Chapter 7 Flashcards
Skin
- Largest organ system
- 15% of body weight
- Main function: provide a barrier against injury, infection, ultraviolet radiation (UV), temperature balance
- Important role: perception of touch, pain, pressure, and vibration
- Elimination of waste, support of underlying structures, absorption of Vitamin D
Epidermis
- Outermost layer composed of squamous epithelial cells, providing a barrier against external environment
- KERATINOCYTES: cells formed in the basal layer of skin that migrates to superficial layers. Protects skin from water loss, pathogens, and injury. Die and shed for removal.
- MELANOCYTES: produce melanin, pigment that determines color of skin/hair and also absorbs UV rays.
- MERKEL CELLS: receptor cells that detect light touch, palms of hands and soles of feet
- LANGERHANS CELLS: plays a role in cutaneous immune system reactions. Presents the lymphocytes with foreign antigens to trigger and immune response in the epidermis.
Dermis
- Layer under the epidermis, composed of connective tissue, capillaries, blood vessels, & lymph vessels.
- Nourishment and protects structures from injury and assists with wound healing.
- Collagen and elastin fibers provides strength and elasticity which helps protects from alterations in tissue integrity (decrease with age)
Subcutaneous Tissue
- Mostly composed of adipose tissue
- Inner most layer
- Insulates body, absorbs shock, pads internal organs and structures
- Contains blood vessels and nerves to assist in thermoregulation and sensation
Pressure Injury
- Related to pressure, shearing,
- Localized
- ## Over bony prominences
Risk Factors of Impaired Skin Integrity
AGE
- Early in life/mature skin:
*maceration= irritation of the epidermis due to moisture.
*dermatitis= red skin irritation due to feces, urine, stoma effluent, and wound secretions
*Diaper rash, skin tears, pressure injuries
- Older age/ decrease in elasticity, subcutaneous tissue, blood supply, hydration:
*skin tears= loss of top layer of the skin caused by mechanical forces.
*Tissue trauma
*Skin exposed to sun = premature wrinkling which accelerates aging process
*Pressure injuries, itchy, dry, flaky skin, skin infections
MOBILITY ISSUES/ PARALYSIS: causes skin frailty = at risk vulnerable skin
- Alterations in thermoregulation, incontinence, loss of collagen, muscle atrophy, impaired sensation
*Congenital conditions: Spina bifida, cerebral palsy
Chronic Disease: liver failure, kidney disease, cancer
- Skin tears
**Pressure injuries: damage to skin/underlying tissue caused by long periods of contact or shear with a surface that interferes with circulation
- Cellulitis= infection of superficial layers of skin
OBESITY
- Decreased moisture, dry skin, maceration, elevated skin temp, decreased blood and lymphatic flow
*Skin tears, pressure injuries, diabetic ulcers, moisture lesions, skin-fold rashes
CANCER
- Radiation resulting in inflammation, skin surface damage, decreased blood supply
- Pressure injuries, delayed wound healing, skin infections, radiation induced dermatitis
Skin Assessment
- Medical history, factors that are high risk, assessing for abrasions, edema, moisture, rashes, abnormalities, texture and temperature
- Erythema = redness of the skin due to dilation of blood vessels/ tissue discoloration
- Blanch-able = redness that temporarily becomes white or pale when pressure is applied then goes back to red
- Non-blanch-able = redness that does not go away when pressure is applied (structural damage has occurred in the small vessels supplying blood to underlying skin and tissues)
- Examine bony prominences
- Palpate temp: inflammation for increased temp and cool to the touch for decreased blood flow
- Dark skin tones are harder to detect erythema which increases risk of pressure injuries.
Stages of Pressure Injury
- Stage 1: non-blanchable erythema of intact skin, harder to detect in dark skin
- Stage 2: partial-thickness skin loss, exposed dermis, pink/red viable tissue in wound bed, tissue is moist with not visible deep tissue. (ex: ruptures blister)
- Stage 3: Full thickness loss, exposed adipose tissue, granulation tissue (new skin tissue that forms on the surface of wound) is present, wound edges may be rolled, formation of dead tissue, present undermining and tunneling. no visible fascia, muscles, tendons, bones, ligament, or cartilage.
- Stage 4: Full-thickness skin and tissue loss. Can see bone, cartilage, ligaments, tendons, muscles, fascia. Edges are rolled, undermining and tunneling as well as dead tissue may be seen
- Unstageable: Obscured full thickness skin and tissue loss. CANNOT SEE THE DAMAGE TO THE WOUND BED BECAUSE OF….. Slough= yellow stringy tissue. or Eschar= hard nonviable black/brown tissue. Removal of these you can inspect the stage 3 or 4 injury
Types of Pressure Injuries
- Deep tissue pressure injury: skin may/may not be intact or broken. DTPI has localized, non-blanchable, deep red, maroon, or purple discoloration. Intense and/or persistent pressure and shearing force
- Device Related Pressure Injury: prolonged pressure from devices on client. Medical devices, equipment, furniture, or everyday objects left in direct contact with skin like oxygen masks/ tubing, urinary catheters, cervical collars, and compression stockings. Injury takes form of the object.
- Mucosal Membrane Pressure Injury: respiratory tract, GI tract, genitourinary tract that require medical equipment can cause injury to mucosal tissues
- Assess skin temperature, level of moisture, edema, hardened skin, localized pain for darker skin tones. skin can appear shiny, taut, or indurated
Types of Wound Care
- Surgical debridement: surgically removing dead tissue/ debris that can cause infection with scalpel or scissors. Can sent for culture
- Irrigation: removes surface materials and decreases bacterial levels in the wound. Can be performed at the bedside or in the surgical suite depending on the pressure needed for irrigation. 0.9% sodium chloride solution is used.
- Biological debridement: enzymatic agents like collagenase, papain, bromelain is applied to wounds to clear dead tissue and debris. larvae therapy
Sterile Dressing vs. Clean Dressing
- Sterile: after surgery, used for the first two days,
-Clean: can be used after 2 days or used at home
Transparent Film Dressing
- Used for things like IV’s, necrotic tissue, superficial skin tears
- Wounds without a lot of drainage because they do not absorb
- Covers and protects from microorganisms and infection
- Some oxygen exchange/ moist environment for healing and autolytic debridement
- Application can cause maceration of wound edges, removal can cause skin damage
- comfortable and easy to apply
Hydrocolloid Dressing
- Autolytic debridement
- Little absorption, maintains a moist healing environment, growth of new granulation tissue
- Used for burns, small abrasions, pressure injuries, postoperative wounds…. DO NOT use to treat gangrene or ischemic wounds
- Stays in place for 7 days or changed if needed
- Hard to assess because they are not transparent, but are comfortable
- Can cause contact dermatitis and foul smelling, yellow, gelatinous film due to trapped bacteria. Need to be able to differentiate this with infection.
Alginate Dressings
- From seaweed
- Moist environment for healing and absorption of exudate
- Hemostasis
- Does not stick to wound if used right
- Used for wounds with a lot of exudate or/ packing for deep wounds (do not use with dry wounds)
- Secondary dressing is required to secure it in place
- Stays in place up to 7 days
- Variety of forms: ribbons, pads, beads,
Hydrofiber Dressing
- Moderate and highly exudative wounds
- Highly absorbency
- Stays in wound for several days
- Draws less fluids from the wound edges which results in less maceration around the wound compared to alginate.
