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Nursing Taylor Chapter 31: Skin Integrity and Wound Care
Terms in this set (45)
Largest Organ of the Body
Three layers of the skin:
avascular, renewed every 15-30 days, stratified epithelial cells; no blood vecels
main support structure, highly vascular, contains nerves, hair follicles, and elastic connective tissue
anchors the skin to the underlying tissues; adipose tissue; stores fat for energy, insulation
Line body cavities that open to the outside of the body.
Functions of the Skin
Vitamin D Production,
Factors Affecting the Skin
*Unbroken and healthy skin and mucous membranes defend against harmful agents.
*Resistance to injury is affected by age, amount of underlying tissues, and illness.
*Adequately nourished and hydrated body cells are resistant to injury.
*Adequate circulation is necessary to maintain cell life.
2 yo and younger infant's skin and mucous membranes are thinner and weaker, so easily injured and subject to infection.
A child's skin becomes increasingly resistant to injury and infection.
The maturation of epidermal cells is prolonged, leading to thin, easily damaged skin.
Circulation and collagen formation are impaired, leading to decreased elasticity and increased risk for tissue damage from pressure.
Causes of Skin Alterations
*Very thin and very obese people are more susceptible to skin injury.
*Excessive perspiration during illness predisposes skin to breakdown (fluid loss during illness causes dehydration; skin appears loose and flabby).
*Jaundice causes yellowish, itchy skin.
*Diseases of the skin cause lesions that require care.
break or disruption in the normal integrity of the skin and tissues:
Result of a planned invasive therapy or treatment (surgery, lumbar puncture)
edges and little bleeding
Result of from trauma, accidents (gunshots, burns)
edges, uncontrolled bleeding, high risk of infection
occur from intentional and unintentional trauma where the skin surface is open
ex: incisions and abrasions (разрезы и потертости)
results from a blow, force, or strain cause by a fall, assault, or crash; skin surface is not broken
ex: ecchymosis (кровоподтек) and hematoma
Wound edges are well approximated (приближены) and the risk of infection is lessened.
Healing is impaired, wound edges are not approximated, increased risk of infection
all or a portion of the dermis is intact.
Full thickness wound
the entire dermis and the sweat glands and the hair follicles are severed.
the dermis and underlying subcutaneous fat tissue are damaged and destroyed.
Types and Causes of Wound
Cut by sharp instrument
Blunt instrument. Skin is intact. Bruising
Friction. Top layer of skin
(рваная рана) Tearing of skin. Blunt or irregular object. Loose flap of skin and tissue. Tissue not aligned
Blunt or sharp object. Needle
Foreign object entering the skin
(отрыв) Tearing from structure. Possible damage to blood vessels, nerves
Toxic agent causing cellular necrosis
High or low temp.
Ultraviolet light or radiation exposure
Bad circulation caused by pressure with friction
Injury or poor venous return.
Injury and underlying ischemia. Atherosclerosis or thrombosis
Death of tissue
Thick grouping of microorganisms. Slimy (слизь) impairs wound healing
Epithelial cell migration
(потрошение) Wound completely separates with protrusion of viscera through the incisional area.
(свищ) An abnormal passage from an internal organ or vessel to the outside of the body or from one internal organ or vessel to another.
Swelling at a wound site that interferes with blood supply to the area.
Principles of Wound Healing
Intact skin is the first line of defense against microorganisms.
Surgical asepsis is used in caring for a wound.
The body responds systematically to trauma of any of its parts.
An adequate blood supply is essential for normal body response to injury.
Normal healing is promoted when wound is free of foreign material.
The extent of damage and the person's state of health affect wound healing.
Response to wound is more effective if proper nutrition is maintained.
Phases of Wound Healing
- blood vessels constrict and blood clotting begins through platelet activation and clustering.
- white blood cells move to the wound.
- granulation tissue is formed to fill the wound.
- collagen is remodeled forming a scar.
Occurs immediately after initial injury
Involved blood vessels constrict and blood clotting begins
(liquid) is formed causing swelling and pain
Platelets stimulate other cells to migrate to the injury to participate in other phases of healing
Increased perfusion results in heat and redness
Adequate skin Perfusion
1) heart must be able to pump adequately
2) volume of circulating blood must be sufficient
3) arteries & veins must be patent & functioning well
4) local capillary pressure must be higher than external pressure
Follows hemostasis and lasts about 4 to 6 days.
WBCs move to the wound.
Macrophages enter wound area and remain for extended period.
They ingest debris and release growth factors that attract fibroblasts to fill in wound.
Patient has generalized body response.
Begins at time of injury
Prepares wound for healing
Phase begins within 2 to 3 days of injury and may last up to 2 to 3 weeks.
New tissue is built to fill wound space through action of fibroblasts.
Capillaries grow across wound.
A thin layer of epithelial cells forms across wound
(new) forms a foundation for scar tissue development.
Final stage of healing begins about 3 weeks to 6 months after injury.
Collagen is remodeled.
New collagen tissue is deposited.
(avascular collagen tissue) becomes a flat, thin, white line.
Factors Affecting Wound Healing
children and healthy adults heal more rapidly
Circulation and oxygenation:
adequate blood flow is essential
healing requires adequate nutrition
specific condition of the wound affects healing
corticosteroid drugs and postoperative radiation therapy delay healing
- 2-7 days after injury
- usually within the first 48 hrs.
- surgical emergency
- usually due to infection or abscess
A wound with a localized area of injury to the skin and/or underlying tissue.
Bad circulation caused by pressure with friction:
compressing blood vessels;
- deficiency of blood in a particular area
Friction or shearing
forces tearing or injuring blood vessels
nonblanchable (не бледнеющая) erythema (redness) of a localized area over a bony prominence.
partial thickness skin loss and presents as a shallow (неглубокий), open ulcer.
full thickness skin loss; not involving underlying fascia: subcutaneous fat may be visible but bone, tendon, or muscle is not exposed.
R̲e̲qu̲i̲r̲e̲s̲ débridement through wet-to-dry dressings, surgical intervention, or proteolytic enzymes
Full thickness tissue loss with extensive destruction to bone, tendon, muscle.
base of ulcer covered by slough and/or eschar (струп) in wound bed.
(DTI) Deep tissue injury
Yellow, tan, gray, green, or brown
fibrinous tissue that consists of fibrin, pus, and proteinaceous material. Slough can be found on the surface of a previously clean wound bed and it is thought to be associated with bacterial activity.
Tan, Brown, Black
thick leathery scab or dry crust that is necrotic and must be removed before the stage can be determined accurately.
Measurement of a Pressure Ulcer
Size of wound
Depth of wound
Presence of undermining, tunneling, or sinus tract
Cleaning a Pressure Ulcer
Clean with each dressing change.
Use careful, gentle motions to minimize trauma.
Use 0.9% normal saline solution to irrigate and clean the ulcer.
Report any drainage or necrotic tissue.
Wound Assessment and Drainage
Inspection for sight and smell
Sutures, drains or tubes, and manifestation of complications
Palpation for appearance, drainage, and pain
Composed primarily of the clear, serous portion of the blood and from serous membranes. Clear and watery.
Consists of large numbers of red blood cells and looks like blood.
Mixture of serum and red blood cells.
Made up of white blood cells, liquefied dead tissue debris, and both dead and live bacteria.
Wound Dressings' Purposes
- Provide physical, psychological, and aesthetic comfort
- Remove necrotic tissue
- Prevent, eliminate, or control infection
- Absorb drainage
- Maintain a moist wound environment
- Protect wound from further injury
- Protect skin surrounding wound
Sings of Infection in Wound
- Wound is swollen.
- Wound is deep red in color.
- Wound feels hot on palpation.
- Drainage is increased and possibly purulent.
- Foul odor may be noted.
- Wound edges may be separated, with dehiscence present.
RYB Wound Classification
Removal of devitalized tissue and foreign material.
Uses transparent films, the body's own enzymes and defense mechanisms.
Use of sterile fly larvae
Transparent Films (Tegaderm)
-minimal drainage, small/partial thickness, stage I pressure ulcers, IV's, superficial
Hydrocolloid Dressings (Duoderm)
-Partial and full-thickness wounds
- light to moderate drainage
- with necrosis/slough
- NOT for wounds w/ infection
-Partial and full-thickness wounds
- Burns and dry wounds
- minimal exudate
-Infected or noninflected wounds
- moderate-heavy exudate
-Partial-full thickness wounds
- tunneling wounds
-moist red and yellow
-Absorbing light-heavy amounts of drainage
-NOT with dry eschar
- protect from bacterial contamination and reduce contamination
- acute/chronic wounds
Tipe of dressings
absorb blood or drainage.
s are strips of tape with eyelets which are used to secure a gauze dressing that needs frequent changing.
are used to protect intravenous insertion sites.
are used to keep a wound moist.
Factors Affecting the Response to
Hot and Cold Treatments
- Method and duration of application
- Degree of heat and cold applied
- Patient's age and physical condition
- Amount of body surface covered by the application
INCREASES tissue metabolism
INCREASES local blood flow
REDUCES muscle tension
HELPS relieve pain
REDUCES muscle spasms
Types of Bandages
Types of Binders
— used for chest and abdomen
— used for rectum, perineum, and groin area
— used to support an arm
Type of Drainage Systems
- Drains into dressings
- Penrose drain
- Drains into a suction device
- Jackson-Pratt drain
- Hemovac drain
- Open Drainage System
- Provides sinus tract
- Typically used after incision and drainage of abscess in abdominal surgery.
- Doesn't have a collection device
- Promotes drainage passively
- Drainage moves from area of higher pressure to area of lower pressure
- Closed Systems
- Decreases dead space by collecting drainage
Used for Bile drainage
Color Classification of Open Wounds - RYB
= red —
= yellow —
= black —
Mixed wound — contains components of RY&B wounds where B is treated first then Y > R
Wound Repair Intentions
- Well approximated (skin edges tightly together)
- Edges aren't well approximated
- Takes longer to heal
- Has more scar tissue
Tertiary Intention/Delayed Primary Closure
- Left open after several days to allow edema or infection to resolve or fluid to drain and are then closed.
Nutritional Risk for Pressure Ulcer
Albumin < 3.2
Prealbumin < 19
Lymphocytes < 1800
Hemoglobin A1C > 8%
(normal < 6%)
Glucose > 120
Body weight > 5-10%
Topics for Home Health Care Teaching
Appearance of the skin/recent changes
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