
Dehiscence
The partial or total separation of wound layers
Evisceration
protrusion of visceral organs through a wound opening
The Braden Scale
Widely used risk-assessment tool, a valid tool to use for pressure ulcer risk assessment.
Tissue perfusion
Oxygen fuels the cellular functions esswential to the healing process; therefore the ability to perfuse the tissues with adequate amounts of oxygenated blood is critical to wound healing.
Age
Increased age affects all phases of wound healing
Abrasion
Superficial with little bleeding and is considered a partial-thickness wound.
Laceration
Sometimes bleeds more profusely, depending on the depth and location of the wound.
Puncture
Bleed in relation to the depth and size of the wound. The primary dangers are internal bleeding and infection.
Nursing Diagnoses
Risk for infection
Impaired tissue integrity
Acute or chronic pain
Imbalanced nutrition: less than body requirements
Impaired Skin integrity
Impaired physical mobility
Ineffective peripheral tissue perfusion
Risk for impaired skin integrity
Health promotion to prevent pressure ulcers
Topical skin care and incontinence management (protect bony prominences, skin barriers for incontinence), positioning (turn every 1-2 hours as indicated), support surfaces (decrease the amount of pressure exerted over bony prominences).
Debridement
The removal of nonviable, necrotic tissue
Gauze
Dry or moist
Film dressing
Traps moisture over the wound, providing a moist environment
Hydrocolloid
Protects the wound from surface contamination
Hydrogel
Maintains a moist surface to support healing
Wound vacuum assisted closure (V.A.C)
Uses negative pressure to support healing
Cleaning
Apply noncytotoxic solution
Irrigation
To remove exudates, use sterile technique with 35 mL syringe and 19 gauge needle
Suture Care
Consult health care facility policy
Drainage evacuators
Portable units exert a safe, constant, low-pressure vacuum to remove and collect drainage.
Sutures
Threads or metal used to sew body tissues together
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